Ayesha I. Mian

Depression in pregnancy and the postpartum period: balancing adverse effects of untreated illness with treatment risks.

The author reviews the risks and benefits of untreated maternal depression during pregnancy and the postnatal period and its effects on the well-being of the mother and infant. She then discusses the significant role psychiatrists can play in detecting and managing maternal depression as a primary measure for preventing future child psychopathology. A literature search was conducted on PubMed to identify both preclinical and clinical studies concerning deleterious effects of maternal depression on offspring. Additional searches focused on available safety data concerning the use of antidepressants during pregnancy and lactation. Key search items included depression during pregnancy, postpartum depression, lactation, and antidepressants. Burgeoning evidence was found concerning the adverse effects of maternal depression on the developing fetus and infant in the perinatal period. No controlled studies on the safety of antidepressant use in pregnancy and lactation were found; therefore, case reports, and some retrospective and prospective case series, must serve as guidelines for the treating clinician. Each case of maternal depression needs to be evaluated on an individual basis and decisions about treatment interventions should involve both the patient and family. Maternal depression during pregnancy and the postnatal period is associated with a significant disease burden in that it affects not only the mother but may also have both short- and long-term effects on offspring. Therefore, early detection and management of maternal depression, of which perinatal screening of mothers is an important component, are warranted.

'The one truly serious philosophical problem': Ethical aspects of suicide

Suicide is a major global public health problem with an estimated one million deaths every year. It is one of the most personal yet one of the most complex acts anyone can perform, as it goes to the very core of the concept of human existence and the meaning of life. The philosophical debate on suicide has spanned centuries with no clear answers. Juxtaposed within the various perspectives that suicide can be studied from is the ethical perspective that brings into sharp focus the conflict between personal autonomy and societal responsibility towards suicidal individuals. Mental health professionals find themselves in the midst of this conflict as they are assumed to have the responsibility to prevent suicide in their patients, while patients’ responsibility towards themselves is frequently overlooked. Mental health professionals need to be aware of the ethical concerns that arise in the care of suicidal patients.

Toolbox for Evaluating Residents as Teachers

ObjectiveThe authors review existing assessment tools related to evaluating residents’ teaching skills and teaching effectiveness.MethodsPubMed and PsycInfo databases were searched using combinations of keywords including “residents,” “residents as teachers,” “teaching skills,” and “assessments” or “rating scales.”ResultsEleven evaluation tools that utilized self-reports, learner evaluations, or observed structured teaching evaluations were found. These varied in length from one to 58 items, most of which were both valid and reliable. Additional evaluation tools were found that utilized direct audio- or videotaped recordings of teaching.ConclusionThis toolbox should facilitate program directors and others in assessing residents’ teaching skills and should promote rigorously conducted research on residents as teachers.

Evaluation and treatment of acute psychosis in children with systemic lupus erythematosus (SLE): consultation–liaison service experiences at a tertiary-care pediatric institution

Background Neurological and psychiatric manifestations of systemic lupus erythematosus (SLE) are prevalent in children with SLE. There are few data on the evaluation and management of psychotic features in children with this systemic autoimmune disorder. Objective The authors describe contemporary Child and Adolescent Psychiatry Consultation and Liaison service management of acute psychosis in children with lupus. Method The authors reviewed the records (2003–2008) of all pediatric SLE inpatients who were administered a traditional or atypical antipsychotic agent. They describe clinical features, initial and discharge mental status examinations, and inpatient psychotropic medication usage. Results Ten pediatric SLE patients (age 10–19 years) required psychiatric management for psychosis during the review period. Paranoid delusions (70%), visual hallucinations (60%), and auditory hallucinations (60%) were the most common psychotic symptoms documented. All children were initially treated with an antipsychotic medication. Seven children were maintained on an atypical antipsychotic during their hospitalization. Two children had extrapyramidal signs, but no other adverse events were documented. All children were improved at discharge, and 40% had complete resolution of psychosis; 8 of the 10 patients were discharged on a psychotropic medication. Discussion Psychotic manifestations associated with severe disease presentations were successfully treated by child psychiatrists. Atypical antipsychotics were well-tolerated and used as an adjunct to immunosuppressive regimens in these patients. Prospective studies are necessary to improve the care of children and adolescents with SLE and severe psychiatric manifestations.

The Texas Regional Psychiatry Minority Mentor Network: A Regional Effort To Increase Psychiatry’s Workforce Diversity

As highlighted by the Surgeon General’s 2001 report, there is a need to eliminate mental health disparities among ethnic minorities that are underserved (1). Healthcare disparities have resulted in decreased access to bilingual services for underrepresented and underserved minorities, increased risk for misdiagnosis, more inpatient hospitalizations, and less follow-up after hospitalizations (2, 3). The current mental-health workforce is also deficient with respect to diversity. In 2007, 16% of psychiatry trainees were from underrepresented groups such as African American, Hispanic American, Native American, or of Pacific Islander descent. Also, 24% were of Asian descent. Even smaller proportions of the membership of the American Psychiatric Association (APA) (4) or of psychiatric faculty (5) belong to the underrepresented ethnic groups. Although the need for mentoring has been described as an important part of academic medicine, fewer than 50% of medical students and, in some fields, less than 20% of faculty are reported to have a mentor (6). Members of underrepresented groups and women have been shown to have more difficulty in establishing a mentoring relationship (7). Many models have been implemented to improve the recruitment, retention, and promotion of minorities in medical school and academic departments across the country (8–12), although there is only generally limited evidence to support the efficacy of mentorship (13). In this article, we describe the development and implementation of a program of mentorship and cultural-competence education that targets the elimination of mentalhealth disparities. This program, the Texas Regional Psychiatry Minority Mentor Network (TRPMMN), has three goals: 1) to interest minority medical students in psychiatry as a profession; 2) to increase the cultural competence of mental-health providers; and 3) to increase retention through mentorship and support of the minority faculty. We also report data on some academic accomplishments of the medical students, residents, and juniorfaculty program participants from the first 18 months of the program’s implementation.

Use of aripiprazole in adolescents with a history of lupus-associated psychosis and refractory psychiatric manifestations

Neurologic and psychiatric manifestations are prevalent in children and adults with lupus (labeled by convention neuropsychiatric systemic lupus erythematosus or NPSLE). However, there is a paucity of data on the evaluation and management of NPSLE in youth, with only a few publications describing the use of atypical antipsychotics in children and adolescents with lupus. In children, aripiprazole, a D2/5-HT1A partial agonist, appears to cause less prominent metabolic derangements than other second-generation antipsychotics. This agent may be an important tool in the treatment of pediatric patients with lupus who are at risk for weight gain and dyslipidemia due to disease and corticosteroid effects. The authors present two cases in which psychiatric symptoms associated with treatment-refractory lupus responded to aripiprazole pharmacotherapy.