Edward K. Silberman

Growth hormone response to clonidine as a probe of noradrenergic receptor responsiveness in affective disorder patients and controls

The growth hormone (GH) response to the alpha-adrenergic agonist clinidine was blunted in 19 depressed patients compared to 20 controls. The difference remained significant when age- and sex-matches pairs of patients and controls were compared from this sample, either including or excluding subjects with elevated GH baseline levels. Plasma levels of free 3-methoxy-4-hydroxyphenyl-glycol (MHPG) were assayed in blood samples drawn just before the clonidine infusion. A modest negative correlation was found between the plasma MHPG values and the magnitude of the GH responses to clonidine, although baseline plasma MHPG levels were not significantly different between patients and controls. The diminished GH response to clonidine observed suggests that many depressed patients may have decreased alpha-adrenoreceptor responsiveness. Decreased responsiveness may in some cases be associated with relatively increased indices of presynaptic noradrenergic availability. Such a model might have implications for understanding the functional status of the noradrenergic neurotransmitter system in depressed patients and the possible subtyping of affective disorder patients.

Processing of Emotional Properties of Stimuli by Depressed and Normal Subjects

This study investigated whether depressed subjects differ from controls in their ability to appreciate emotional aspects of verbal material, or in their use of emotional qualities of stimuli in learning and remembering. When asked to rate the degree of emotionality of words, depressed subjects did so essentially identically with controls. However, despite apparently similar evaluatory processing, the depressed failed to remember as well as controls. Depressed subjects were more dependent than controls on both high emotionality and high stimulus concreteness for recognition memory, but were less benefited by these properties in free recall. While providing no evidence for deficits specific to emotionality, our results suggest that relatively shallow processing of semantic aspects of stimuli may be an important factor in the memory impairment of depression.

Recruiting Researchers in Psychiatry: The Influence of Residency vs. Early Motivation.

BackgroundThe declining numbers of clinician-researchers in psychiatry and other medical specialties has been a subject of growing concern. Residency training has been cited as an important factor in recruiting new researchers, but there are essentially no data to support this assertion. This study aimed to explore which factors have influenced motivation to conduct research among senior psychiatry residents.MethodsThe authors surveyed senior residents, inquiring about their level of interest in research, demographics, background, research experiences, and factors influencing motivation for research. The authors had confirmed participation from 16 of 33 residency programs with a class size of 10 or more. They received 127 responses, a 67% response rate, from participating programs.ResultsResidents with high stated interest in research differed from those with low and moderate interest in their research-intense post-residency plans. They were more likely to have graduate degrees. Those planning research careers had a consistent pattern of interest and involvement in research, starting well before residency. The majority of residents had had research exposure in college, but research involvement of those with very high versus lower interest diverged sharply thereafter. Those with high research interest were overwhelmingly male and tended to have lower debt than those with less interest.ConclusionThe great majority of residents appear to have decided whether or not to pursue a research career by the time they reached residency, and few of those with less than the highest research interest were enrolled in research tracks. Efforts to increase recruitment into research should center on identifying early developmental influences, eliminating barriers specific to women, and ensuring adequate funding to provide secure careers for talented potential researchers.

Impact of the Information Age on Residency Training: Communication, Access to Public Information, and Clinical Care

Access to technology in practice helps physicians manage information, communicate, and research topics; however, those in training receive almost no formal preparation for integrating web-based technologies into practice. One reason for this is that many faculty—aside from junior faculty or those in recent generations—did not grow up using Internet communication, may use it minimally, if at all, in their own practices, and may know little about its forms and varieties. This report presents a case to illustrate how these disparities may play out in the supervisory situation and makes suggestions about helping supervisors integrate technology-awareness into their teaching.

The march of symptoms in a psychotic decompensation. Case report and theoretical implications.

The onset and evolution of symptoms were studied in a female patient with a history of recurrent depressive psychoses. In each episode, her psychotic decompensations were characterized by an orderly and progressive sequence including similar psychological or somatic precipitants, mounting anxiety, nystagmoid eye movements associated with panic, unfolding delusions, and olfactory hallucinations, culminating in a complete psychotic regression. The evolving sequence repeated during each episode in the present case is compared with that of a similarly stereotyped progression of symptoms in temporal lobe and Jacksonian seizures. Kindling is suggested as a model relevant to the understanding of both epilepsy and the functional psychoses. Detailed observation of the evolution of symptoms during psychotic episodes may provide important clues to the underlying pathological anatomy and physiology of psychotic illness.

Learning priorities of staff, residents, and students for a third-year psychiatric clerkship.

Psychiatric clerkships combine classroom instruction with patient care. The different learning experiences in those two settings prompted the authors to survey 86 third-year medical student clerks, 44 staff psychiatrists, and 15 PGY-2 psychiatric residents about the importance of 31 skill and knowledge areas as learning goals for clerks. All groups of respondents included the following five items (16.2%) among the most important: performing a mental status examination, becoming comfortable with psychiatric patients, evaluating suicidally, developing interview skills, and suspecting drug and alcohol problems. The importance placed by staff on aspects of the doctor-patient relationship was not apparent to students, who perceived psychiatric diagnosis as receiving higher priority than staff intended. The implications of these findings for curriculum planning are discussed.

Practice and Career Outcomes of Double-Boarded Psychiatrists

BACKGROUND The practice patterns and career paths of physicians who are double-boarded in medicine, family practice, or neurology and psychiatry are not well understood. Given increased attention to integrated medical and psychiatric care, these individuals may play an important role. OBJECTIVE To compare the practice patterns and career paths of physicians who are double-boarded in medicine, family practice, or neurology and psychiatry with physicians who are boarded in general psychiatry, and among double-boarded physicians with various training sequences and specialty types. METHOD A survey was distributed to all physicians identified by the American Board of Medical Specialties (ABMS) as double-boarded in medicine, family practice, or neurology and psychiatry, and an equal number of physicians who are boarded in general psychiatry. RESULTS Compared with psychiatrists who are not double-boarded, double-boarded psychiatrists are significantly more likely to be older, more likely to be male, to practice in consultation-liaison or inpatient settings, and to assume positions of leadership in departments of psychiatry or in general health care organizations. Among the various groups of double-boarded physicians, 39% continue to practice their medical specialty in addition to their psychiatry practice, although this varies by medical specialty, sequence or type of program, and motivation for double-board training. CONCLUSION Double-boarded physicians appear to be a distinct group within psychiatry and may serve as an important bridge to the general medical environment because of their leadership roles and medical psychiatric practice patterns. Further understanding of their career development and roles is warranted.

Should We Train Psychiatrists as Primary Care Providers

The author discusses the proposition that psychiatrists would be appropriate primary physicians for specific types of patients. The author reviews the arguments for and against psychiatrists as primary care providers, proposes questions that must be addressed in training for such a role, and describes current models of primary care education and practice for psychiatrists. The author believes that primary care may be an appropriate career track within psychiatry and suggests that the development of family medicine may provide useful guidance in incorporating primary care functions into psychiatry.

Parallel Process and the Evolving View of the Therapeutic Situation

In the 60 years since Harold Searles (1955) wrote “The Informational Value of the Supervisor’s Emotional Experiences,” there have been no advances in psychodynamic psychotherapy that would invalidate his insights. He proposed that rather than being a “dispassionate mentor” whose passing emotional reactions are “merely incidental” to supervision, the supervisor, like the therapist, is inherently an emotional participant in the therapy; the supervisor’s inner responses to the supervisory situation can potentially shed light on the patient and the process of therapy. In the years following Searles’s paper, writers and researchers on psychoanalytic therapy confirmed his observations and expanded on his ideas. While Searles called the phenomenon reflection, subsequent writers labeled it parallel process, a term which has endured in the literature. Such processes prominently include oscillations between the therapist’s observation of versus identification with the patient, which are recapitulated in the interactions between therapist and supervisor (Arlow, 1963; Frances & Clarkin, 1981). Ekstein and Wallerstein (1958) suggested that impasses in treatment may stem from an emotionally distorted therapist– supervisor relationship, a proposition for which Doehrman (1976) later found empirical confirmation. The theoretical implications of parallel process and the empirical evidence base for the phenomenon have been summarized by McNeill and Worthen (1989). Differences between Searles’s view of parallel process and that of more recent writers are more of degree than kind. The examples he cites center on patients’ deficiencies or negative affects, such as confusion, disorganization, despair, anger, hostility, and greed, although he does devote a paragraph to the idea that positive emotions may be played out in parallel as well. Searles’s emphasis reflects the historical preoccupation of psychoanalytic psychotherapy with anxiety provoking negative affects and the defenses against them, often to the exclusion of positive emotions such as love, joy, forgiveness, and compassion (Vaillant, 2008). While it is a long-established notion that positive affect propels therapy and should not be interpreted, modern thinkers are more aware that patients’ strengths, not their deficits, make therapy possible and emphasize the need to pay explicit attention to them in their interpretations. The advent of “positive psychology” (Seligman & Csikszentmihalyi, 2000) is one among various manifestations of this evolution. Were he writing today, Searles might have devoted more attention

An Ounce of Prevention: A Public Health Approach to Improving Physician Well-Being

The physician workforce is facing a crisis, with increasing numbers of physicians reporting distress, career dissatisfaction, burnout, and depression [1, 2]. Impaired well-being is a pressing issue for physicians at all career stages, ranging from medical students to practicing physicians [3, 4]. However, residents are at particularly high risk, enduring long hours, and high stress, with little control over their lives [4]. Improving physician well-being has been identified as an urgent national priority within the medical community [5]. Numerous interventions to improve physician well-being have been proposed and described in the literature. However, many interventions have not been rigorously studied, and those that have, often report only small benefits [6]. It remains unclear how effective any single intervention will be in improving physician well-being on a large scale [7]. Furthermore, educators and administrators who seek to implement well-being interventions in their own institutions may be faced with a long list of potential options, with little guidance about how to choose. Should one implement mindfulness training or burnout screening? Balint groups or increased ancillary staff? Reducedfee mental health treatment or a coaching program? As with any complex public health issue, a comprehensive and integrated approach is needed in order to make a significant impact. To our knowledge, no clear conceptual model has yet been proposed in the literature to help better describe, categorize, and organize the myriad potential interventions available to promote physician well-being.