George A. Keepers

Prediction of neuroleptic-induced dystonia

For patients receiving neuroleptics, age, sex, neuroleptic potency, and dose all influence the likelihood of a dystonic reaction. Little is known, however, of the relative importance of these factors or of the feasibility of predicting dystonia in individual patients.We reviewed 135 charts of psychotic inpatients to examine these factors and their usefulness in predicting dystonia. Age, sex, neuroleptic type, dose, and occurrence of dystonia were recorded for the first 4 days of drug treatment and were used to construct a linear discriminant function that classified the cases as to whether dystonia was expected. Internal cross-validation was performed, and the error rate of this classification procedure was calculated. Forty-nine (36%) of the patients had dystonia. A younger age was the most powerful predictor of dystonia. Male gender was second in predictive power with minor effects from neuroleptic dose and potency. The overall error rate (false-positive and false-negative errors combined) of the discriminant function was 30%. These results suggest the possibility of predicting dystonia in individual patients but should be regarded with caution since the predictive procedure has not been tested prospectively. If confirmed, these data may allow treatment strategies that protect patients from dystonia while sparing patients not at risk unnecessary treatment with antiparkinson agents. (J Clin Psychopharmacol 1987;7:342–345)

Acute extrapyramidal syndromes in neuroleptic-treated elders : a pilot study

The incidence, morbidity, and risk factors for acute extrapyramidal syndromes (EPS) such as akathisia and drug-induced parkinsonism (DIP) in neuroleptic-treated elders have not been systematically explored. This study presents data on 17 elderly patients who were prospectively examined for up to 4 weeks for acute EPS, functional and cognitive status, and behavioral disturbances. Seventy-one percent of subjects developed DIP, and 18% developed akathisia. Predictors of DIP included pre-neuroleptic treatment parkinsonian signs and neuroleptic dose, despite use of low doses of neuroleptics. Development of acute EPS was associated with failure to improve behaviorally. New-onset urinary incontinence was the most common functional abnormality. (J Geriatr Psychiatry Neurol 1991;4:222-225).

The milestones for general psychiatry residency training

The Accreditation Council of Graduate Medical Education’s (ACGME)Milestones project represents the most recent development in the evolution of medical training in the USA. Beginning with the establishment of the American Medical Association (AMA) in 1845, medical training in the USA has been increasingly focused on the development of high caliber physicians whose practice is scientifically based. The Association of American Medical Colleges (AAMC) was established in 1876 to reform medical education which had previously been entirely unregulated but with minimal practical effect. The AMA, however, through the formation of its Council on Medical Education [5, 6] was able to influence training in medical schools, hospital internship programs, and specialty training. Abraham Flexner’s report for the Carnegie Foundation published in 1910 essentially established our current system of training and resulted in the closure of inadequate schools and curricular reform that banished naturopathy and other alternative practices from medical education. Flexner strongly endorsed the residency program established by John Hopkins in 1889 that would subsequently become the framework for all residency training in the USA [4]. Subsequently, the AMA began a program, in 1914, of evaluation and approval of hospital internships and published the “Essentials of Approved Residencies and Fellowships” in 1928. The American Board of Psychiatry and Neurology (ABPN), established in 1934, was charged by the AMA, American Psychiatric Association (APA), and American Neurological Association with the task of establishing training standards in psychiatry and neurology as well as the certification of specialists in these areas [5]. In 1940, the AMACouncil onMedical Education in conjunctions with the American Board of Internal Medicine and the American College of Physicians established the Conference Committee on Graduate Training in Internal Medicine, a forerunner of the ACGME Residency Review Committees (RRC). The American College of Surgeons and American Board of Surgery followed suit in 1949. With the establishment of Medicare and federal funding for residency training, academic educators realized that the multiple councils then in existence with widely varying standards for approval of training programs required reform. The need for oversight and uniformity of standards was thought compelling and was supported by the AMA, other medical groups, and the government. In 1972, the AMA brought together the AMA, the American Board of Medical Specialties (ABMS), the American Hospital Association, the AAMC, and the Council ofMedical Specialty Societies to form a Liaison Committee for Graduate Medical Education (LCGME) to coordinate and oversee the activities of the several independent RRC’s then in existence [7]. A more independent and streamlined organization was required to accomplish these tasks, and the ACGME replaced the LCGME in 1981. In the following years, our current system of RRC’s, program requirements, and periodic accreditation site visits was developed. The milestones for residency training represent the next step in the outcomes-based accreditation project of the ACGME [10, 14]. Milestones are based on the six core competencies for graduate medical education established in 1999 by the ACGME and the ABMS and describe specific behaviors, attributes, or outcomes to be demonstrated by residents as they progress through training. The core competencies focus on educational outcomes, as opposed to educational process, as a measure of success in achieving training goals and objects. The US Department of Education mandated the use of outcome measures for all educational programs receiving federal funding in the 1980’s, including those for accreditation [1]. The ACGME C. R. Thomas (*) University of Texas Medical Branch at Galveston, Galveston, TX, USA e-mail: crthomas@utmb.edu

Psychiatric Resident and Faculty Views on and Interactions With the Pharmaceutical Industry

ObjectiveSales visits, or detailing, by pharmaceutical industry representatives at academic institutions has been increasingly criticized. The authors surveyed psychiatric residents and faculty members on their views and interactions with representatives of the pharmaceutical industry.MethodsIn 2007, a 46- item online survey measuring attitudes toward and interactions with pharmaceutical industry representatives was sent to 49 faculty psychiatrists and 40 psychiatric trainees (residents and fellows) at a Northwest academic medical center.ResultsSixty- five percent (N=58) of surveys were completed. Two- thirds of respondents did not agree that pharmaceutical representatives have an important teaching role. Only 24% of faculty and 18% of trainees agreed that pharmaceutical representatives provide useful and accurate information on new drugs. Forty- one percent of faculty and 53% of trainees agreed that pharmaceutical representatives should be restricted from making presentations on campus. Trainees were less likely than faculty to agree that they would maintain contact with representatives if no gifts or food were distributed. Nevertheless, most respondents endorsed that pharmaceutical companies supported important conferences, and more than 90% had attended an industry- sponsored event in the previous year. In open- ended questioning, respondents revealed worries that bans would undermine the ability to secure national speakers and to support other activities that residents valued.ConclusionFaculty and psychiatric residents and fellows do not view pharmaceutical representatives as having an important teaching role and mistrust the information they offer but believe that loss of industry financial support does adversely affect educational and other highly valued activities. They favor greater policy restrictions but do not support an outright ban on pharmaceutical support.

Medical student views on interactions with pharmaceutical representatives.

ObjectiveIn 2006, the Housestaff Association presented the Dean at Oregon Health and Science University (OHSU) with a proposal to effectively end the influence of the pharmaceutical industry on campus. The Dean convened a workgroup to examine the issue, and faculty, residents, and medical students were surveyed on their views and interactions. Authors present here the responses from medical students.MethodsA web-based, anonymous survey was sent to all OHSU medical students in 2007; 59% completed it. The survey included items measuring attitudes about the pharmaceutical industry and interactions with pharmaceutical representatives (PRs).ResultsOnly 5% of clinical and 7% of preclinical students agreed that PRs have an important teaching role, and fewer than 1 in 6 believed that PRs provided useful and accurate information on either new or established drugs; 54% of clinical students indicated that PRs should be restricted from making presentations on campus, versus 32% of preclinical students, and only 30% of clinical students agreed that accepting gifts had no impact on their own prescribing, versus 50% of preclinical students. Students who acknowledged the influence of PRs and perceived less educational benefit were less likely to accept gifts such as textbooks; however, 84% of clinical students had attended an on-campus event sponsored by a pharmaceutical company in the previous year.ConclusionOnly a small proportion of OHSU medical students value interactions with PRs, but many still attend events sponsored by pharmaceutical companies.

Geriatric Training in Adult Psychiatry Residency Training Programs

The authors surveyed all Accreditation Council for Graduate Medical Education-accredited psychiatry residency training programs in the United States to determine 1) the type and amount of geriatric training provided, and 2) differences in the programs that door do not offer geriatric training for residents. Substantial geriatric training was offered in 50.7% of all programs. Compared with the programs without geriatric training, these programs were more likely to be in a Psychiatry Department, with a Division of Geriatric Psychiatry and/or a geriatric fellowship program. These data suggest that current geriatric training in many psychiatry residency programs is inadequate to prepare residents for treating elderly patients and to encourage residents to pursue careers in geriatric psychiatry.

Harnessing Technology to Implement Measurement-Based Care

A significant gap exists between the outcomes of randomized controlled trials (RCTs) and treatment-as-usual in mental health care—this observation has been thoughtfully reviewed by Fortney et al. [1] and is well supported by the primary literature [2–7]. The superior response of psychiatric symptoms to treatment under clinical trial conditions as compared to conventional conditions has been attributed to clinical trial protocols’ utilization of measurement-based care (MBC), defined as the routine monitoring of mental health treatment progress using evidence-based patient-reported outcome measures, to guide implementation of algorithm-based treatments [1]. RCTs investigating the impact of patient-reported outcome measures specifically have consistently demonstrated a significant improvement in treatment outcomes [8, 9]. Evidence is also emerging that the framework of MBC may be added to almost any treatment from medication management to various psychotherapies [10, 11]. Despite this, less than 20% of psychiatrists consistently use MBC in their treatments [12], a statistic uncovering a significant lag in translating MBC research into clinical practice. With strong evidence for effectiveness, why is MBC not the current standard of care? While literature specifically addressing successful models of MBC training and implementation in psychiatry remains sparse, studies show that in order for innovations in clinical practice across medical specialties to be successfully adopted, these changes must be effective, applicable to a large population, cost neutral, positively correlated with patient satisfaction, and relatively straightforward to implement [13]. New technology, known as a measurement feedback system, can automatically assign patient-reported outcome measures based on diagnostic symptom criteria, then score, graph, and norm the completed measure(s), allowing clinicians immediate access to clinically actionable data; measurement feedback system technology renders adoption of MBC immediately practical in domains of efficacy, applicability, and patient satisfaction. This means of collecting data is patient-centered in that patients may complete assigned measures outside of the clinical space, on their own time, using any web-enabled personal electronic device (e.g., smartphone, tablet, personal computer). Integrating a measurement feedback system into the electronic health record (EHR) creates a seamless flow of objective data documentation that enhances the presence of a patient’s own responses and voice within their medical record. These features support the Quadruple Aim of improving patient outcomes and experiences, reducing healthcare costs, and improving clinician satisfaction. For the clinician, EHRintegrated patient-reported outcome measures allow for monitoring of treatment impact both at the level of the individual patient and that of the larger clinical population. Current models of reimbursement seem to deter the adoption of innovative technologies in medicine, as there is minimal funding or reimbursement to guarantee return on investment. However, the time to implement MBC is now. Payers and accreditation bodies will soon require reporting of patientreported outcome measures under programs such as MACRA [14], thus there is a looming imperative for practicing psychiatrists to utilize MBC. More basically stated, if the underresourced mental health system is to provide best care to patients, psychiatry needs to become more receptive to patient feedback about the efficacy of treatment provided. However, many questions arise when considering the practical aspects of implementing MBC. How can accessibility and quality of care be improved without adding administrative burden or contributing to provider burnout? What options are feasible to implement? Do currently available products have long-term viability? Implementation of MBC via a measurement feedback system can address many of these concerns while offering benefits to a variety of stakeholders from patients to administrators. In psychiatry practices, which use fewer support staff than other specialties, clinicians may make use of measurement feedback system technology to track outcomes while reducing administrative burden and enhancing * Whitney E. Black blackwh@ohsu.edu

Timing of neuroleptic-induced dystonia and dystonia pathophysiology

The length of time following initiation of antipsychotics but preceding episodes of acute dystonia (AD) has implications regarding AD pathophysiology. In animal models AD is observed during rising neuroleptic levels suggesting dopaminergic blockade as pathogenic. In humans, there are reports of AD during low, falling serum levels consistent with the “miss-match” hypothesis of AD. To clarify the time course of AD we reviewed charts of 263 neuroleptic treated patients for AD. Reviewers noted the time of AD and the drug treatment. Data were analyzed to determine the distribution of AD following neuroleptic dosing. Timing data for the 71 patients with AD showed AD occurring on average 10.5 hours following last neuroleptic dose. Distribution of the ADS was bivariate (group means = 6.1 and 20.6 hours). 85.5% of ADS occurred during falling serum neuroleptic levels. Average daily neuroleptic dose was 517 CPZ equivalent/day though 38.1% of AD occurred at doses less than 250 CPZ equivalent/ day. Neuroleptic drug, dose, and dosing schedule did not explain the bivariate distribution. Implications of these data for AD pathophysiology will be discussed.