Jennifer L. Derenne

Teaching a Systematic Approach for Transitioning Patients to College: An Interactive Continuing Medical Education Program

ObjectiveThe purpose of this article is to determine the effectiveness of a hands-on continuing education program for practicing child and adolescent psychiatrists (CAPs) with a focus on best practices in transitioning psychiatric patients to college. The plan was to build on the unique knowledge and skill set of CAPs, use audience and facilitator feedback from prior programs to inform program content, structure, and format, and incorporate findings from the evolving literature.MethodsA 3-h interactive workshop was designed with an emphasis on audience participation. The workshop was divided into three main segments: didactics, whole group discussion/brainstorming, and small group discussion of illustrative case vignettes.ResultsImprovements and changes in knowledge, skills, and attitudes related to transition planning were identified by program participants. Quantitative feedback in the form of course evaluations, pre- and posttests, and a 6-month follow-up questionnaire indicate that the use of interactive teaching techniques is a productive learning experience for practicing CAPs. Qualitative feedback was that the discussion of the case vignettes was the most helpful.DiscussionThe use of a workshop format is an effective strategy to engage practicing CAPs in learning about and implementing best practices to support the transition of their patients to college and into young adulthood. Comprehensive and proactive transition planning, facilitated by clinicians, should promote the wellness of college-bound patients and help to reduce the potential risks in the setting of an upcoming transition.

Psychiatry’s Role in Teaching Medical Students, Psychiatric Residents, and Colleague Physicians About Human Sexuality

As psychiatrists, we seek to understand and foster mental health in relation to many aspects of life, including intimate life and the deeply personal domain of sexuality. In this special issue of Academic Psychiatry, we take a careful look at psychiatry’s role in teaching medical students, psychiatric residents, and colleague physicians about human sexuality and the sexual concerns that arise in clinical care. The authors in this issue discuss the ways in which medical professionals address sensitive sexual healthrelated topics with their patients and how the medical system at times fails patients by neglecting the important role of sexual health in human health and well-being. The work in this collection articulates critical implications for undergraduate medical curricula and psychiatric training programs. And, taken together, the collection makes the persuasive argument that assessment of sexual function and treatment of sexual concerns is certainly within the purview—and some would suggest the imperatives—of the field of psychiatry. Sexual concerns are common. Most people believe that healthy sexual function is an extremely important factor in one’s quality of life (1). Individuals rely on clinicians to answer questions about normal sexual functioning, safe sexual practices, contraception, family planning, and sexually transmitted illnesses. Clinicians, in turn, are better able to diagnose and treat medical conditions when their patients are honest with them about sexual practices that may be relevant to their medical concerns. Sexual function may be compromised by common medical conditions such as diabetes mellitus (2), or by the hormonal changes associated with normal aging (3). In some cases, sexual dysfunction may be related to psychological concerns such as paraphilias (4), anxiety, stress (5), or the direct result of psychopharmacologic treatments for mood disorders, anxiety, or psychosis (6). Patients do not bring sexual concerns to their physician’s attention. Despite the fact that healthy sexual function is important, patients report that they feel uncomfortable discussing such issues with their physician. Studies show that patients feel uncomfortable talking about sexual issues and believe that their clinician will be similarly ill at ease (7). More concerning are the beliefs that they will be judged as being “abnormal” and the fears that their concerns will not be validated or taken seriously. Patients also report that they do not ask their medical provider about sexual problems due to concerns that there will not be an effective intervention or treatment available to them (7). Lesbian, gay, bisexual, and transgender (LGBT) patients, in particular, are more likely not to seek medical care— and therefore neglect their personal health—due to barriers accessing the health care system such as systemic discrimination, ineligibility of extended health care coverage to same-sex partners, and a dearth of health data collection for LGBT populations (8). A surprising number of physicians do not feel comfortable discussing sexual issues. Fewer than 50% of U.S. and Canadian medical schools have formal curricula ( 2 hours) devoted to teaching human sexuality, and those that do have a very limited amount of time to cover the information in a way that leaves trainees feeling adequately prepared (9). The majority of graduates feel that they lack Received May 9, 2010; revised May 28, 2010; accepted June 1, 2010. Dr. Roberts is Chairman and Katharine Dexter McCormick and Stanley McCormick Memorial Professor, Department of Psychiatry and Behavioral Sciences, at Stanford University. Dr. Derenne is affiliated with the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin in Milwaukee. Address correspondence to Jennifer Derenne, M.D., Medical College of Wisconsin, Department of Psychiatry and Behavioral Medicine, 8701 Watertown Plank Road, Milwaukee, WI 53226; JDerenne@mcw.edu (e-mail). Copyright

Clinical Ratings Scales and Assessment in Eating Disorders

Eating disorders have one of the highest mortality rates among psychiatric condition. However, these conditions are difficult to detect by both primary-care physicians and mental health professionals. As a result, eating-disordered patients often go unrecognized and untreated. The utilization of standardized rating scales and structured interviews can increase the recognition of these conditions and also improve treatment planning and outcome monitoring. This chapter provides a detailed review of the available self-report instruments and semi-structured interviews for the eating disorders.

A Model CSMH Curriculum for Child and Adolescent Psychiatry Training Programs

Child and adolescent psychiatrists (CAP) care for high school students preparing to enter college. They also may continue to see students while on school vacations and may care for college students in various settings (emergency room, inpatient hospital unit, private practice, college student health service, or counseling center). As increasing numbers of students with mental health diagnoses pursue secondary education, CAP need to be knowledgeable about campus systems of care, principles of transition, and privacy and educational laws affecting college students. This article describes an informal needs assessment of general CAP members of the American Academy of Child and Adolescent Psychiatry and details the results of a survey of CAP program directors on training opportunities in college student mental health (CSMH). The authors present a sample curriculum for a clinical rotation in CSMH, as well as providing ideas for core didactic lectures, and proposing the development of online resources to reduce the burden of creating new lectures and standardize experiences among training programs.

Body Image, Media, and Eating Disorders—a 10-Year Update

More than 10 years after its publication in 2006, our media column “Body Image, Media, and Eating Disorders” [1] consistently remains a popular download from Academic Psychiatry. No doubt, interest in body image and eating disorders continues to be strong. Our previous column focused largely on the role of body image in more traditional media, e.g., television and films. However, in the digital age, our daily media diet has shifted dramatically to computers and handheld digital devices. In the time that has passed, the latest trends in fashion, diet, and exercise have changed, and our reliance on Internet-mediated activities has skyrocketed. While some progress has been made in terms of body positivity and acceptance, concerns about eating disorders remain. In this update, we will focus largely on the sweeping impact of the Internet and digital media on body image and eating disorders. Probably the most noteworthy change in the last 10 years has been the impact of ubiquitous Internet access and mobile smartphones. Having immediate access to information and communication with friends and family is associated with both challenges and opportunities. Cell phones have allowed parents to contact their children at any time (and vice versa), and for kids, the instant access to communicate with friends is highly valued. On the other hand, many youngsters also are stressed and frustrated by the awesome ability of others to post commentary, photos, and criticism. At worst, peers can block each other, resulting in widespread ostracism and shame. Digital media has taken on, for many youth, the role of an ongoing “reality tv” show, fostering perpetual drama and, for some, creating more stress than comfort and connection. Digital media, particularly those using images, such as Instagram or Snapchat, raises in many more concerns about how they “appear” to others, and may well foster greater concerns and self-consciousness about body image. The constant availability of relatively sophisticated cameras and photo editing software has led to the development of “selfie” culture. Individuals experiment with snapping multiple photos from the most flattering angles and poses, as well as using filters, selfie sticks, cropping, and photo shopping to capture a flawless image for posting. This obsession with perfection has further increased the focus on ideal body image, including pressure to conform to the young, thin ideal, which continues to be valued in our society. For those who are vulnerable to comparing their bodies to others, this may trigger body dissatisfaction, increased drive for thinness, and the development of disordered eating. However, the research on this is mixed— some studies suggest a correlation between media exposure and body image [2–5], while others do not [6]. It is possible that media does not solely influence the thin ideal; rather, the images seen in photos and videos reflect what society and peers have already idealized [6]. Alternately, it is reasonable to consider a bidirectional relationship in which society and media affect each other equally. Social media are forms of electronic communication, typically apps and websites, used to create online communities to share content such as information, ideas, blogs, personal messages, photos, articles, and videos. They include sites like Facebook, Instagram, YouTube, Snapchat, Vine, Twitter, Tumblr, and Google +. As the Internet has become more prominent in our lives, these sites have proliferated and are widely used across age groups, although they are officially restricted to those older than 13 years. Seventy-one percent of 13–17-year-olds surveyed by the Pew Research Center in * Jennifer Derenne jderenne@stanford.edu

Helping Patients and Families Navigate the Transition to College: Common Themes, Lessons Learned, and Best Practices

The clinical cases in this book serve to highlight a number of strategies and themes that can be used to guide the development of best practices in transition preparation and planning for youth with mental health conditions headed to college. Mental health care transition, in this context, demands a team effort involving the young person, his/her family, high school personnel, treatment providers on both sides of the transition, and other designated supporters. A developmental perspective is key to the process, acknowledging the importance of the young person in decision-making and recognizing that age-appropriate support and structure before, during and after the transition makes sense for many student/patients. Clinicians need to assess the readiness of patients for the transition to college across multiple domains of function and should be prepared to raise difficult issues such as mental stability, the stresses inherent in what is usually considered a happy milestone, alternative post-secondary options and paths, over-reliance on parental and school supports, and the need for ongoing care once on campus. Comprehensive and well-communicated plans for continuity of care, including relapse prevention plans and services through the school’s ODS, are an important aspect of transition preparation and planning. Mental health practitioners have important roles to play in facilitating safe and effective transitions of their patients to college.

“This Beer Should Do the Trick!”: Heading to College with Social Anxiety Disorder

Social Anxiety Disorder may adversely impact transition to college. Alcohol and cannabis can be misused or abused in an attempt to self-medicate symptoms. Academic underachievement is common due to lack of self-advocacy, fear of public speaking, and avoidance of classes. This chapter describes the case of a young woman diagnosed with Social Anxiety Disorder and Major Depression Disorder prior to college matriculation. While her symptoms were relatively stable prior to starting college, she experiences a relapse of both anxiety and depressive symptoms in the context of disrupted treatment. This contributes to misuse of alcohol as well as declining academic achievement. Discussion focuses on the need to adequately prepare the patient and family for the transition to college through psychoeducation, establishing a treatment team on or near campus, anticipating potential difficulties with academics and social relationships, and developing a plan for accessing campus resources and supports. Other topics discussed include introversion, social maturity, and developmental readiness for college.

Juggling Priorities: Staying Sober in College as a Nontraditional Student

Nontraditional students are defined as those who (1) are >24 years old, (2) are financially independent from their parents, (3) are working full time, (4) are attending classes part time, (5) have dependents, (6) are single parents, and (7) have a GED or high school equivalent. Nontraditional students are prone to higher levels of stress and anxiety and are more likely to leave school before earning a degree. This chapter describes the case of a nontraditional college student, who decides to return to college after a failed transition from high school to community college several years earlier. The student is also 5 years sober from alcohol and struggles to find substance-free activities on campus. Discussion focuses on understanding the ways that nontraditional students feel pulled between family and academic responsibilities, suggests ways to help nontraditional college students feel connected to their peers, and reviews ways that universities can promote a substance-free culture on campus.

The Range of Postsecondary Options and Thinking About the Differences Between High School and College

In the not too distant past, college was reserved for those who were exceptionally academically gifted or wealthy. Times have changed, and some post-high school training is now generally necessary to enter the workforce. In many communities, attending college immediately following high school is the norm and is considered the expected developmental path for many young people. Parents, teachers, coaches, and even physicians often assume that young people want to go to college, and that they should do so right away. Students and families may resist deviating from this path, as many tend to want to stay in step with their peers. They may also feel pressure to attend a parent’s alma mater, or to follow a similar path as older siblings or extended family members. However, not every student is cut out for college, and others benefit from careful planning to facilitate a successful transition. It is important for family and medical providers to understand this and to be receptive to considering alternate pathways.

“Anxiety Galore”: Transition to College with Generalized Anxiety Disorder

Generalized Anxiety Disorder is a common mental health concern that often begins in adolescence and, unfortunately, persists into adulthood. Symptoms may fluctuate based on stressful life events, such as transitioning from high school to college. This chapter presents the case of a young man who has struggled with symptoms of anxiety since childhood and describes how his symptoms cause impairment as he makes the transition from high school to college. It details how to best help individuals with anxiety prepare for the start of college while also navigating the college mental health system and optimizing the appropriate services and supports. Finally, as alcohol and drugs can be common, yet unhealthy coping mechanisms in this population, there is discussion of strategies to optimize treatment adherence and reduce temptation to misuse alcohol and benzodiazepines.