Joseph Stoklosa

Human Trafficking, Mental Illness, and Addiction: Avoiding Diagnostic Overshadowing

This article reviews an emergency department-based clinical vignette of a trafficked patient with co-occurring pregnancy-related, mental health, and substance use disorder issues. The authors, including a survivor of human trafficking, draw on their backgrounds in addiction care, human trafficking, emergency medicine, and psychiatry to review the literature on relevant general health and mental health consequences of trafficking and propose an approach to the clinical complexities this case presents. In their discussion, the authors explicate the deleterious role of implicit bias and diagnostic overshadowing in trafficked patients with co-occurring addiction and mental illness. Finally, the authors propose a trauma-informed, multidisciplinary response to potentially trafficked patients.

Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.

ObjectiveAlthough it is widely acknowledged that second-generation antipsychotics are associated with cardiometabolic side effects, rates of metabolic screening have remained low. The authors created a quality-improvement (QI) intervention in an academic medical center outpatient psychiatry resident clinic with the aim of improving rates of screening for metabolic syndrome in patients being prescribed antipsychotic medications.MethodsThe core components of the QI intervention included resident education and creation of a metabolic screening bundle for the electronic medical record. Quarterly audits of individual patient electronic medical records assessed whether a patient was currently prescribed antipsychotics and whether metabolic-syndrome screening had been documented at any time in the preceding 12 months.ResultsIn each audit period, from 131 to 156 patients (30%–36% of total clinic sample) were prescribed antipsychotic medication. After the intervention, rates of documentation of the components of the metabolic screening bundle increased between 3.5- and 10-fold (final rates: 39% for blood pressure, 44% for BMI, and 55% for glucose and lipid panel). Rates of documenting the full bundle increased nearly 30-fold (final rate: 31%).ConclusionProvider-education combined with introduction of a documentation bundle in the electronic medical record increased rates of documented metabolic screening in patients being prescribed antipsychotic medications by psychiatry residents.

Simulation-Based Training for Residents in the Management of Acute Agitation: A Cluster Randomized Controlled Trial

ObjectiveSimulations are used extensively in medicine to train clinicians to manage high-risk situations. However, to our knowledge, no studies have determined whether this is an effective means of teaching residents to manage acutely agitated patients. This study aimed to determine whether simulation-based training in the management of acute agitation improves resident knowledge and performance, as compared to didactic-based instruction.MethodsFollowing a standard lecture on the management of agitated patients, first-year psychiatry residents were randomized (in clusters of three to four residents) to either the intervention (n = 15) or control arm (n = 11). Residents in the intervention arm then received simulation-based training on the management of acute agitation using a scenario with an agitated standardized patient. Those in the control arm received simulation-based training on a clinical topic unrelated to the management of agitation using a scenario with a non-agitated standardized patient who had suffered a fall. Baseline confidence and knowledge were assessed using pre-intervention self-assessment questionnaires and open-ended clinical case vignettes. Efficacy of the intervention as a teaching tool was assessed with post-intervention open-ended clinical case vignettes and videotaped simulation-based assessment, using a different scenario of an agitated standardized patient.ResultsResidents who received the agitation simulation-based training showed significantly greater improvement in knowledge (intervention = 3.0 vs. control = 0.3, p = 0.007, Cohen’s d = 1.2) and performance (intervention = 39.6 vs control = 32.5, p = 0.001, Cohen’s d = 1.6). Change in self-perceived confidence did not differ significantly between groups.ConclusionsIn this study, simulation-based training appeared to be more effective at teaching knowledge and skills necessary for the management of acutely agitated patients, as compared to didactic-based instruction alone. Subjective evaluations of confidence in these skills did not improve significantly compared to controls, corroborating the need for using objective outcome measures when assessing simulation-based training.

Rational Antipsychotic Choice: Weighing the Risk of Tardive Dyskinesia and Metabolic Syndrome

Schizophrenia is a devastating, chronic illness that typically requires lifelong treatment, most often including antipsychotic medications.1 Long-term medication treatment implies prolonged, and sometimes cumulative, exposure to the side effects of antipsychotics.2 Clinicians are faced with a choice as to whether to prescribe a first-generation antipsychotic (FGA) or second-generation antipsychotic (SGA) for their patients with schizophrenia; how to make an informed choice has become an important topic for all clinicians. SGAs were initially touted as promising both improved efficacy and fewer side effects, specifically extrapyramidal side effects (EPS) and tardive dyskinesia (TD), when compared to FGAs. Current treatment algorithms for schizophrenia,3,4 including the American Psychiatric Association’s guidelines,5 list SGAs as the first-line treatment of schizophrenia, with FGAs often not featured until several steps into the algorithm.

Clinical Case Vignettes: A Promising Tool to Assess Competence in the Management of Agitation.

ObjectiveWhile standardized patients (SPs) remain the gold standard for assessing clinical competence in a standardized setting, clinical case vignettes that allow free-text, open-ended written responses are more resource- and time-efficient assessment tools. It remains unknown, however, whether this is a valid method for assessing competence in the management of agitation.MethodsTwenty-six psychiatry residents partook in a randomized controlled study evaluating a simulation-based teaching intervention on the management of agitated patients. Competence in the management of agitation was assessed using three separate modalities: simulation with SPs, open-ended clinical vignettes, and self-report questionnaires.ResultsPerformance on clinical vignettes correlated significantly with SP-based assessments (r = 0.59, p = 0.002); self-report questionnaires that assessed one’s own ability to manage agitation did not correlate with SP-based assessments (r = −0.06, p = 0.77).ConclusionsStandardized clinical vignettes may be a simple, time-efficient, and valid tool for assessing residents’ competence in the management of agitation.

Psychosocial Difficulties in Adolescent Idiopathic Scoliosis: Body Image, Eating Behaviors, and Mood Disorders

OBJECTIVE To examine the recent literature on psychologic comorbidities prevalent in youth living with adolescent idiopathic scoliosis (AIS)-including body image, eating behaviors, and mood disorders-to improve patient outcomes. METHODS A comprehensive literature review was performed using the PubMed database. Eligible studies were extracted based on defined inclusion criteria, and the effects of AIS on psychologic comorbidities were evaluated. Studies were categorized and analyzed based on 3 recurrent themes: body image, eating behaviors, and mood. RESULTS Body image presents the most important link between psychosocial difficulties and AIS. Self-reported body image is a significant factor for successful treatment outcomes in AIS. As such, specific patient-reported outcome measures have recently been developed and validated to aid in the treatment of AIS. Although patients with AIS consistently demonstrate altered anthropometry compared with their healthy counterparts, links between these factors and pathologic behaviors, such as abnormal fear of gaining weight or disordered eating, are not clear. Equally unclear is the association between AIS and altered moods, notably depression and anxiety, because of the wide variety of disparate instruments used to measure mood disorders in patients with AIS. CONCLUSIONS Patients with AIS undergoing treatment often face psychosocial difficulties. Together, the current literature points to a growing understanding and appreciation of the psychosocial aspects of AIS, but a clear need for more study is needed to optimize treatment of these patients.

Intensely Suicidal Behavior with a First Manic Episode

CASE HISTORYPresenting ProblemMs. A is a 20-year-old single woman with a history of major depressive episodes who was brought to an emergency department by her parents after she attempted to jump off the roof of their vacation home in the setting of several days of poor sleep, decreased appetite, ra