Marshall Forstein

The Use of Palliative Sedation for Existential Distress: A Psychiatric Perspective

&NA; This article introduces a structure for standardization in the ongoing debate about the application of palliative sedation for psychological and existential suffering at the end of life. We differentiate the phenomenon of existential distress from the more general one of existential suffering, defining existential distress as a special case of existential suffering that applies to persons with terminal illness. We introduce both a clinical classification system of existential distress based on proximity to expected death and a decision‐making process for considering palliative sedation (represented by the mnemonic, TIRED). Neuropsychiatric clinical cases will be used to demonstrate some of the concepts and ethical arguments.

Teaching psychiatry residents to work at the interface of mental health and primary care

The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.

Commentary on Cheuvront's “High-Risk Sexual Behavior in the Treatment of HIV-Negative Patients”

ABSTRACT This paper discusses Cheuvronts High-Risk Sexual Behavior in the Treatment of HIV-Negative Patients. Unprotected sexual behavior between gay men evokes powerful feelings as the AIDS epidemic continues to expand. Simple notions of unprotected sex as self-destructive belie the complex and varied meanings of sexual behavior in men who grow up in a homophobic and alienating society. The very concept of risk-taking as pathological, rather than a manifestation of self-care, must be examined in a cultural and social context. Therapists have an obligation to look beyond formulaic interpretations of behavior to help gay men understand whether engaging in unprotected sex is a reasonable calculated risk in the interest of psychological and spiritual self care, or a consequence of some internal struggle or unmet needs which are indeed destructive of the self.

AIDS: A History

The AIDS epidemic transformed the lives of a generation of gay men and lesbians in ways that we could never have imagined. More than three decades after the first cases were evident, not one social, economic, political, and scientific institution in the world has escaped the impact of HIV/AIDS. What follows is a personal chronicle of my journey through the history of HIV, focusing on some of the issues that have transformed the lesbian, gay, bisexual, and transgender communities, and psychiatry and medicine. For those coming to consciousness after 1981, AIDS has always been part of the world. Younger people often do not know the history of the civil rights or the gay liberation movement. The HIV pandemic continues to plague the worlds most vulnerable people. The obstacles most in the way of eradicating this virus include religious prohibitions against same sex behavior, poverty, lack of access to medical and mental health care. Medical science has transformed the infection from an acute, lethal disease to a chronic condition where access to care and support is available. What stands in the way now are the coexisting epidemics within our nations and the stigma associated with sexual and substance use behaviors.

Psychodynamic Psychotherapy with Gay Male Couples

This chapter will explore theoretical and clinical issues which affect the psychodynamic assessment and treatment of gay male couples. I shall discuss the social and intrapsychic development of the gay individual and suggest how this development affects same-sex coupling.

Developing a Collaborative Care Training Program in a Psychiatry Residency

BACKGROUND Collaborative care is an evidence-based approach for improving quality mental health access in primary care settings. Although job opportunities will grow over the next decade, few psychiatry residencies have established curricula to train the next generation of psychiatrists to work in this expanding model of care. OBJECTIVE In this article, the authors describe the collaborative care training experience at a safety-net academic institution to provide a template for psychiatry residencies designing curricula to prepare psychiatry residents for collaborative care practices.

A Biopsychosocial Approach to HIV/AIDS Education for Psychiatry Residents

AIDS psychiatry has been described as a paradigm for teaching psychosomatic medicine with a biopsychosocial approach (1–7). The need for HIV/AIDS education has been emphasized in descriptions, studies, and surveys of psychiatric residency training programs (3–6). HIV/AIDS psychiatry provides opportunities for psychiatry residents to learn about preventing illness and managing chronic and acute illness in persons with psychiatric disorders. It magnifies the significance of assessing acute mental status changes in medically ill persons, discussing sexual and drug-use behaviors, and integrating a cognitive assessment into every psychiatric consultation. The complexities of AIDS and its treatments also magnify the complicated interactions of medications as influenced by mechanisms of drug metabolism and the necessity for building rapport to facilitate the recognition and management of psychiatric symptoms and disorders that affect adherence to medication and participation in treatment. HIV/AIDS complexities also substantiate the value of integrating palliative approaches to care throughout the course of illness, not only at the end of life. AIDS is similar to most other complex and severe medical illnesses, such as cancer, cardiovascular illnesses diabetes mellitus, emphysema, and systemic lupus erythematosis. Severe, complex illnesses have a profound impact on the lives of individuals, their loved ones, and families. Nonadherence tomedical care heightens suffering,morbidity, andmortality. Most persons with severe, complex illnesses can benefit from a comprehensive, compassionate, biopsychosocial approach to care. Integrating medical and psychiatric care for persons with HIV and AIDS can improve adherence, ameliorate suffering, and decrease morbidity and mortality. AIDS differs from many other complex and severe illnesses because it leads to other multi-morbid and debilitating medical illnesses, such as endocrine, hematologic, renal, pulmonary, neoplastic, and cardiac illness, as well as concomitant illnesses, such as hepatitis C (HCV). AIDS is also associated with specific psychiatric disorders, such as mood disorders, anxiety disorders, psychosis, and HIV-associated neurocognitive disorders (HAND). AIDS differs from many complex and severe illnesses in two ways that are very relevant to HIV/AIDS education. The first is that it is an unusual illness because it is almost entirely preventable, and adherence to risk-reduction behaviors has public health implications. The second is that HIV and AIDS are associated with sex, drug use, and AIDS-associated stigma and discrimination, or AIDSism (8). Whereas nonadherence to prevention and treatment of all illnesses has tragic consequences to patients, families, and loved ones, nonadherence to prevention and treatment of HIV and AIDS also results in HIV transmission and has significant public health implications. The most significant challenges to AIDS education in psychiatric residency training include illness-related and training-related factors. Illness-related challenges include an illness with rapidlychanging prevalence, incidence, and treatments, as well as stigma and AIDSism. Training-related factors include pressures of time and productivity, as well as complacency and denial regarding HIV and AIDS. During 4 years of training, psychiatry residents rotate through the inpatient and outpatient units of psychiatry and general care, the emergency room, and intensive care units. Each of these settings provides an opportunity for HIV training. In this article, we document the relevance of AIDS education for psychiatry residents and describe an HIV and AIDS curriculum Received February 11, 2012; accepted April 19, 2012. From the Dept. of Psychiatry, Mount Sinai Medical School, New York, NY, Dept. of Psychiatry, Harvard Medical School, Boston, MA. Send correspondence to Mary Ann Cohen, M.D., e-mail: macohen@nyc.rr.com Copyright

First-Episode Psychosis: Influences of Culture and Medical Comorbidity

This case, a composite drawn from clinical experiences, is designed to present a growing challenge in inpatient care. Specifically, patients presenting with symptoms that require hospitalization have become increasingly complex, with multiple diagnoses that contribute both independently and interdependently to the patient’s presentation and course of illness. At the same time, the boundaries of inpatient care are becoming narrower, with less time for comprehensive evaluation or full resolution of symptoms. The patient presented is referred to as “African.” It is acknowledged that “African” identities are varied, both politically and culturally; nevertheless, this designation was chosen as a compromise balancing cultural truth with the protection of confidentiality.

Guidelines for the general psychiatry application process and for inter-residency transitions.

Selecting a psychiatry program is a seminal event. There is often not enough guidance about this process. The American Association of Directors of Psychiatric Residency Training (AADPRT) recognized that this was a high-stakes process and that there was the opportunity to provide input about the process and promoting fairness and consistency, which could help provide the best opportunity for applicants to select where they will train and for programs to accept trainees who are well qualified for what a program offers and will best fit into the learning environment. A workgroup created guidelines included herein for the application process to begin general psychiatry training and to transition from one program to another, including transfer from one General Psychiatry program into another and entry into Child and Adolescent Psychiatry Residencies as well as subspecialty fellowships in psychiatry.

They’ve All Come to Look for America

Access to knowledge and information has never been more easily and extensively available than in the current digital age. Yet the organization of that information on the web and the question of its accuracy and validity often remains questionable. The speed with which information and commentary are accessible might obviate the need for the printed word, especially books that are long in development and soon outdated. While this is more likely in data-driven written materials than in literature, some books serve us well by virtue of how they are conceptualized and constructed, how helpful they are in perspective, and how accessible they are, even after some of the information itself might need updating. The book titled International Medical Graduate Physicians edited by Nyapati R. Rao and Laura Weiss Roberts will remain highly useful for international medical graduate (IMG) physicians applying to psychiatry residencies and for the faculty members who teach and supervise them in U.S. Accreditation Council for Graduate Medical Education (ACGME) residency programs. The title, however, should not dissuade U.S. medical school graduates or residents from making use of this resource. The book is a compendium of useful reviews of psychiatric residency training that would benefit all medical students applying in psychiatry, as it addresses core issues that are relevant regardless of one’s country of origin or immigration status. Both beginning and experienced training directors will find many chapters in the book elucidating and helpful in understanding why IMGs require specific attention, as they constitute a significant proportion of physicians throughout many regions of the U.S. Medical students born in the U.S. from immigrant families may find particular resonance as they bridge not only two cultures but also the “culture” of medicine. The book is divided into two parts—“Foundations” and “Perspectives.” Part I provides a range of topics that address the overarching issues relevant to all of psychiatric residency training with a focus on the implications for IMGs. Part I emphasizes how to understand the processes and components of psychiatry training, focusing on the fact that IMGs may come from medical schools and cultures that have varying emphases on how, andwhat, internationalmedical students learn. U.S. Medical Graduate (USMG) physicians are more likely to have a similar experience and knowledge base than their IMG counterparts who come from schools that do not have as yet an international accreditation system. Program directors may be more likely to review IMG applicants frommedical schools they know about from their IMG faculty members or successful residents. IMGs come frommany different cultures and may not be aware that while all U.S. residencies are governed by the same regulations, they may exist in areas of the country that will require adaptation to the social, geographical, ethnic, and religious local cultures, as well as to the culture of medicine.