Robert O. Cotes

Electroconvulsive therapy in China: clinical practice and research on efficacy.

Objective Electroconvulsive therapy (ECT) was first introduced in China in the early 1950s and has evolved into a significant psychiatric treatment. Research from Chinese psychiatrists provides important clinical data for ECT practitioners. However, most of the research has only been published in Chinese language journals. This article summarizes data from publications in the Chinese scientific community related to the clinical practice of ECT and research on efficacy in the treatment of psychiatric disorders. Methods Descriptive study primarily based on Chinese language literature identified from searches of the China National Knowledge Infrastructure and the Medline databases (1979–2012). Results More than 900 journal papers on ECT have been published in the Chinese language between 1979 and 2012. Currently, modified ECT has replaced unmodified ECT, and treatments were performed both in inpatient and outpatient settings. Electroconvulsive therapy is primarily used for the treatment of schizophrenia and mood disorders and has been shown to be very effective in both. The primary use of ECT in China is in the treatment of schizophrenia. The Chinese literature provides a rich database on the efficacy of modified and unmodified ECT, with and without adjunctive antipsychotics, in the treatment of schizophrenia. Conclusion The Chinese medical literature provides an important database that will help advance the practice of ECT in both China and the international community.

Clozapine-Induced Myocarditis: Prevention and Considerations in Rechallenge

The incidence of clozapine-induced myocarditis is 0.2%–3%, and it can be life threatening, with a mortality rate as high as 50%. It can be subtle in its presentation, with the most common symptoms including flulike symptoms, fever, fatigue, and dyspnea. Approximately 80% of cases of clozapineinduced myocarditis occur within 4 weeks of drug initiation, and 90% occur within 8 weeks. The diagnosis is typically guided by a preponderance of clinical evidence, as even the diagnostic gold standard of endomyocardial biopsy has limited sensitivity and specificity. We present the case of a 44-year-old woman who developed clinical signs and symptoms of clozapineinduced myocarditis, approximately 2 weeks following the initiation of clozapine treatment for psychosis.

Cocaine-Induced Psychotic Disorders: Presentation, Mechanism, and Management

Cocaine, the third mostly commonly used illicit drug in the United States, has a wide range of neuropsychiatric effects, including transient psychotic symptoms. When psychotic symptoms occur within a month of cocaine intoxication or withdrawal, the diagnosis is cocaine-induced psychotic disorder (CIPD). Current evidence suggests those with CIPD are likely to be male, have longer severity and duration of cocaine use, use intravenous cocaine, and have a lower body mass index. Differentiating CIPD from a primary psychotic disorder requires a detailed history of psychotic symptoms in relation to substance use and often a longitudinal assessment. Treatment includes providing a safe environment, managing agitation and psychosis, and addressing the underlying substance use disorder. This review begins with a clinical case and summarizes the literature on CIPD, including clinical presentation, differential diagnosis, mechanism and predictors of illness, and treatment.

Beyond the Psychiatric Horizon: Preparing Residents for the Twenty-First Century.

The science of medicine and the health care delivery system are evolving rapidly. These changes impact psychiatrists, residency training programs, and the public. An Institute of Medicine report highlighted a gap between a new physician’s knowledge and the actual skills needed for current medical practice, reflecting the quick pace of this change [1]. It is the responsibility of residency programs to ensure that their graduates are prepared for the current medical environment [2]. Psychiatric residency training occurs in many forms including didactics, experientially through bedside teaching by faculty, through role modeling and mentorship, by residents teaching other residents, and through self-directed learning. As the social, political, and technological changes of the early twenty-first century unfold, both the content and process of residency training in psychiatry must adapt to prepare trainees for the advances and challenges of tomorrow. Using the Accreditation Council for Graduate Medical Education (ACGME) six core competencies as a framework [2], this article will focus on the topics most relevant to preparing residents for psychiatry in the twenty-first century.

Simulated Patients and Scenarios to Assess and Teach Psychiatry Residents

The role and utility of simulated and standardized patients in medical education has evolved tremendously since its first introduction in 1963. The United States Medical Licensing Examination (USMLE) routinely uses standardized patients in the assessment of clinical skills to assess a candidate’s ability to elicit information, perform exams, and communicate clinically relevant findings. Psychiatry has been slower to adopt the use of simulated or standardized patients, partly due to the difficulty in creating scenarios depicting valid emotions [1, 2]. However, there are several areas of psychiatric education that lend themselves well to using a simulated patient or simulated scenario for learner assessment or for teaching. Here, we share examples from several programs where simulation has helped enhance teaching and assessment of residents. We address some of the practical issues in working with simulated patients. Finally, we briefly review the advantages and disadvantages of using simulation in psychiatric education. We do not intend this to be an exhaustive review of the use of simulated patients in psychiatry, but rather representative examples of ways simulated patients have been used successfully in residency training. To clarify our use of language related to this pedagogical method, we define “simulated patient” as any person who is not an actual patient and is being utilized to play the role of a patient in a learning or testing encounter; a “standardized patient” is a subset of simulated patients for which a person has been specially trained to act as a patient so that specific symptoms or signs can be demonstrated and/or feedback given to a learner.

Electroconvulsive therapy in China (II): research on the technical parameters and mechanism of action.

Objective This article summarizes the publications in the Chinese scientific literature related to the technical parameters and mechanism of action associated with electroconvulsive therapy (ECT). Methods The researchers conducted a comprehensive search of the Chinese language literature identified from searches of the China National Knowledge Infrastructure and the Medline databases (1979–2012). Results More than 900 journal papers on ECT have been published in the Chinese language between 1979 and 2012. Most studies found that electrode placement, anesthesia, and muscle relaxants are important clinical factors associated with both clinical efficacy and adverse effects. Chinese researchers have reported new leads regarding the possible mechanism of ECT. Conclusion The Chinese medical literature provides an important database that will help advance ECT research in both China and the international community.

Limb Self-Amputation Without Replantation: A Case Report and Management Considerations

Background Major self-mutilation describes severe acts of harm to oneself, generally leading to permanent damage and loss of function in the absence of suicidal intent. The most common presentations include limb amputation, genital amputation, or auto-enucleation. Coordination of care is multidisciplinary with psychiatrists playing a pivotal role. Little literature is available with respect to managing care of patients who do not undergo replantation of a self-amputated limb. Case Presentation The authors present the case of a 20-year-old male patient after self-amputation of his upper extremity in the context of a psychotic spectrum illness and religiously preoccupied thought content. This is the first reported case to our knowledge of a patient who self-amputated an extremity and did not have replantation despite presenting with the limb in an appropriate time window. His treatment course highlights the challenges associated with these occurrences. Discussion While self-amputation most often occurs in the context of psychosis, we assert that if replantation does not occur, these individuals will have similar outcomes as their non-psychotic counterparts. Management should focus on psychiatric consultation early on to provide supportive psychotherapy and medication management. Chaplaincy consultation should be pursued early in the treatment course for hyperreligious patients. Cognitive behavioral therapy for psychosis, insight oriented therapies, family therapy, and a focus on improving resilience can also be helpful as the individual becomes more psychiatrically stable.

Characteristics of Medicaid Recipients Receiving Persistent Antipsychotic Polypharmacy

Antipsychotic polypharmacy (APP) is a common strategy despite guidelines advising against this practice. This article seeks to quantify the prevalence and correlates of APP using Medicaid Analytic eXtract files from 2003 to 2004. Nineteen percent of Medicaid recipients who received an antipsychotic were treated with APP. Individuals who received APP were more likely to be white, male, disabled, between the ages of 18–29, diagnosed with a psychotic disorder, and diagnosed with a higher number of psychiatric conditions. Geographic variation in APP rates was also observed. Quality improvement initiatives may help reduce APP for medically vulnerable patients.