Journals RSS : Gourt

Mindreadings [From the Editor]

Letter from America: acute in-patient psychiatry bed shortages [Editorials]

The number of in-patient beds for psychiatric treatment in America has declined dramatically over the past 40 years. Public and private policies have encouraged an extremely short-term, crisis-stabilisation model of treatment. This is true on both general and subspecialty units. As a result, readmissions have increased, emergency rooms are crowded, and many patients end up homeless or incarcerated in the criminal justice system. These changes have created a public health crisis in America, and are the greatest challenges that American psychiatry faces today.

The role of the medical director in mental health [Articles]

This article sets out the history of medical directorship, outlines the authors’ view of the current contribution that medical directors can and should be making to the mental health arena and looks forward to the possibilities of this evolving role. The focus of the article is mainly on English policy and healthcare structures, recognising that these vary in the other jurisdictions of the UK. However, certain principles should be of wider interest and application.

Puerperal psychosis: identifying and caring for women at risk [Articles]

Puerperal (postpartum) psychosis – the acute onset of a manic or psychotic episode shortly after childbirth – most commonly occurs in women with a bipolar disorder diathesis who have a vulnerability to a specific childbirth-related trigger. Women with bipolar disorder are at particularly high risk of puerperal psychosis, with a severe affective episode following between 25 and 50% of deliveries. Suicide is a leading cause of maternal death in the UK and it is clear that we must do more to identify and better manage women at high risk of illness related to childbirth. The clinical picture of puerperal psychosis can vary dramatically from hour to hour and can escalate quickly to a true psychiatric emergency. It is vital that clinical services identify women who are unwell and can respond quickly to the severity of illness, delivering treatment in the most appropriate setting for the mother and her baby.

Clinical significance of neurological abnormalities in psychosis [Articles]

The neurological deficits in sensory and motor function in schizophrenia have been described using a confusing variety of terms, reflecting their uncertain relevance and significance to psychosis. In this article we explore the nature of neurological abnormalities in psychosis, describe their assessment and suggest their potential relevance for clinician and patient. We propose that the assessment of neurological abnormalities and extrapyramidal side-effects should figure in the assessment of any patient with psychosis, particularly at illness onset. Furthermore, we suggest that neurological abnormalities can inform prognostic predictions and help to identify patients with more complex future care needs.

Understanding community care law in England and Wales [Articles]

Although psychiatrists in England and Wales are generally familiar with the Mental Health Act 1983 and the Mental Capacity Act 2005, there is a body of law that is available to assist patients in the community with which they are generally less familiar. There are two main reasons for this. The first is that it is a rather confused amalgam of different statutes and case law affecting each other in ways that are less than clear. The other is that the care programme approach (CPA) was meant to cut through all this and make care provision straightforward. In fact, the latter has never been the case and community care law has always sat uneasily alongside the CPA, but in October 2008 the CPA was withdrawn from some patients with mental health problems. This article explains what is meant by community care law and how psychiatrists can use it to help their patients.

Self-harm in adolescents [Articles]

Self-harm in adolescents is common and is increasing. It can present to professionals as a symptom of major mental health disturbance or it can form part of a cultural ‘norm’. This article reviews current knowledge about self-harm in 12- to 18-year-olds. Definitions of self-harming behaviour, epidemiological and aetiological factors, risk assessment and management of self-harming in various settings are discussed in terms of pragmatic clinical approaches and evidence-based practice.

The challenges of managing self-harm effectively: INVITED COMMENTARY ON... SELF-HARM IN ADOLE SCENTS [Articles]

This commentary discusses how much we appear to know about self-harm and the circumstances in which it may occur but how little we really know about what works in managing it. It reviews how suggestions for its management conflict with what we know about self-harm and the outcomes of young people. The challenge appears to be how better to identify those at risk of further self-harm and to train frontline staff in this, so that at-risk individuals may be referred to specialist services. Perhaps there is also a need to review the evidence for what actually works in reducing repetition of self-harm.

Article 2 of the Human Rights Act 1998 and the treatment of prisoners [Articles]

People detained in prisons, psychiatric hospitals, police custody and immigration detention centres remain a cause of concern, particularly to professionals, politicians and the media. As the number of people detained by the state increases, Courts have been taking an increasing interest in cases in which individuals have died in state custody. Such cases are subsumed under Article 2 of the Human Rights Act 1998 – the right to life. Article 2 case law has elucidated key principles that can be applied in practice. Importantly, it imposes on states not only a negative duty not to take life intentionally or negligently, but also a positive duty to safeguard life. The inherent positive obligations have two aspects: first, there is a duty to provide an effective and impartial investigation in cases of death resulting from the activities of state officials, and second, a duty to safeguard and protect life.

Clinical implications of neuropsychiatric systemic lupus erythematosus [Articles]

Systemic lupus erythematosus (SLE) is a disorder which can affect the central nervous system and result in a broad range of psychiatric syndromes such as psychosis, mood disorders, acute confusion and cognitive dysfunction. Despite the robust nomenclature of neuropsychiatric SLE (NPSLE), psychiatric syndromes in patients are often non-specific and may be secondary to concurrent non-SLE-related conditions and complications of medical therapies. Although the exact immunopathological mechanism for psychiatric presentation remains elusive, prompt exclusion of other factors contributing to the psychiatric symptoms coupled with effective assessment strategies and management with immunosuppression and psychiatric therapy are imperative. Psychiatrists and rheumatologists must work in close liaison to identify, treat and prognosticate patients with psychiatric syndromes in order to improve their quality of life, vocational aptitude and, ultimately, survival.

Metamorphosis by Franz Kafka [Mindreadings]

This article examines the short story Metamorphosis by the enigmatic Czech writer Franz Kafka, whose work has been the subject of extensive critical discussion. His writings have been seen in the context of existentialism, Jewish mysticism and as a warning of the advent of totalitarianism. Kafka has attracted the attention of psychoanalysts and psychiatrists, who have maintained that his life and work manifest evidence of unresolved Oedipal issues and of schizoid personality. Metamorphosis is open to a multitude of interpretations, but a potentially fruitful approach is to see parallels between the predicament of the story’s main character, Gregor Samsa, and that of people with severe mental illness. The story highlights the fate of those who are judged to be different by society and how issues of alienation, impaired communication and rejection arise.

Interpersonal dynamics and multidisciplinary teamwork [Articles]

Analysing interpersonal dynamics is an approach through which the multidisciplinary team can develop a shared understanding of their patients. This empirically based method provides an insight into repeated patterns of dysfunctional behaviour, which not only have been evident in the past, but are currently having an impact on the patient’s relationships with caring staff. The technique is accessible to any team member with only minimal training required. It provides the team with a coherent map of the patient’s relationship patterns that underpins the formulation of an effective strategy for care. The multidisciplinary team is then able to work towards shared goals, supporting all members in their provision of effective interventions within the full range of therapeutic modalities. The approach promotes positive staff–patient interactions and provides an additional dimension to the assessment and management of risk.

Systemic thinking and values-based practice [Articles]

Values-based practice is a new approach to working with complex and conflicting values in mental health practice. Theoretically, it argues that many clinical and ethical dilemmas in psychiatry arise because of the different value perspectives taken by the players involved. By exploring the differences in value systems ‘held’ by each player, it may be possible to come to a richer consensus that can incorporate both similarities and differences. In particular, values-based practice suggests that, traditionally, the value perspective of the patient is often either not considered or is ignored, and that by giving it voice, clinical practice will become more patient-centred. In this article, I will compare values-based practice with other types of systemic thinking in mental healthcare and I will discuss some areas of clinical practice where values-based practice may be difficult to apply.

'At last I am alone', from the diary of Dora Carrington [In Other Words]

Correction [Correction]

In This Issue [In This Issue]

Eating Disorders: Hope Despite Mortal Risk [Editorials]

Risk for Depression and Cognitive Deterioration in Older Individuals: The Important Role of Past and Present Environmental Influences [Editorials]

Integrated Treatment of Aggression in the Context of ADHD in Children Refractory to Stimulant Monotherapy: A Window Into the Future of Child Psychopharmacology [Editorials]

2009 in Review [Editorials]

Issues for DSM-V: The Limitations of Field Trials: A Lesson From DSM-IV [Editorials]

John Case Nemiah, M.D. 1918-2009 [In Memoriam]

Cognitive-Behavioral Therapy for Pathological Gambling: Cultural Considerations [Clinical Case Conference]

Pathological gambling is a common disorder with severe consequences for patients and their families. This case study describes cognitive-behavioral therapy (CBT) for pathological gambling and its general principles and provides an example of a modification of CBT techniques in the treatment of a 51-year-old immigrant Afro-Caribbean woman. The case depicts the contribution of beliefs, especially those that are part of a cultural system, to the perpetuation of a patient’s disorder; the influence of family members’ attitudes, moved by their cultural beliefs and values, in shaping the patient’s behavior; and the consideration of these issues in guiding specific interventions, such as challenging irrational thoughts or helping patients devise strategies to change their behavior in a culturally congruent manner.

The Outcome of Bulimia Nervosa: Findings From One-Quarter Century of Research [Reviews and Overviews]

OBJECTIVE: The present review addresses the outcome of bulimia nervosa, effect variables, and prognostic factors. METHOD: A total of 79 study series covering 5,653 patients suffering from bulimia nervosa were analyzed with regard to recovery, improvement, chronicity, crossover to another eating disorder, mortality, and comorbid psychiatric disorders at outcome. Forty-nine studies dealt with prognosis only. Final analyses on prognostic factors were based on 4,639 patients. RESULTS: Joint analyses of data were hampered by a lack of standardized outcome criteria. There were large variations in the outcome parameters across studies. Based on 27 studies with three outcome criteria (recovery, improvement, chronicity), close to 45% of the patients on average showed full recovery of bulimia nervosa, whereas 27% on average improved considerably and nearly 23% on average had a chronic protracted course. Crossover to another eating disorder at the follow-up evaluation in 23 studies amounted to a mean of 22.5%. The crude mortality rate was 0.32%, and other psychiatric disorders at outcome were very common. Among various variables of effect, duration of follow-up had the largest effect size. The data suggest a curvilinear course, with highest recovery rates between 4 and 9 years of follow-up evaluation and reverse peaks for both improvement and chronicity, including rates of crossover to another eating disorder, before 4 years and after 10 years of follow-up evaluation. For most prognostic factors, there was only conflicting evidence. CONCLUSIONS: One-quarter of a century of specific research in bulimia nervosa shows that the disorder still has an unsatisfactory outcome in many patients. More refined interventions may contribute to more favorable outcomes in the future.

Increased Mortality in Bulimia Nervosa and Other Eating Disorders [Articles]

OBJECTIVE: Anorexia nervosa has been consistently associated with increased mortality, but whether this is true for other types of eating disorders is unclear. The goal of this study was to determine whether anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified are associated with increased all-cause mortality or suicide mortality. METHOD: Using computerized record linkage to the National Death Index, the authors conducted a longitudinal assessment of mortality over 8 to 25 years in 1,885 individuals with anorexia nervosa (N=177), bulimia nervosa (N=906), or eating disorder not otherwise specified (N=802) who presented for treatment at a specialized eating disorders clinic in an academic medical center. RESULTS: Crude mortality rates were 4.0% for anorexia nervosa, 3.9% for bulimia nervosa, and 5.2% for eating disorder not otherwise specified. All-cause standardized mortality ratios were significantly elevated for bulimia nervosa and eating disorder not otherwise specified; suicide standardized mortality ratios were elevated for bulimia nervosa and eating disorder not otherwise specified. CONCLUSIONS: Individuals with eating disorder not otherwise specified, which is sometimes viewed as a "less severe" eating disorder, had elevated mortality risks, similar to those found in anorexia nervosa. This study also demonstrated an increased risk of suicide across eating disorder diagnoses.

The Efficacy of Self-Help Group Treatment and Therapist-Led Group Treatment for Binge Eating Disorder [Articles]

OBJECTIVE: The purpose of this investigation was to compare three types of treatment for binge eating disorder to determine the relative efficacy of self-help group treatment compared to therapist-led and therapist-assisted group cognitive-behavioral therapy. METHOD: A total of 259 adults diagnosed with binge eating disorder were randomly assigned to 20 weeks of therapist-led, therapist-assisted, or self-help group treatment or a waiting list condition. Binge eating as measured by the Eating Disorder Examination was assessed at baseline, at end of treatment, and at 6 and 12 months, and outcome was assessed using logistic regression and analysis of covariance (intent-to-treat). RESULTS: At end of treatment, the therapist-led (51.7%) and the therapist-assisted (33.3%) conditions had higher binge eating abstinence rates than the self-help (17.9%) and waiting list (10.1%) conditions. However, no between-group differences in abstinence rates were observed at either of the follow-up assessments. The therapist-led condition also showed more reductions in binge eating at end of treatment and follow-up assessments compared to the self-help condition, and treatment or waiting period completion rates were higher in the therapist-led (88.3%) and waiting list (81.2%) conditions than in the therapist-assisted (68.3%) and self-help (59.7%) conditions. CONCLUSIONS: Therapist-led group cognitive-behavioral treatment for binge eating disorder led to higher binge eating abstinence rates, greater reductions in binge eating frequency, and lower attrition compared to group self-help treatment. Although these findings indicate that therapist delivery of group treatment is associated with better short-term outcome and less attrition than self-help treatment, the lack of group differences at follow-up suggests that self-help group treatment may be a viable alternative to therapist-led interventions.

Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder [Articles]

OBJECTIVE: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder. METHOD: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables. RESULTS: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization. CONCLUSIONS: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder [Articles]

OBJECTIVE: The authors sought to evaluate the clinical efficacy of dialectical behavior therapy compared with general psychiatric management, including a combination of psychodynamically informed therapy and symptom-targeted medication management derived from specific recommendations in APA guidelines for borderline personality disorder. METHOD: This was a single-blind trial in which 180 patients diagnosed with borderline personality disorder who had at least two suicidal or nonsuicidal self-injurious episodes in the past 5 years were randomly assigned to receive 1 year of dialectical behavior therapy or general psychiatric management. The primary outcome measures, assessed at baseline and every 4 months over the treatment period, were frequency and severity of suicidal and nonsuicidal self-harm episodes. RESULTS: Both groups showed improvement on the majority of clinical outcome measures after 1 year of treatment, including significant reductions in the frequency and severity of suicidal and nonsuicidal self-injurious episodes and significant improvements in most secondary clinical outcomes. Both groups had a reduction in general health care utilization, including emergency visits and psychiatric hospital days, as well as significant improvements in borderline personality disorder symptoms, symptom distress, depression, anger, and interpersonal functioning. No significant differences across any outcomes were found between groups. CONCLUSIONS: These results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder.

Risks for Depression Onset in Primary Care Elderly Patients: Potential Targets for Preventive Interventions [Articles]

OBJECTIVE: Prevention of late-life depression, a common, disabling condition with often poor outcomes in primary care, requires identification of seniors at highest risk of incident episodes. The authors examined a broad range of clinical, functional, and psychosocial predictors of incident depressive episodes in a well-characterized cohort of older primary care patients. METHOD: In this observational cohort study, patients age ≥65 years without current major depression, recruited from practices in general internal medicine, geriatrics, and family medicine, received annual follow-up assessments over a period of 1 to 4 years. Of 617 enrolled subjects, 405 completed the 1-year follow-up evaluation. The Structured Clinical Interview for DSM-IV (SCID) determined incident major depressive episodes. Each risk indicator’s predictive utility was examined by calculating the risk exposure rate, incident risk ratio, and population attributable fraction, leading to determination of the number needed to treat in order to prevent incident depression. RESULTS: A combination of risks, including minor or subsyndromal depression, impaired functional status, and history of major or minor depression, identified a group in which fully effective treatment of five individuals would prevent one new case of incident depression. CONCLUSIONS: Indicators routinely assessed in primary care identified a group at very high risk for onset of major depressive episodes. Such markers may inform current clinical care by fostering the early detection and intervention critical to improving patient outcomes and may serve as the basis for future studies refining the recommendations for screening and determining the effectiveness of preventive interventions.

Effects of Chronic Stress on Memory Decline in Cognitively Normal and Mildly Impaired Older Adults [Articles]

OBJECTIVE: The literature provides evidence of a strong relationship between greater stress and memory loss, but few studies have examined this relationship with both variables measured over time. The authors sought to determine the prospective association between subjective and objective measures of chronic stress and rate of memory decline in cognitively normal and mildly impaired older adults. METHOD: This longitudinal study was conducted at a university research center and included 61 cognitively normal subjects and 41 subjects with mild cognitive impairment (ages 65–97). Fifty-two subjects were followed for up to 3 years (mean=2 years) and received repeated stress and cognitive assessments. Exclusion criteria were dementia, significant medical or psychiatric conditions, and medication use (e.g., corticosteroids) that might affect cortisol level or cognitive functioning. The main outcome measure was a regression-based slope reflecting performance change on tests of global cognition and episodic memory as a function of baseline diagnosis, recent life events, and salivary cortisol. Examiners were blind to stress ratings and cortisol levels at the time of cognitive testing. RESULTS: Higher event-based stress ratings collected over the follow-up period were associated with faster cognitive decline in subjects with mild cognitive impairment but not in cognitively normal subjects. In contrast, higher cortisol levels were associated with slower cognitive decline in subjects with mild cognitive impairment but not in cognitively normal subjects. CONCLUSIONS: Chronic stress affects cognitive functioning differently in cognitively normal subjects and those with mild cognitive impairment. Cortisol, while likely to have neurotoxic effects over time, may enhance cognitive functioning in older adults compromised by existing cognitive deficits.

Adjunctive Divalproex Versus Placebo for Children With ADHD and Aggression Refractory to Stimulant Monotherapy [Articles]

OBJECTIVE: The purpose of the present study was to evaluate the efficacy of divalproex for reducing aggressive behavior among children 6 to 13 years old with attention deficit hyperactivity disorder (ADHD) and a disruptive disorder whose chronic aggression was underresponsive to a prospective psychostimulant trial. METHOD: Children received open stimulant treatment during a lead-in phase that averaged 5 weeks. Agent and dose were assessed weekly and modified to optimize response. Children whose aggressive behavior persisted at the conclusion of the lead-in phase were randomly assigned to receive double-blind, flexibly dosed divalproex or a placebo adjunctive to stimulant for 8 weeks. Families received weekly behavioral therapy throughout the trial. The primary outcome measure was the proportion of children whose aggressive behavior remitted, defined by post-trial ratings of negligible or absent aggression. Result: A significantly higher proportion of children randomly assigned to divalproex met remission criteria (eight out of 14 [57%]) than those randomly assigned to placebo (two out of 13 [15%]). Divalproex was generally well tolerated. CONCLUSIONS: Among children with ADHD whose chronic aggressive behavior is refractory to optimized stimulant treatment, the addition of divalproex increases the likelihood that aggression will remit. A larger trial is necessary to specify with greater precision the magnitude of benefit for adjuvant divalproex.

Neural Activation Underlying Acute Grief in Women After the Loss of an Unborn Child [Articles]

OBJECTIVE: The traumatic loss of an unborn child by induced termination of pregnancy because of fetal malformation is a major life event that causes intense maternal grief. Increasing evidence supports the hypothesis that the same neural structures involved in the experience of physical pain are involved in the experience of social pain and loss. METHOD: To investigate neural activation patterns related to acute grief, the authors conducted a functional MRI study of 12 post-termination women and 12 noninduced women who delivered a healthy child. Brain activation was measured while participants viewed pictures of happy baby, happy adult, and neutral adult faces. RESULTS: Relative to comparison women, post-termination women showed greater activation in the middle and posterior cingulate gyrus, the inferior frontal gyrus, the middle temporal gyrus, the thalamus, and the brainstem in response to viewing happy baby faces. Functional connectivity between the cingulate gyrus and the thalamus during the processing of happy baby faces was significantly stronger in post-termination women. CONCLUSIONS: Overall, acute grief after the loss of an unborn child was closely related to the activation of the physical pain network encompassing the cingulate gyrus, the inferior frontal gyrus, the thalamus, and the brainstem. To the authors’ knowledge, the stronger functional thalamocingulate connectivity in post-termination women is the first in vivo demonstration of an involvement of the neural maternal attachment network in grief after the loss of an unborn child.

Prior Treatment and Its Effect on Outcome [Letters to the Editor]

Drs. Leichsenring, Salzer, and Leibing Reply [Letters to the Editor]

Improving Verbal Memory Performance in Schizophrenia [Letters to the Editor]

Drs. Fisher and Vinogradov Reply [Letters to the Editor]

Vocal Cord Dysfunction Arising From Vagal Nerve Stimulator Removal [Letters to the Editor]

Effects of the CACNA1C Risk Allele for Bipolar Disorder on Cerebral Gray Matter Volume in Healthy Individuals [Letters to the Editor]

The Great Gatsby [Book Forum]

Soul of the Age: A Biography of the Mind of William Shakespeare [Book Forum]

The Lazarus Project [Book Forum]

The White Tiger [Book Forum]

Au Revoir to All That: Food, Wine, and the End of France [Book Forum]

[Books Received]

[Annual Author Index]

[In Appreciation]

Mary Frances ("Fran") MacNeil [Announcement]

About This Journal [About This Journal]

This Month in Archives of General Psychiatry [This Month in Archives of General Psychiatry]

The Virgin of the Rocks [Art and Images in Psychiatry]

Gene-Environment Interactions: Biologically Valid Pathway or Artifact? [From JAMA]

Functional Neuroanatomy of Visual Masking Deficits in Schizophrenia [Original Article]

Context Visual masking procedures assess the earliest stages of visual processing. Patients with schizophrenia reliably show deficits on visual masking, and these procedures have been used to explore vulnerability to schizophrenia, probe underlying neural circuits, and help explain functional outcome. Objective To identify and compare regional brain activity associated with one form of visual masking (ie, backward masking) in schizophrenic patients and healthy controls. Design Subjects received functional magnetic resonance imaging scans. While in the scanner, subjects performed a backward masking task and were given 3 functional localizer activation scans to identify early visual processing regions of interest (ROIs). Setting University of California, Los Angeles, and the Department of Veterans Affairs Greater Los Angeles Healthcare System. Participants Nineteen patients with schizophrenia and 19 healthy control subjects. Main Outcome Measure The magnitude of the functional magnetic resonance imaging signal during backward masking. Results Two ROIs (lateral occipital complex [LO] and the human motion selective cortex [hMT+]) showed sensitivity to the effects of masking, meaning that signal in these areas increased as the target became more visible. Patients had lower activation than controls in LO across all levels of visibility but did not differ in other visual processing ROIs. Using whole-brain analyses, we also identified areas outside the ROIs that were sensitive to masking effects (including bilateral inferior parietal lobe and thalamus), but groups did not differ in signal magnitude in these areas. Conclusions The study results support a key role in LO for visual masking, consistent with previous studies in healthy controls. The current results indicate that patients fail to activate LO to the same extent as controls during visual processing regardless of stimulus visibility, suggesting a neural basis for the visual masking deficit, and possibly other visual integration deficits, in schizophrenia.

Brain Monoamine Oxidase A Binding in Major Depressive Disorder: Relationship to Selective Serotonin Reuptake Inhibitor Treatment, Recovery, and Recurrence [Original Article]

Context Highly significant elevations in regional brain monoamine oxidase A (MAO-A) binding were recently reported during major depressive episodes (MDEs) of major depressive disorder (MDD). The relationship between MAO-A levels and selective serotonin reuptake inhibitor (SSRI) treatment, recovery, and recurrence in MDD is unknown. Objectives To determine whether brain MAO-A binding changes after SSRI treatment, whether brain MAO-A binding normalizes in subjects with MDD in recovery, and whether there is a relationship between prefrontal and anterior cingulate cortex MAO-A binding in recovery and subsequent recurrence of MDE. Design Case-control study. Setting Tertiary care psychiatric hospital. Participants Twenty-eight healthy subjects, 16 subjects with an MDE secondary to MDD, and 18 subjects with MDD in recovery underwent carbon 11–labeled harmine positron emission tomography scans. Subjects with MDE were scanned before and after 6 weeks of SSRI treatment. All were otherwise healthy, nonsmoking, and medication free. Subjects with MDD in recovery were followed up for 6 months after MAO-A binding measurement. Main Outcome Measure Monoamine oxidase A VT, an index of MAO-A density, was measured in the prefrontal cortex, anterior cingulate cortex, posterior cingulate cortex, dorsal putamen, ventral striatum, thalamus, anterior temporal cortex, midbrain, and hippocampus. Results Monoamine oxidase A VT was significantly elevated in each brain region both during MDE and after SSRI treatment as compared with healthy controls. During recovery, MAO-A VT was significantly elevated in each brain region; however, those who went on to recurrence had significantly higher MAO-A VT in the prefrontal and anterior cingulate cortex than those who did not. Conclusions Elevated MAO-A binding after SSRI treatment indicates persistence of a monoamine-lowering process not present in health. This provides a strong conceptual rationale for continuing SSRI treatment during early remission. Greater MAO-A binding in the prefrontal and anterior cingulate cortex in subjects with MDD in recovery and its association with subsequent recurrence argue that deficient monoamine neuromodulation may persist into recovery and contribute to recurrence.

Blood Lead Levels and Major Depressive Disorder, Panic Disorder, and Generalized Anxiety Disorder in US Young Adults [Original Article]

Context Lead is a ubiquitous neurotoxicant, and adverse cognitive and behavioral effects are well-documented in children and occupationally exposed adults but not in adults with low environmental exposure. Objective To investigate the association of current blood lead levels with 3 common psychiatric disorders—major depression, panic, and generalized anxiety—in young adults. Design Cross-sectional epidemiologic survey. Setting Nationally representative sample of US adults. Participants A total of 1987 adults aged 20 to 39 years who responded to the National Health and Nutrition Examination Survey (1999-2004). Main Outcome Measures Twelve-month DSM-IV criteria–based diagnoses of major depressive disorder, panic disorder, and generalized anxiety disorder assessed using the Composite International Diagnostic Interview. Results The mean (SD) blood lead level was 1.61 (1.72) µg/dL (range, 0.3-37.3 µg/dL) (to convert to micromoles per liter, multiply by 0.0483). Increasing blood lead levels were associated with higher odds of major depression (P = .05 for trend) and panic disorder (P = .02 for trend) but not generalized anxiety disorder (P = .78 for trend) after adjustment for sex, age, race/ethnicity, education status, and poverty to income ratio. Persons with blood lead levels in the highest quintile had 2.3 times the odds of major depressive disorder (95% confidence interval [CI], 1.13-4.75) and 4.9 times the odds of panic disorder (1.32-18.48) as those in the lowest quintile. Cigarette smoking was associated with higher blood lead levels and outcome, but models that excluded current smokers also resulted in significantly increased odds of major depression (P = .03 for trend) and panic disorder (P = .01 for trend) with higher blood lead quintiles. Conclusions In these young adults with low levels of lead exposure, higher blood lead levels were associated with increased odds of major depression and panic disorders. Exposure to lead at levels generally considered safe could result in adverse mental health outcomes.

Personality Change During Depression Treatment: A Placebo-Controlled Trial [Original Article]

Context High neuroticism is a personality risk factor that reflects much of the genetic vulnerability to major depressive disorder (MDD), and low extraversion may increase risk as well. Both have been linked to the serotonin system. Objectives To test whether patients with MDD taking selective serotonin reuptake inhibitors (SSRIs) report greater changes in neuroticism and extraversion than patients receiving inert placebo, and to examine the state effect hypothesis that self-reported personality change during SSRI treatment is merely a change of depression-related measurement bias. Design A placebo-controlled trial. Setting Research clinics. Patients Adult patients with moderate to severe MDD randomized to receive paroxetine (n = 120), placebo (n = 60), or cognitive therapy (n = 60). Outcome Measures NEO Five-Factor Inventory and Hamilton Rating Scale for Depression. Results Patients who took paroxetine reported greater personality change than placebo patients, even after controlling for depression improvement (neuroticism, P < .001; extraversion, P = .002). The advantage of paroxetine over placebo in antidepressant efficacy was no longer significant after controlling for change in neuroticism (P = .46) or extraversion (P = .14). Patients taking paroxetine reported 6.8 times as much change on neuroticism and 3.5 times as much change on extraversion as placebo patients matched for depression improvement. Although placebo patients exhibited substantial depression improvement (Hamilton Rating Scale for Depression score, –1.2 SD, P < .001), they reported little change on neuroticism (–0.18 SD, P = .08) or extraversion (0.08 SD, P = .50). Cognitive therapy produced greater personality change than placebo (P ≤ .01); but its advantage on neuroticism was no longer significant after controlling for depression (P = .14). Neuroticism reduction during treatment predicted lower relapse rates among paroxetine responders (P = .003) but not among cognitive therapy responders (P = .86). Conclusions Paroxetine appears to have a specific pharmacological effect on personality that is distinct from its effect on depression. If replicated, this pattern would disconfirm the state effect hypothesis and instead support the notion that SSRIs' effects on personality go beyond and perhaps contribute to their antidepressant effects.

Clinical Effectiveness of Individual Cognitive Behavioral Therapy for Depressed Older People in Primary Care: A Randomized Controlled Trial [Original Article]

Context In older people, depressive symptoms are common, psychological adjustment to aging is complex, and associated chronic physical illness limits the use of antidepressants. Despite this, older people are rarely offered psychological interventions, and only 3 randomized controlled trials of individual cognitive behavioral therapy (CBT) in a primary care setting have been published. Objective To determine the clinical effectiveness of CBT delivered in primary care for older people with depression. Design A single-blind, randomized, controlled trial with 4- and 10-month follow-up visits. Patients A total of 204 people aged 65 years or older (mean [SD] age, 74.1 [7.0] years; 79.4% female; 20.6% male) with a Geriatric Mental State diagnosis of depression were recruited from primary care. Interventions Treatment as usual (TAU), TAU plus a talking control (TC), or TAU plus CBT. The TC and CBT were offered over 4 months. Outcome Measures Beck Depression Inventory-II (BDI-II) scores collected at baseline, end of therapy (4 months), and 10 months after the baseline visit. Subsidiary measures were the Beck Anxiety Inventory, Social Functioning Questionnaire, and Euroqol. Intent to treat using Generalized Estimating Equation and Compliance Average Causal Effect analyses were used. Results Eighty percent of participants were followed up. The mean number of sessions of TC or CBT was just greater than 7. Intent-to-treat analysis found improvements of –3.07 (95% confidence interval [CI], –5.73 to –0.42) and –3.65 (95% CI, –6.18 to –1.12) in BDI-II scores in favor of CBT vs TAU and TC, respectively. Compliance Average Causal Effect analysis compared CBT with TC. A significant benefit of CBT of 0.4 points (95% CI, 0.01 to 0.72) on the BDI-II per therapy session was observed. The cognitive therapy scale showed no difference for nonspecific, but significant differences for specific factors in therapy. Ratings for CBT were high (mean [SD], 54.2 [4.1]). Conclusion Cognitive behavioral therapy is an effective treatment for older people with depressive disorder and appears to be associated with its specific effects. Trial Registration isrctn.org Identifier: ISRCTN18271323

Heterogeneity of DSM-IV Major Depressive Disorder as a Consequence of Subthreshold Bipolarity [Original Article]

Context There is growing evidence that major depressive disorder (MDD) might be overdiagnosed at the expense of bipolar disorder (BPD). Objectives To identify a subgroup of subthreshold BPD among DSM-IV MDD, which is distinct from pure MDD regarding a range of validators of bipolarity, and to examine the pattern of these validators among different groups with affective disorders. Design Ten-year prospective longitudinal and family study including 3 follow-up waves. Data were assessed with the DSM-IV Munich Composite International Diagnostic Interview. Setting Community sample in Munich, Germany. Participants A total of 2210 subjects (aged 14-24 years at baseline) who completed the third follow-up. Main Outcome Measures Cumulative incidence of pure MDD, BPD, and subthreshold BPD (defined as fulfilling criteria for MDD plus having manic symptoms but never having met criteria for [hypo]mania). Results Among 488 respondents with MDD, 286 (58.6%) had pure MDD and 202 (41.4%) had subthreshold BPD (cumulative incidence, 9.3%). Compared with respondents who had pure MDD, respondents with subthreshold BPD were found to have a significantly increased family history of mania, considerably higher rates of nicotine dependence and alcohol use disorders, rates of panic disorder that were twice as high, and a tendency toward higher rates of criminal acts. Prospective analyses showed that subthreshold BPD converted more often into BPD during follow-up, with DSM-IV criterion D (symptoms observable by others) being of critical predictive relevance. With increasing severity of the manic component, rates for diverse validators accordingly increased (eg, alcohol use disorders, parental mania) or decreased (harm avoidance). Conclusions Data suggest that MDD is a heterogeneous concept including a large group with subthreshold BPD, which is clinically significant and shares similarities with BPD. Findings might support the need for a broader concept and a more comprehensive screening of bipolarity, which could be substantial for future research and adequate treatment of patients with bipolarity.

Relationship Between Antiepileptic Drugs and Suicide Attempts in Patients With Bipolar Disorder [Original Article]

Context On January 31, 2008, the Food and Drug Administration issued an alert regarding increased risk of suicidal thoughts and behavior related to use of antiepileptic drugs (AEDs). On July 10, 2008, a Food and Drug Administration scientific advisory committee voted that, yes, there was a significant positive association between AEDs and suicidality but voted against placing a black box warning on AEDs for suicidality. Objective To determine if AEDs increase the risk of suicide attempt in patients with bipolar disorder. Design A pharmacoepidemiologic study in which suicide attempt rates were compared before and after treatment and with a medication-free control group. Analyses were restricted to AED and lithium monotherapy. Setting We used the PharMetrics medical claims database to study the relationship between the 11 AEDs identified in the FDA alert, and lithium, to suicide attempts. Main Outcome Measure Suicide attempts. Patients A cohort of 47 918 patients with bipolar disorder with a minimum 1-year window of information before and after the index date of their illness. Results Overall, there was no significant difference in suicide attempt rates for patients treated with an AED (13 per 1000 person-years [PY]) vs patients not treated with an AED or lithium (13 per 1000 PY). In AED-treated subjects, the rate of suicide attempts was significantly higher before treatment (72 per 1000 PY) than after (13 per 1000 PY). In patients receiving no concomitant treatment with an antidepressant, other AED, or antipsychotic, AEDs were significantly protective relative to no pharmacologic treatment (3 per 1000 vs 15 per 1000 PY). Conclusions Despite Food and Drug Administration reports regarding increased risk of suicidality associated with AED treatment, the current study reveals that, as a class, AEDs do not increase risk of suicide attempts in patients with bipolar disorder relative to patients not treated with an AED or lithium. Use of AEDs reduces suicide attempt rates both relative to patients not receiving any psychotropic medication and relative to their pretreatment levels.

Disrupted Amygdalar Subregion Functional Connectivity and Evidence of a Compensatory Network in Generalized Anxiety Disorder [Original Article]

Context Little is known about the neural abnormalities underlying generalized anxiety disorder (GAD). Studies in other anxiety disorders have implicated the amygdala, but work in GAD has yielded conflicting results. The amygdala is composed of distinct subregions that interact with dissociable brain networks, which have been studied only in experimental animals. A functional connectivity approach at the subregional level may therefore yield novel insights into GAD. Objectives To determine whether distinct connectivity patterns can be reliably identified for the basolateral (BLA) and centromedial (CMA) subregions of the human amygdala, and to examine subregional connectivity patterns and potential compensatory amygdalar connectivity in GAD. Design Cross-sectional study. Setting Academic medical center. Participants Two cohorts of healthy control subjects (consisting of 17 and 31 subjects) and 16 patients with GAD. Main Outcome Measures Functional connectivity with cytoarchitectonically determined BLA and CMA regions of interest, measured during functional magnetic resonance imaging performed while subjects were resting quietly in the scanner. Amygdalar gray matter volume was also investigated with voxel-based morphometry. Results Reproducible subregional differences in large-scale connectivity were identified in both cohorts of healthy controls. The BLA was differentially connected with primary and higher-order sensory and medial prefrontal cortices. The CMA was connected with the midbrain, thalamus, and cerebellum. In GAD patients, BLA and CMA connectivity patterns were significantly less distinct, and increased gray matter volume was noted primarily in the CMA. Across the subregions, GAD patients had increased connectivity with a previously characterized frontoparietal executive control network and decreased connectivity with an insula- and cingulate-based salience network. Conclusions Our findings provide new insights into the functional neuroanatomy of the human amygdala and converge with connectivity studies in experimental animals. In GAD, we find evidence of an intra-amygdalar abnormality and engagement of a compensatory frontoparietal executive control network, consistent with cognitive theories of GAD.

Smaller Global and Regional Cortical Volume in Combat-Related Posttraumatic Stress Disorder [Original Article]

Context Two sets of findings predict smaller cerebral cortical gray matter volume in adult posttraumatic stress disorder (PTSD). Measures of intracranial tissue volume and cerebral tissue volume have been observed to be smaller in adolescents with maltreatment-related PTSD. Second, lower intelligence, a risk factor for PTSD, is associated with smaller cerebral tissue volumes. Nevertheless, to our knowledge, only 1 study has observed globally smaller cerebral tissue volume in adults with PTSD. Objectives To apply a recently developed method providing improved estimates of cortical volume and to estimate associations between adult PTSD and selected regional cortical volumes not yet investigated. Design Between-group comparison of global and regional cerebral cortical volumes in adult patients with combat-related PTSD and controls. Setting Two Department of Veterans Affairs medical centers with large inpatient and outpatient PTSD catchments. Participants Ninety-seven combat-exposed veterans of the Vietnam and Persian Gulf wars. Main Outcome Measure Global and regional cortical volumes determined using the FreeSurfer software program and the Desikan et al parcellation (modified). Results Cerebral cortical volume, thickness, and area were observed to be smaller in association with adult combat-related PTSD. Robust associations were observed between PTSD and smaller cortical volumes in the parahippocampal gyrus, superior temporal cortex, lateral orbital frontal cortex, and pars orbitalis of the inferior frontal gyrus. Conclusions Cerebral cortical volume, thickness, and area may be smaller in adult chronic severe PTSD; however, the extracted structural variables did not mediate relations between intelligence and PTSD. The 4 regions exhibiting especially smaller cortical volumes in this sample share involvement in mechanisms subserving "top-down" facilitation of the identification of objects and words. Compromise of these regions may result in difficulty in relearning pretrauma schemata for interpreting the civilian physical and social environments.

Error in Table in: Role of GABRA2 in Trajectories of Externalizing Behavior Across Development and Evidence of Moderation by Parental Monitoring [Correction]

Professionalism in Psychiatry: A Very Special Collection [EDITORIALS]

When Residents Need Health Care: Stigma of the Patient Role [RESEARCH ARTICLES]

OBJECTIVE: Whether and under what circumstances medical residents seek personal health care is a growing concern that has important implications for medical education and patient welfare, but has not been thoroughly investigated. Barriers to obtaining care have been previously documented, but very little empirical work has focused on trainees who seek health care at their home institution. METHODS: A self-report survey on special issues in personal health care of residents was created and distributed at the University of New Mexico School of Medicine in 2001. The authors report findings regarding stigma, fear of jeopardy to training status, and attitudes toward seeking self-care for residents in dual roles as patients and trainees. RESULTS: Residents (N=155) rated their concerns regarding stigma and jeopardy to training status and the likelihood of seeking care at their training institution for six vignettes. The vignettes were paired to make comparisons between attending or supervisor as treating physician and between clinical scenarios. Alcohol abuse, nausea and diarrhea, panic attacks, and pregnancy were the most highly stigmatizing to residents; diabetes and hypertension were the least. Differences were also found for gender and specialty. CONCLUSION: Residents’ perceived stigma for clinical situations was an influential factor, strongly affecting concern about jeopardizing training status and likelihood of avoiding care at their home institution.

Developing a Modern Standard to Define and Assess Professionalism in Trainees [RESEARCH ARTICLES]

OBJECTIVE: Assessing professionalism in medical education poses many challenges. The authors discuss common themes and principles in managing professionalism in medical education. METHODS: The authors review the development of standards of professionalism in medical education. They define educational goals for professionalism and also discuss the practical problems with assessing professionalism and addressing it with the trainees. Strategies for remediation of unprofessional conduct are outlined. RESULTS: Given the importance of role models in the development of professional behavior, maintaining an environment that fosters professionalism is an implicit feature of teaching professionalism. Professionalism should be a part of the objectives for each course and clinical rotation, using clearly defined goals and objectives. Assessment of professionalism should begin early and be conducted frequently, giving trainees the opportunity to change. A formal mentoring system can be an effective mechanism to develop role models and teach professionalism. CONCLUSION: Teaching professionalism through formal curricula is paramount in helping develop new generations of compassionate and responsible physicians. Additional strategies such as consistent role modeling of professional behaviors are also needed to encourage the development of professional physicians.

Mind-Brain Dualism [RESEARCH ARTICLES]

End-of-Life Care Education forPsychiatric Residents:Attitudes, Preparedness, andConceptualizations of Dignity [RESEARCH ARTICLES]

OBJECTIVE: The authors examined psychiatric residents’ attitudes, perceived preparedness, experiences, and needs in end-of-life care education. They also examined how residents conceptualized good end-of-life care and dignity. METHODS: The authors conducted an electronic survey of 116 psychiatric residents at the University of Toronto. The survey had a mix of qualitative and quantitative questions. RESULTS: Eighty-two of 116 invited psychiatric residents participated for a response rate of 71%. With favorable attitudes, residents felt least prepared in existential, spiritual, cultural, and some psychological aspects of caring for dying patients. Trainees conceptualized dignity at the end of life in a way very similar to that of patients, including concerns of the mind, body, soul, relationships, and autonomy. Residents desired more longitudinal, contextualized training, particularly in the psychosocial, existential, and spiritual aspects of care. CONCLUSION: This is the first study to examine the end-of-life educational experience of psychiatric residents. Despite conceptualizing quality care and the construct of dignity similarly to dying patients, psychiatric residents feel poorly prepared to deliver such care, particularly the nonphysical aspects of caring for the dying. These results will inform curriculum development in end-of-life care for psychiatric residents, a complex area now considered a core competency.

Confession [RESEARCH ARTICLES]

Cultivating Empathy for the Mentally Ill Using Simulated Auditory Hallucinations [RESEARCH ARTICLES]

OBJECTIVE: The authors address the issue of cultivating medical students’ empathy for the mentally ill by examining medical student empathy pre- and postsimulated auditory hallucination experience. METHODS: At the University of Utah, 150 medical students participated in this study during their 6-week psychiatry rotation. The Jefferson Scale of Physician Empathy, Student Version, was used before and after the experience. The auditory hallucinations were provided as part of the "Hearing Voices That Are Distressing" curriculum created by the National Empowerment Center, which attempted to simulate the experience of hearing auditory hallucinations. While the students were listening to the auditory hallucinations, they underwent a psychiatric interview and simplified cognitive testing and were asked to socially interact in the community. We conducted a paired sample t-test of significance to identify pre- and postsimulated auditory hallucination changes in medical student empathy. Fifty students were randomly selected to serve as a comparison group. RESULTS: The paired sample t-test revealed that after listening to the simulated auditory hallucinations and participating in the simplified neurocognitive testing, the students’ empathy score increased. Students in the comparison group had no significant difference in their empathy scores. CONCLUSION: These results suggest that empathy may increase when students are given a brief glimpse into the mind of a mentally ill patient by listening to simulated auditory hallucinations. Specific interventions to increase empathy for the mentally ill can lead to a better understanding of how empathy can improve patient care, enhance the doctor-patient relationship, and direct future educational strategies.

Professionalism and Ethics Education on Relationships and Boundaries: Psychiatric Residents' Training Preferences [RESEARCH ARTICLES]

OBJECTIVE: Awareness of the privileges and limits of one’s role as physician, as well as recognition and respect for the patient as a human being, are central to ethical medical practice. The authors were particularly interested in examining the attitudes and perceived needs of psychiatric residents toward education on professional boundaries and relationships given the heightened current focus on professionalism and ethics.METHODS: Residents from six psychiatric residencies provided views on professionalism and ethics education on a survey encompassing 10 domains of professionalism. The authors focus on residents’ perceived need for education on boundaries in the psychiatrist-patient relationship and in peer-peer and supervisor-trainee interactions.RESULTS: Respondents (N=134) felt that nine relationship and boundary issues arising during training should receive more education: being asked to work with inadequate supervision, resolving conflicts between attendings and trainees, resident health care, adequately caring for patients while adhering to work-hour guidelines, performing work beyond one’s competence, mistreatment of residents, sexual/romantic relationships between faculty and trainees, mistreatment of medical students, and sexual/romantic relationships between residents and medical students (p<0.05 in all cases). In addition, 15 relationship and boundary issues arising during clinical practice were felt to warrant more education: responding to impaired colleagues, coping with mistakes in clinical care, reporting mistakes, balancing personal and professional life, resolving conflicts, writing prescriptions for friends or family, allocation of health care resources, providing medical advice to friends and family, physicians’ social responsibilities, interacting with families, medicine as a profession, gender bias, being asked to falsify clinical information, accepting gifts from patients, and personal relationships with patients (p<0.05 in all cases).CONCLUSION: The authors found a perceived need for more education for psychiatric residents for the majority of topics pertaining to boundaries and relationships. Residents who reported encountering ethical dilemmas more frequently wanted more education on these topics.

Door [RESEARCH ARTICLES]

Medical Students' Affirmation of Ethics Education [RESEARCH ARTICLES]

OBJECTIVE: Despite the acknowledged importance of ethics education in medical school, little empirical work has been done to assess the needs and preferences of medical students regarding ethics curricula. METHODS: Eighty-three medical students at the University of New Mexico participated in a self-administered written survey including 41 scaled questions regarding attitudes, needs, and preferences toward medical ethics and ethics education. RESULTS: Students reported strong personal interest in learning more about ethics in clinical medicine and research. They most strongly endorsed as valid objectives of ethics education the goals of helping professionals "better recognize ethical issues and clarify values-laden choices," "improve patient care and clinical decision-making," and "improve ethical practices in clinical research." Participants strongly agreed that "professional attitudes and values are an appropriate focus for medical education" and also expressed strong interest in learning more about specific ethical topics and learning methods. Women more strongly endorsed interest in additional ethics education and a preference for increased ethics education than men. Preclinical participants expressed a greater desire for additional training on all ethics topics than clinical students. CONCLUSION: The medical students surveyed strongly affirmed ethics education in medical school and expressed clear preferences for curricular topics and teaching methods.

Learning the Ropes [RESEARCH ARTICLES]

Relationships Between Drug Company Representatives and Medical Students:Medical School Policies and Attitudes of Student Affairs Deans and Third-Year Medical Students [RESEARCH ARTICLES]

OBJECTIVES: The authors sought to ascertain the details of medical school policies about relationships between drug companies and medical students as well as student affairs deans’ attitudes about these interactions. METHODS: In 2005, the authors surveyed deans and student affairs deans at all U.S. medical schools and asked whether their schools had a policy about relationships between drug companies and medical students. They asked deans at schools with policies to summarize them, queried student affairs deans regarding their attitudes about gifts, and compared their attitudes with those of students who were studied previously. RESULTS: Independently of each other, 114 out of 126 deans (90.5%) and 114 out of 126 student affairs deans (90.5%) responded (identical numbers are not misprints). Ten schools had a policy regarding relationships between medical students and drug company representatives. Student affairs deans were much more likely than students to perceive that gifts were inappropriate. CONCLUSION: These 2005 policies show trends meriting review by current medical schools in considering how to comply with the 2008 Association of American Medical Colleges recommendations about relationships between drug companies and medical students or physicians.

Students' Views on Factors Affecting Empathy in Medical Education [RESEARCH ARTICLES]

OBJECTIVE: Empathy is a prominent goal of medical education that is too often underachieved. Using concept mapping, the authors constructed a student-generated conceptual model of factors viewed as affecting empathy during medical education. METHODS: During the 2005–2006 academic year, 293 medical students and interns answered a brainstorming survey asking respondents to list factors affecting empathy, and 34 participants then sorted the factors into categories and rated each factor’s relative importance. Factors and ratings were examined using multidimensional scaling and cluster analyses, Pearson’s r, and Student’s t test. This process, known as "concept mapping," was conducted using Concept Systems. RESULTS: One hundred sixty perceived empathy factors were identified and sorted into four clusters: personal experiences, connections and beliefs; negative feelings and attitudes toward patients; mentoring and clinical experiences that promote professional growth (rated most important); and school and work experiences that undermine development of empathy (rated least important). All students rated factors in a similar hierarchical fashion across all four clusters with no differences among groups. Listening was the most highly rated factor. CONCLUSION: Students consider experiences that promote personal and professional growth to be the most important factors affecting empathy in medical education. Though less important to students, negative feelings and attitudes toward patients, as well as negative school and work experiences, affect empathy at all stages of education.

Steinbeck: A Teaching Resource for Medical Educators [MEDIA COLUMN]