[Show abstract][Hide abstract] ABSTRACT: A history of childhood sexual abuse (CSA) has been associated with adult depression, but data on abuse severity and disclosure are scant, particularly among low-income ethnic minorities. CSA often co-occurs with other adversities, which also increase the risk of depression. This study examined the peritrauma variable of abuse severity and the posttrauma variables of disclosure and self-blame as predictors of current depression symptoms in 94 low-income African-American and Latina women with histories of CSA. After controlling for nonsexual childhood adversity and adult burden (i.e., chronic stress), severe CSA overall was associated with higher depression scores, especially among Latinas who disclosed their abuse. Depression symptoms among African-American women were highest in those who disclosed and reported high levels of self-blame at the time of the incident. The link between depression and specific peri- and post-CSA factors in minority women may help guide future interventions.
The Journal of nervous and mental disease 07/2011; 199(7):471-7. DOI:10.1097/NMD.0b013e31822142ac · 1.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Psychiatric training was once synonymous with learning psychotherapy, but current psychiatric trainees face many options for integrating psychopharmacology and psychotherapy into their future practices, including providing primarily medication-focused visits. We examined psychiatry residents' attitudes towards learning psychotherapy, practicing psychotherapy in the future, and overall identification as psychotherapists.
We surveyed residents from 15 US residency programs during 2006-2007. The survey included 36 Likert-scaled items inquiring about residents' attitudes towards their psychotherapy training and supervision, their level of psychotherapy competence, the role of psychotherapy in their psychiatric identity, and their future practice plans. Four items asked about personal psychotherapy experience. Here we describe findings related to attitudes concerning being a psychotherapist and future practice plans.
Among 249 respondents, most (82%) viewed becoming a psychotherapist as integral to their psychiatric identity. Fifty-four percent planned to provide formal psychotherapy, whereas 62% anticipated psychopharmacology would be the foundation of treatment for most patients. Residents with personal psychotherapy experience and first-year postgraduate residents (PGY-1) were more likely to identify as psychotherapists, plan to pursue further psychotherapy training postresidency, and anticipate psychotherapy being central to their future practice.
Despite concerns about the diminishing role of psychotherapy in the practice of psychiatry and in psychiatrists' professional identity, most psychiatric residents view psychotherapy as integral to their professional identities and future practice plans.
Annals of Clinical Psychiatry 02/2011; 23(1):30-9. · 2.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Most psychiatric residents enter training intent on learning both psychopharmacologic and psychotherapeutic interventions. After graduation, however, many emphasize pharmacotherapy over psychotherapy.
A multisite survey of psychiatry residents queried psychotherapy interests, attitudes, and practice intentions. Factors associated with self-reported decreased interest in psychotherapy since beginning residency were examined.
Although 11.8% of the entire sample (n = 229 PGY1-PGY4 residents) reported decreased interest in psychotherapy during training, among PGY4s the corresponding figure was 16.4%. Positive attitudes towards psychotherapy, and self-perceived competence in cognitive-behavioral and psychodynamic psychotherapy were most highly correlated with maintained interest in psychotherapy. Dissatisfaction with the quality of psychotherapy faculty and curriculum, and viewing departmental leadership as unsupportive of psychotherapy training were correlated with decreased interest during training.
Maintaining residents' interest in psychotherapy requires improvements in curriculum, teaching, and supervision throughout training. Our data underscore the crucial role that departmental leadership must play in supporting trainees' goals of becoming comprehensively trained psychiatrists.
American journal of psychotherapy 01/2011; 65(1):47-59.
[Show abstract][Hide abstract] ABSTRACT: Currently in the United States, more than one in three psychiatric residents are international medical graduates (IMGs). In light of forecasts of physician shortages, this proportion is likely to continue growing. Although central to psychiatric care, sexual health competence levels of IMGs may be lower than those of U.S. graduates.
The authors conducted a nonsystematic review of the literature and online data to establish the learning needs of IMGs in this area.
Data on five areas are summarized: demographic and sociocultural data of IMGs in the United States; the need for sexual medicine competence for practicing psychiatrists; how sexual health is currently taught in foreign medical schools; attitudes toward sexuality and sexual problems among physicians and patients of different cultures; and the management of sexual issues, including sexual boundaries, by IMGs.
The authors found evidence suggesting that IMGs from areas most culturally dissimilar to the United States are likely to benefit from sexual medicine curricula in the context of cultural competence training. The diversity and resilience of IMGs are emphasized. Implications for immediate training and future research are outlined.
[Show abstract][Hide abstract] ABSTRACT: Adult posttraumatic stress symptoms and a biomarker index of current health risk in childhood sexual abuse (CSA) survivors were investigated in relation to CSA severity, disclosure, and other peri- and post-trauma factors.
A community sample of 94 African American and Latina female CSA survivors was assessed.
Severe CSA predicted posttraumatic stress symptoms overall, avoidance/numbing symptoms, and greater biomarker risk and was not mediated by post-trauma variables. Moderate CSA severity was mediated by post-trauma disclosure, predicted reexperiencing symptoms, but was unrelated to biomarker risk. No overall ethnic differences were found.
Results suggest targets for interventions to improve the well-being of minority women CSA survivors.
[Show abstract][Hide abstract] ABSTRACT: Few studies of residents' attitudes toward psychotherapy training exist. The authors examined residents' perceptions of the quality of their training, support for training, their own competence levels, and associations between self-perceived competence and perceptions of the training environment.
An anonymous, web-based questionnaire was distributed to residents at 15 U.S. training programs in 2006-2007. Likert-scaled items were used to evaluate attitudes regarding psychotherapy training and self-perceived competence in five modes of psychotherapy: brief, cognitive-behavioral, combined psychotherapy and psychopharmacology, psychodynamic, and supportive.
Surveys were completed by 249 of 567 residents (43.9%). Over one-half agreed that their program provided high-quality psychotherapy training. Concerns about the adequacy of the time and resources provided by their programs were expressed by 28%. Although residents generally believed that their training directors supported psychotherapy training, approximately one-third did not believe that other key department leaders were supportive. Across years of training and modes of therapy, residents perceived their own competence in neutral to slightly positive terms, with self-perceived competence increasing with years of training.
Given the current residency training requirements, these data provide a mixed picture about how residents experience psychotherapy training. Residency programs may need to reassess the quality and quantity of resources dedicated to psychotherapy training. Critical appraisal of support provided by key departmental leadership is also warranted.
[Show abstract][Hide abstract] ABSTRACT: Psychotropic medication nonadherence is a major public health problem, but few studies have focused on Latinos. The authors systematically reviewed the literature on rates of and factors influencing antipsychotic, antidepressant, and mood stabilizer nonadherence among U.S. Latinos.
MEDLINE and PsycINFO were searched by using the keywords adherence, compliance, Latino, Hispanic, psychotropic, and related terms; bibliographies from relevant reviews and studies were also searched. Twenty-one studies met inclusion criteria: published since 1980 in English or Spanish and measured psychotropic medication nonadherence rates among U.S. Latino adults. Information was extracted about study design and objective, location, population, medication type, participant demographic characteristics, adherence measures, adherence rates, and factors related to adherence.
In the 17 studies that included Latinos and other minority groups, mean nonadherence rates were 41%, 31%, and 43%, respectively, among Latinos, Euro-Americans, and African Americans, with an overall effect size of .64 between Latinos and Euro-Americans. In the four studies that included only Latinos, the mean nonadherence rate was 44%. Ten of 16 studies found that Latinos had significantly lower adherence rates than Euro-Americans. Risk factors for nonadherence included being a monolingual Spanish speaker, lacking health insurance, experiencing access barriers to high-quality care, and having lower socioeconomic status. Protective factors included family support and psychotherapy.
Rates of nonadherence to psychotropic medications were found to be higher for Latinos than for Euro-Americans. Further investigation is needed to understand the potentially modifiable individual and society-level mechanisms of this discrepancy. Clinical and research interventions to improve adherence should be culturally appropriate and incorporate identified factors.
[Show abstract][Hide abstract] ABSTRACT: This secondary data analysis from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study compared clinical characteristics and outcome after citalopram treatment for Hispanic outpatients whose language preference was English (N=121) or Spanish (N=74).
Data for Hispanic outpatients with nonpsychotic major depression were gathered from two STAR*D regional centers. Participants received citalopram for up to 14 weeks, with dosage adjustments based on routine clinical assessments. Efforts were made to achieve remission with a measurement-based care approach, with adjustments symptoms and side effects.
Spanish speakers were older, were more likely to be women, were less educated, had lower income, had more medical burden, and were more likely than English speakers to be seen in primary care rather than in psychiatric clinics. Compared with Spanish speakers, English speakers had more previous suicide attempts and more family history of mood disorders. The groups did not differ in a clinically meaningful way in severity of depression. Before adjustment for baseline differences, Spanish-speaking participants had lower rates of and slower times to remission and response compared with English speakers. After adjustment for baseline variables, these differences were no longer significant. Relapse rates did not differ between groups.
Compared with English-speaking Hispanic patients, Spanish-speaking Hispanic patients may have a less robust response to antidepressants. The reasons for this are not clear but may include more disadvantaged social status. The degree to which these results can be generalized to other Hispanic populations or to other non-English-speaking groups remains to be seen.
[Show abstract][Hide abstract] ABSTRACT: The risks and factors contributing to major depressive episodes in HIV infection remain unclear. This 2-year prospective study compared cumulative rates and predictors of a major depressive episode in HIV-infected (HIV+) men (N=297) and uninfected (HIV-) risk-group controls (N=90).
By design participants at entry were without current major depression, substance dependence or major anxiety disorder. Standardized neuromedical, neuropsychological, neuroimaging, life events, and psychiatric assessments (Structured Clinical Interview for DSM III-R) were conducted semi-annually for those with AIDS, and annually for all others.
Lifetime prevalence of major depression or other psychiatric disorder did not differ at baseline between HIV+ men and controls. On a two-year follow-up those with symptomatic HIV disease were significantly more likely to experience a major depressive episode than were asymptomatic HIV+ individuals and HIV-controls (p<0.05). Episodes were as likely to be first onset as recurrent depression. After baseline disease stage and medical variables associated with HIV infection were controlled, a lifetime history of major depression, or of lifetime psychiatric comorbidity (two or more psychiatric disorders), predicted subsequent major depressive episode (p<0.05). Neither HIV disease progression during follow-up, nor the baseline presence of neurocognitive impairment, clinical brain imaging abnormality, or marked life adversity predicted a later major depressive episode.
Research cohort of men examined before era of widespread use of advanced anti-HIV therapies.
Symptomatic HIV disease, but not HIV infection itself, increases intermediate-term risk of major depression. Prior psychiatric history most strongly predicted future vulnerability.
[Show abstract][Hide abstract] ABSTRACT: The authors compare and contrast psychiatry residency training in the United States to that in Canada and selected countries in South America, Europe, and Asia.
Nine individuals who are intimately familiar with psychiatry residency training in the United States (primarily chairs, training directors, associate training directors, or residents) and who trained in other countries describe their past training programs in terms of clinical experiences, didactic structure, supervision, evaluation, and major differences from U.S. training.
Medical education and psychiatry training vary considerably in different regions in terms of the duration of training, structure of clinical experiences, level of responsibility and autonomy of trainee, amount of classroom teaching, national examinations, and credentialing. Some are much less structured than training in the United States (e.g., Sweden) while others are somewhat more structured (e.g., Korea), but differences appear to be lessening.
Although similarities outweigh differences between programs in various continents and countries, training programs around the globe have much to learn from each other.
[Show abstract][Hide abstract] ABSTRACT: The authors compared the subjective functioning of 137 middle-aged and elderly outpatients with schizophrenia or schizoaffective disorder with that of 77 normal subjects, using the Medical Outcomes Study (MOS) 36-Item Short Form (SF-36) Health Survey. The SF-36 is a generic outcome measure that provides a profile of functioning in several different domains.
Measures included the MOS-SF-36, along with standardized instruments for assessing psychopathology, cognition, dyskinesia, quality of well-being, and everyday functioning.
Schizophrenia patients reported greater disability than normal subjects in all areas (mental and physical) assessed by the SF-36 except for bodily pain. Logistic-regression analysis suggested that the best predictors for being in the schizophrenia group were 1) physical and emotional functioning and 2) pain. Among patients, age at onset of illness, depressive symptoms, and cognitive functioning predicted 39% of the variance in the SF-36 Mental Health Composite score.
Subjective functioning of older people with schizophrenia is affected by perceived physical health, depressive symptoms, and cognitive impairment.
American Journal of Geriatric Psychiatry 01/2003; 11(6):629-37. · 4.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examined acquired immune deficiency syndrome (AIDS)-related grief resolution and psychiatric morbidity in 286 human immunodeficiency virus (HIV)-positive and HIV-negative gay men examined between 1989 and 1993 in San Diego, CA. Psychiatric morbidity, mood ratings, and bereavement assessments were obtained using the Structured Clinical Interview for DSM-III-R, Hamilton Rating Scales for Depression and Anxiety, and Texas Revised Inventory of Grief. Sixty percent of the men (N = 171) reported a loss within the previous 12 months. Eighteen percent of the bereaved met criteria for unresolved grief. No differences were evident in lifetime psychiatric disorders, yet men with unresolved grief demonstrated an elevated prevalence of current major depression and panic disorder when compared with resolved grievers. Clinician sensitivity to the grief process and its relationship to psychiatric complications is an important component of comprehensive psychiatric and medical care of men at high risk for HIV during this era of AIDS.