Background: Evidence has shown that pro re nata (PRN) medications are often prescribed to manage agitation and disruptive behaviors. They require meticulous monitoring to prevent adverse effects and medication overuse. This article describes an audit that evaluated staff adherence to the use of an "agitation and arousal" chart that monitored PRN medication use on a child and adolescent psychiatric ward.Methods: The audit was conducted using the Plan-Do-Study-Act cycle design. Results from the first cycle were analyzed and presented in multiple formats. The second cycle was undertaken 4 months later. Adherence to the chart was re-evaluated with the expected audit standard set at 100%.Results: Sample sizes were similar in both cycles. Across the 2 cycles, 53% to 64% of inpatients were prescribed PRN medications and required use of the chart. There was an overall improvement in staff adherence across all areas of the chart, but the expected audit standard was only achieved in "medication choice as per guideline" and "medication dose as per guideline."Conclusions: The audit highlighted improved staff adherence to the expected audit standards in most areas following staff education, but the desired 100% compliance with standards in all areas was not achieved. Ongoing education and monitoring were recommended.
Psychiatry has long been considered a biopsychosocial discipline, but, in the age of evidence-based medicine, clinical care is becoming increasingly fragmented and manualized. We continue to separate "biological" and "psychological" modalities in spite of mounting evidence that psychotherapy has a direct impact on brain physiology, and that psychopharmacological treatments carry meaning that often determines its real-life effectiveness. Evidence-based treatments (EBTs) focus clinical attention on the patient's symptomatic presentation and functional capacity that define their generic DSM-5 diagnosis. Yet, understanding the person of our patients and their experience of the illness goes beyond static diagnostic labels and involves exploration of their unique subjective and relational dynamics. Therapeutic alliance, a major factor in the treatment outcome across both psychotherapeutic and psychopharmacological modalities, has become increasingly marginalized as more psychiatrists shift toward single consultation practices, where the full scope of the relational meaning is largely lost. Conversely, the minority of practitioners who continue to offer psychotherapy are often less familiar with psychopharmacological modalities. Although psychopharmacology and psychotherapy are both clinically effective, their outcomes and cost-effectiveness are further enhanced when they are applied in tandem, in the context of a nurturing relationship with the treatment provider. Below, we examine the limitations of the current EBT paradigm and the evidence for an individualized integrated wellness model that relies on empirically supported principles of care.
Tens of millions of people are already using chatbots as psychotherapists. Many find them helpful, but some are gravely harmed. This column helps clinicians understand the long history of chatbots; why they have suddenly burst on the scene now; current indications and contraindications; future risks and benefits; and how to identify and treat chatbot-induced disorders. A hybrid model will likely become increasingly prevalent, with human clinicians and chatbots working together to synergize each other's strengths and cancel each other's weaknesses. Chatbots are rapidly infiltrating our field. Clinicians cannot afford to be complacent in learning to adapt to the rapidly changing mental health landscape.
Objective: Medical students are disproportionately affected by mental health conditions. It is therefore crucial to improve access to care for this population. To do this requires an understanding of where students seek treatment and what guides this decision. The goal of this study was to examine what motivates students to seek care based on a survey of medical students at the Michigan State University College of Osteopathic Medicine (MSUCOM).Methods: All medical students at MSUCOM were offered a survey that inquired about demographics; if they had sought mental health treatment, and if so, where they had sought treatment (internal vs. external to the institution); if they had not sought treatment, where they would prefer to seek treatment; and what factors influenced these decisions. This survey was conducted before the COVID-19 pandemic.Results: A total of 354 students (25.3%) completed the survey. Of these, 167 (47%) sought mental health care during medical school, 108 of whom (65%) sought care internally in the institution, and 59 of whom (35%) sought care externally (eg, in the community). Statistically significant factors that influenced students' decisions to seek care internally at their training institution included concerns with confidentiality (OR=0.24, 95% CI: 0.12, 0.49), convenience (OR=2.29, 95% CI: 1.19, 4.40), trust/comfort with provider (OR=2.01, 95% CI: 1.02, 3.97), age (OR=0.56, 95% CI: 0.43, 0.73), and year of medical education (OR=0.49, 95% CI: 0.35, 0.67).Conclusions: As medical schools increase the internal availability of mental health services for their students, these results highlight the importance of ensuring confidentiality and accessibility of services. As more than 1 in every 3 students seeking care preferred external resources, it is important for medical schools to also provide information on community resources.
Objectives: To systematically evaluate the incidence and prevalence of drug-induced QT interval prolongation and torsades de pointes (TdP) among adults exposed to QT-prolonging medications. Design: Systematic review of observational and interventional studies identified through MEDLINE (via PubMed). Setting: Primary and secondary care settings, including inpatient and outpatient populations, across multiple geographical regions. Participants: Adult patients (18 years and older) receiving QT-prolonging drugs and undergoing electrocardiographic monitoring. Studies reporting QTc prolongation using predefined thresholds were eligible. A total of 14,756 participants were included across 42 studies. Intervention: Exposure to QT-prolonging medications. Primary and Secondary Outcomes: The primary outcome was the incidence or prevalence of significant QTc prolongation, defined as QTc >500 ms or an increase in QTc (Delta QTc) >= 60 ms. The secondary outcome was the occurrence of TdP. Results: Of 501 records, 42 studies met the inclusion criteria: 5 were interventional and 37 observational, involving a total of 14,756 patients. Methadone was the most frequently studied drug (17 studies), with reported QTc >500 ms incidence ranging from 0% to 16.2%, and TdP prevalence up to 3.6% and incidence of up to 3.2%. Other frequently studied drugs included hydroxychloroquine (5 studies), azithromycin (4 studies), and antipsychotics such as haloperidol and quetiapine. Incidence of QTc >500 ms varied considerably across settings and drug classes, influenced by heterogeneous QTc correction formulas. Conclusions: Drug-induced QTc prolongation is not uncommon across a range of widely used medications, especially in psychiatric care, yet its monitoring and risk remain inconsistently assessed, particularly in outpatient settings. While TdP was rarely reported, QTc >500 ms occurred with notable frequency. Significant heterogeneity in QTc definitions, study populations, and ECG methodologies limits cross-study comparability, underscoring the need for greater standardization.
