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Recent evidence has questioned modern psychiatric clinical practice, specifically the prescribing of “atypical” antipsychotics. Our Pan-European Research Group wished to ascertain clinical practice amongst European trainees, which treatments trainees would desire for themselves, and factors influencing this.
A semi-structured survey was constructed from prior literature, piloted, and a homogenous sample size of at least 50 was agreed upon from each country, with 50% minimum response rate. It was distributed via web-link, with questions on preference of antipsychotic for patients in given scenarios, and factors influencing choice. Physicians were asked for their preference should they develop psychosis.
i) Treatment choice of antipsychotic for patients
93% (n=600) of respondents chose to prescribe “atypical” antipsychotics (excluding Clozapine), 6% (n=42) choosing “typical” antipsychotics, 1% (n=6) choosing Clozapine as first-line therapy.
ii) Treatment choice if trainees developed psychosis
89% (n=530) of responders chose to prescribe “atypical” antipsychotics (excluding Clozapine), 7% (n=40) choosing “typical” antipsychotics, 4% (n=23) choosing Clozapine as first-line therapy.
iii) Factors influencing choice
These mapped onto three domains: cost, efficacy and side-effect profile (less than 5% other reasons). 79% (n=458) of those who responded felt efficacy most important, 46% (n=270) felt side-effect profile most important and 3% (n=16) considered cost of paramount importance.
38% (n=272) of those who responded to the survey stated that the CATIE trial had influenced their decision-making.
Psychiatry trainees’ choice of antipsychotic medication for both patients and themselves is based on perceived benefits, as opposed to evidence base and recent literature.
Guidelines produced for management of Bipolar Disorder illustrate change in evidence-base for treatment of acute and maintenance phases of illness. Our Pan-European Research Group assessed clinical practice and desired treatments amongst amongst Psychiatry trainees.
A semi-structured survey was piloted, and homogenous sample size (at least 50) agreed upon from each country, with 50% minimum response rate. It was distributed via web-link, questioning preference of mood stabiliser for patients, trainees themselves and factors influencing choice.
Tables 1 summarise choices.
Lithium and Sodium Valproate
2nd Generation Atypical antipsychotics
[Choice of mood stabiliser for patient/themselves]
Factors influencing decision-making mapped onto cost, efficacy and side-effect profile (less than 4% other reasons). 66% (n=538) of respondents felt efficacy most important, 25% (n=202) felt side-effect profile most important and 3% (n=24) considered cost of most importance.
No clear difference exists in choice of mood stabiliser for European trainees and their patients, and decisions based on perceived efficacy are generally in keeping with established guidelines.
The chronic worldwide shortage of psychiatrists has impaired the delivery of first class mental health care (WHO 2008). This international project funded by a World Psychiatric Association grant proposes to examine and compare the effects of country-specific undergraduate and postgraduate factors involved in medical student choice of a psychiatric career. Phase 1 focussed on identifying published proven and novel modifiable factors to improve psychiatric recruitment.
We searched EMBASE, PsychInfo and Medline using the keywords ‘career psychiatry’, ‘medical education’, and ‘career choice’. All 206 papers retrieved using the combined search were reviewed and categorized thematically.
Findings are summarised under three themes:
· Pre-medical school factors: arts & social sciences qualifications, attitudes towards mental illness, high uncertainty tolerance, liberal political views, gender and life goals.
· Medical school factors: availability of psychology/sociology/special-studies modules, electives; length of clinical placement; exposure to motivated patients and effective treatment; quality of teaching and good role models; and conversely negative attitudes from other specialities.
· Post-graduate factors: availability of early clinical posts in psychiatry, work-life balance, remuneration.
· Studies have been limited by small sample sizes, unicentricity, and datedness, given the major reorganisations of mental health services and postgraduate training in many countries.
· During the next stage we will generate the first multicountry comparison, with sufficient power to detect differences in factors influencing a psychiatric career choice at personal, institutional and national level. We will focus on factors that may be modifiable by policy to positively influence career choice towards psychiatry.
Alcoholism has a high prevalence and impacts on morbidity, mortality, life quality, and the economy. Heritability estimates of alcohol dependence are 50-61%. Putative psychological, cultural, and genetic susceptibilities to alcoholism have been identified but understanding of the genetic components is still underdeveloped.
Identify genetic vulnerabilities predisposing individuals to alcoholism and co-morbid psychiatric disorders in the largest study of its kind.
12 centres including 10 trainees are currently collecting blood and clinical samples. Nearly 1700 of 2000 cases of ICD-10/DSM-IV alcohol dependence have been collected; 500 with standardized assessments of alcohol use and comorbdity; and 2000 ancestrally-matched supernormal controls from UCL/collaborators. Genomic DNA will be isolated following standard procedures. Genotyping will be performed using the Affymetrix Gene Chip Human Mapping 1M Array to type up to 1 million single nucleotide polymorphism (SNP) and copy number variant (CNV) markers. Chi-square analysis of allelic association for the alcoholic sample versus controls will occur.
n=65; 57% male; mean age 45years; mean age onset harmful alcohol use 19years; mean age onset withdrawals 32y; mean alcohol intake 21 units; primary depression 27%; secondary depression 49%; antisocial personality disorder 14%. The candidate gene approach in this sample has shown that the GABA receptor B1 (GABRB1) and the tachykinin receptor 1 (TACR1) are involved in genetic susceptibility to alcoholism. The D2 dopamine receptor is next.
Preliminary data suggests high psychiatric comorbidity in a clinical alcohol dependence sample and implicated candidate genes. Next is genomewide analysis of markers, sequencing and biological pathway/systems alterations.
Bipolar disorder (BPD) and alcoholism are strongly comorbid and both have significant genetic influences but no consistent genetic vulnerability has been found. We aimed to find bipolar-alcoholism vulnerability genes.
A genome-wide association study (GWAS) of 510 patients with bipolar disorder (BPD), of whom 143 met Research Diagnostic Criteria (RDC) alcoholism diagnoses, and 506 ancestrally matched supernormal controls. We genotyped 372K genetic markers on an Affymetrix 500K-array. Chi-square analysis of allelic association using PLINK, and permutation testing for gene-wise association of genes previously associated with alcoholism-related phenotypes using COMBASSOC, were performed.
No marker met genomewide significance. Gene-wise analyses of markers clustering near genes already implicated in alcoholism, but which were not associated in non-alcoholic BPD, were: Cadherin-11 (CDH11, p = 6 × 10-4), Exportin 7 (XPO7), neuromedin-U receptor 2 (NMUR2), collagen type XI-alpha 2 (COL11A2) and Semaphorin-5A (SEMA5A).
These genes replicated prior genetic reports implicating “connectivity” (adhesion, migration and neuronal signalling) genes in addictions and comorbid BPD. Connectivity genes regulate neuronal connections during development and play roles in later neuroadaptive and mnemonic processes. These processes may influence addiction vulnerability, as seen clinically in denial, cognitive impairment, and repetitive substance misuse and relapse behaviour. We propose that we have identified genes i) increasing susceptibility to alcoholism that could be unmasked or released by the presence of bipolar affective disorder; ii) and genes increasing susceptibility to affective disorder that also predispose to secondary alcoholism. We were limited by small sample size. Larger future studies are needed.
There is growing concern about the influence of the pharmaceutical industry on psychiatric teaching and psychiatric professionalism as a whole. As a consequence, several national and international medical and psychiatric associations have issued guidelines to regulate the interactions between physicians and industry.
The EFPT-PRIRS study aims to provide the lacking data on the extent and nature of these interactions among psychiatric trainees across Europe.
Study objectives were determined by the EFPT research group (EFPT-RG), after discussion with national and international experts. A survey was then devised compiling previously published questionnaires extending them by questions with specific relevance to psychiatric trainees. The resulting questionnaire was piloted amongst members of the EFPT-RG, modified accordingly and subsequently distributed to the national study coordinators. All 24 EFPT member countries were invited to participate in the study and data collection is currently ongoing.
Preliminary analysis reveals the vast differences in industry - trainee relationships across European countries as well as major differences in personal attitudes towards these interactions.
EFPT-PRIRS will potentially have an impact on the regulation of the interactions between the pharmaceutical industry and psychiatric trainees.
Despite recent recent evidence and subsequent guidelines that have suggested factors such as side-effect profile and cost should be taken into account when prescribing antidepressant medication, relatively little evidence exists on decision-making in clinical practice.
Our Pan-European Research Group looked at clinical practice regarding antidepressants amongst Psychiatry trainees, treatments trainees would desire themselves, and factors influencing decision-making.
A semi-structured survey was constructed from recent literature, was piloted, and a homogenous sample size of at least 50 agreed upon from each country, with 50% the minimum response rate. It was distributed via web-link, questioning preference of antidepressant for patients, and factors influencing choice. Trainees were asked for their preference should they develop a moderate to severe depressive episode, and require medication.
Treatment choices are summarised in Table 1. 79% of trainees would prescribe similar antidepressants for themselves as for patients.
Factors influencing decision-making mapped onto three main domains: cost, efficacy and side-effect profile (5% other reasons). 86% (n = 548) of those who responded felt efficacy most important, 38% (n = 237) felt side-effect profile most important and 6% (n = 33) considered cost of most importance.
Some differences exist in choice of antidepressant for European trainees and their patients, and factors affecting choice conflict with evidence base and guideline suggestions.
The chronic worldwide shortage of psychiatrists has impaired the delivery of first class mental health care. The WHO produced a report on the Mental Health Gap, showing the high burden of mental health, neurological and substance misuse disorders worldwide, estimating a treatment gap of 75% between need and resources.
Aims and objectives
Research to date has highlighted key areas that influence students' choice of a career in psychiatry. There have been several key literature reviews summarising work in the area since the 1950s. The current study updates literature with a systematic review of the past 10 years.
A five level search strategy was used.
A standard Critical Appraisal tool was developed based on the one used by the Best Evidence in Medical Education Group in Dundee. Papers were coded and graded using hierarchies of evidence - Sackett Hierarchy of Evidence and Kirkpatrick Hierarchy.
Results & conclusions
The quality of published studies has risen over the past 30 years, with the past decade producing the most robust evidence. However, it is a complex area to research with many potential confounders, and large gaps in knowledge remain.
Today‘s generation relies on the Internet as their main source of information and uses it for a variety of purposes, including professional networking and education.
With regard to the nature of a therapeutic relationship, it is necessary to establish certain professional boundaries between psychiatrists and their patients. These boundaries can be compromised by a patient‘s request to connect online via social networks. Moreover, disclosure of patient-identifiable information can undermine the assurance of doctor-patient confidentiality. Another potential drawback is the excessive and careless disclosure of private information by the psychiatrist.
The use of emails for psychiatric clinical work can cause concerns on different levels. Firstly, confidentiality of email conversations can not always be garanteed. Secondly, patients and families trying to directly reach clinicians by finding their emails on the internet can disrupt the usual course of care.
The use of smartphone apps and gathering of data through them also creates new ethical issues. The consequence of constantly monitoring citizens by state-sized private companies is a concern, like the use of private or medical data to promote products and influence behaviours, or to determine insurance policy rates.
Due to these ethical challenges, many psychiatrists simply ignore social media and new information technologies. However, they miss valuable opportunities to engage in public health and policy discussions, establish national and international professional networks, and facilitate patients’ access to information about health and services.
These questions and precautions should be inculcated as a part of the psychiatric training so that psychiatrists in the 21st century will be able to navigate themselves in the rapidly developing social media arena as cautious, yet active members.
Burnout syndrome is defined by three domains: emotional exhaustion, cynicism and reduced professional efficacy. Junior doctors have a high susceptibility to burnout reflected in the high prevalence identified in previous work. This is a significant issue as burnout has measurable effects on work performance. There has been limited research conducted on burnout in psychiatry trainees in the United Kingdom.
This paper takes a step towards addressing this gap by extracting the data concerning UK psychiatric trainees collected in the international burnout syndrome study (BoSS), which aimed to assess the prevalence and contributing factors of burnout among psychiatric trainees from over 20 countries, and presenting the findings concerning UK trainees.
Data collected included demographic data and information related to working hours, bullying, harassment and stalking, supervision, suicidal ideation, depression (PHQ−9), and a personality trait assessment. Burnout syndrome was measured using the Maslach burnout inventory (MBI-GS). A total of 3964 psychiatry trainees in the UK were invited, of which 1187 (30%) responded including 811 (20%) providing complete responses for MBI-GS.
The mean age was 33 years, and 49.1% of respondents were male. Gender distribution of participants was the same as non-participants. Mean scores were 2.6 for exhaustion, 2.1 for cynicism and 4.5 for professional efficacy; and severe burnout was found in 309 (38%).
Three factors were positively associated with severe burnout: long working hours, lack of clinical supervision and not having regular time to rest.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The international burnout syndrome study (BoSS) examined burnout in psychiatry trainees and associated factors. Long working hours were significantly associated with burnout.
A high rate of severe burnout in UK psychiatric trainees (38%) was found in the BoSS study. This paper looks at the working hours of UK trainees.
Data collected during the BoSS study included information related to working hours, looking in particular at the working time directive rules. A total of 3964 UK psychiatric trainees were invited to take part, of which 1187 (30%) responded, and 811 (20%) provided complete responses for working hours questions.
The mean age was 33 years, with 49.1% males and equal gender distribution of participants and non-participants. The mean hours of contracted work per week were 42.7 (42.2–43.2) for men, versus 41.1 (40.4–42.0) for women. Actual hours worked were significantly higher at 46.2 (45.0–47.4) for men and 46.0 (44.9–47.1) for women. Forty-six percent of trainees breached one or more working time directive (WTD) safety limits.
Actual hours worked among psychiatric trainees in the United Kingdom are about 10% higher than contracted hours. Female trainees also work more uncontracted hours than male trainees. This is significant when considering the association between hours of work and burnout, and also adds to the perception that women have to work harder for the same recognition as men. Forty-six percent of trainees breached WTD limits.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Postgraduate medical trainees experience high rates of burnout, but evidence regarding psychiatric trainees is missing. We aim to determine burnout rates among psychiatric trainees, and identify individual, educational and work-related factors associated with severe burnout.
In an online survey psychiatric trainees from 22 countries were asked to complete the Maslach Burnout Inventory (MBI-GS) and provide information on individual, educational and work-related parameters. Linear mixed models were used to predict the MBI-GS scores, and a generalized linear mixed model to predict severe burnout.
This is the largest study on burnout and training conditions among psychiatric trainees to date. Complete data were obtained from 1980 out of 7625 approached trainees (26%; range 17.8–65.6%). Participants were 31.9 (SD 5.3) years old with 2.8 (SD 1.9) years of training. Severe burnout was found in 726 (36.7%) trainees. The risk was higher for trainees who were younger (P < 0.001), without children (P = 0.010), and had not opted for psychiatry as a first career choice (P = 0.043). After adjustment for socio-demographic characteristics, years in training and country differences in burnout, severe burnout remained associated with long working hours (P < 0.001), lack of supervision (P < 0.001), and not having regular time to rest (P = 0.001). Main findings were replicated in a sensitivity analysis with countries with response rate above 50%.
Besides previously described risk factors such as working hours and younger age, this is the first evidence of negative influence of lack of supervision and not opting for psychiatry as a first career choice on trainees’ burnout.