This journal article is a systematic review that examines the significance of including grief in the DSM – V. Although grief presents with a specific criteria and unique set of coping strategies, the article argues that the requirements may be too vague and over-diagnose patients. Furthermore, it argues that there may be little benefit in including the diagnosis in the DSM – V as so many symptoms overlap with major depression. Based on the findings of longitudinal cohort studies, the article advocates for the rejection of “complicated grief” and the inclusion of prolonged grief disorder. In doing so, more criteria is included such as identify disruption, marked sense of disbelief about death, avoidance of reminders that person is dead, intense emotional pain related to death, difficulty with reintegration, emotional numbness, feeling that life is meaningless, and intense loneliness must be met. In doing so, this would prevent over-diagnosis. I also believe it is important to distinguish prolonged grief disorder from major depressive disorder as it provides the language for patients and their loved ones to understand what they are going through. A more specific approach in psychotherapy may also be initiated to treat the symptoms of grief such as providing more emotional support and cognitive behavior therapy in preventing ruminating thoughts.

PICO Search Assignment #1

Tiffany Liang

PATIENT PROBLEM/SETTING

40 yo female patient presents to the inpatient psychiatric unit for a schizophrenia episode. Patient has an 18 year history of schizophrenia and currently takes Risperidone 1mg 2x PO q daily.

SEARCH QUESTION: Does the use of dual 2nd generation anti-psychotics reduce the risk of hospital readmissions in schizophrenic patients compared to use of monotherapy 2nd generation anti-psychotics?

QUESTION TYPE: What kind of question is this? (boxes now checkable in Word)

☐Prevalence ☐Screening ☐Diagnosis

☐Prognosis ☒Treatment ☐Harms

• The first choice of study would be a meta-analysis or systematic review as they are regarded as the highest level of study. Meta-analysis systematically reviews the findings of several independent studies. Systematic review is similar in that it proposes a research question and that collects and summarizes all relevant data with eligible criteria. In conclusion, both types of study gathers a larger pool of data to provide more information and greater overview on the topic discussed.

• If these two studies are not available, a randomized control trial would be the next best choice as there is a control and study. In this situation, the control would be one 2nd generation anti-psychotic and the study would be the use of two 2nd generation anti-psychotics. Randomized control trials offers carefully planned experiments and reduces the risk of bias in order to compare the two groups studied and gauge if the study is effective.

PICO SEARCH TERMS:

SEARCH TOOLS & RESULTS

PubMed:

• Schizophrenia Dual Anti-Psychotic (Filters : Meta Analysis, Systemic Review, RCT, 2010-present) – 93

• Schizophrenia anti-psychotic combination (Filters : Meta Analysis, Systemic Review, RCT, 2010-present) – 45
• Dual Antipsychotics (Filers : Meta Analysis, Systemic Review, RCT, 2010-present) – 85

Cochrane :

• Dual Therapy Schizophrenia (Filters: Meta analysis, Systemic Review, RCT, 2010-Present) – 26
• Antipsychotic Polypharmacy (Filters: Meta analysis, Systemic Review, RCT, 2010-Present) – 2

JAMA :

• Dual antipsychotics (Filters : Psychiatry) – 0
• Antipsychotic Polypharmacy (Filters : Psychiatry) – 25

Initially, I limited my search parameters to meta-analyses, systematic reviews, and randomized controlled studies as they are considered the highest level of study. A filter for the past ten years was also applied so that the most relevant data could be gathered. However, many of these studies only followed schizophrenia patients for a short period of time. There was no concrete evidence of whether dual anti-psychotic therapy was beneficial in reducing hospital readmission as the subjects were not studied for long enough. This expanded my search to include other types of studies with no date range to see if a study existed to allow for a longer follow-up period.

ARTICLES

1. Clozapine Combined with Different Anti-Psychotic Drugs for Treatment-Resistant Schizophrenia

2. Combining Anti-Psychotic Medication for the Treatment of Schizophrenia

3. Association of Antipsychotic Polypharmacy vs. Monotherapy Psychiatric Rehospitalization Among Adults with Schizophrenia

What is the clinical “bottom line” derived from these articles in answer to your question?

According to UpToDate, Schizophrenia In Adults : Maintenance Therapy and Side Effect Management, schizophrenia treatment should first be started with the lowest therapeutic dose of a 2nd anti-psychotic medication. 2nd anti-psychotic medications are the first choice as they produce less extrapyramidal symptoms (dystonia, Parkinsonism, akathisia, tardive dyskinesia) due to their lower affinity for dopamine receptors. Risperidone and Aripiprazole are the suggested initial choices of medication as they present with the least adverse effect profile within the class of 2nd generation anti-psychotics. If the trial fails, an alternative anti-psychotic is initiated. Finally, if both trials fail, Clozapine is started. Although Clozapine is highly effective in treating psychotic symptoms, it is reserved for later use due to its severe adverse effect profile such as agranulocytosis and rhabdomyolysis. As schizophrenia is a life-long disease with severely debilitating symptoms, the field of medicine is constantly looking for a better combination of treatment options or new drugs in order to more effectively treat schizophrenia. For this reason, the exploration of using dual 2nd generation anti-psychotic versus a single 2nd generation anti-psychotics is investigated in this PICO study. 

The clinical bottom line of the following studies suggests that there is no concrete correlation in the use of dual 2nd generation anti-psychotics in reducing hospital readmissions for schizophrenia patients. Two of the three articles showed evidence in combining Clozapine and another anti-psychotic in treating schizophrenia patients (Barber 2017; Ortiz-Orendein 2017). However, they both presented with the limiting factor of being conducted over a short period of time. This provides inconclusive evidence as schizophrenia is a long-term disease. The studies weren’t long enough to establish if there was re-hospitalization during a patient’s lifetime. The third article presented with stronger evidence in the benefit of using dual 2nd generation anti-psychotic therapy as it followed patients for the entirety of their life (Tiihonen, 2019). Although there was a correlation between using dual therapy and reduction in hospital readmissions, the sample size was limited to the country of Finland. This is a very small population without a large range of diversity. Therefore, the findings cannot be applied to the general public. In conclusion, these articles suggest that the recommended treatment remains what is advised in UptoDate.  More long-term studies over broader study groups would be needed to provide conclusive evidence that dual 2nd generation anti-psychotic therapy reduces schizophrenia hospital readmissions. 

My inpatient psychiatric unit rotation was truly a memorable one as it exposed me to be an entirely new setting and approach towards patient care. On average, most patients were admitted for a period of two weeks. This provided the rare opportunity to track a patient and progress over time. It was rewarding to observe a patient respond to pharmaceutical therapy in this time. For example, the majority of the patients presented with schizophrenic exacerbations and significant hallucinations. A two-week course of Risperidone and inpatient care ensured that they were compliant with medications. Significant reductions in hallucinations were readily observed. In this process, I also learned to set realistic standards and goals towards psychiatric treatment. Although the ideal situation would be to bring the patient to our version of reality and as a fully functioning individual, we must keep in mind that the goal of treatment is to bring the patient to his level of baseline. This usually means that the patient’s symptoms are managed so that they no longer present as a threat or source of harm to the patient. The best treatment outcome may mean reducing the patient’s suicidal ideations or hallucinations.

Additionally, the psychiatric rotation experience taught me how important the patient interview is. The initial patient interview process often took nearly an hour. This was due to the fact that patient’s were oftentimes slower in thought, experiencing hallucinations, or may present with contradicting information due to personality disorders. It took a much longer time, empathy, and questions to extract the necessary history to diagnose the patient and initiate proper patient. Overall, this experience taught me that extraordinary patience and realistic expectations are needed to provide optimal care for patients.

Typhon Group

Survey: Reviewer: Reviewee: Survey Period: Completed:

Preceptor York PA FINAL Psychiatry Evaluation Preceptors (Dr.Manasherov)
Students (Liang, Tiffany)
2/3/2022

2/3/2022 2:31:42 PM ET

1. Please verify that the student named above is competent to perform the skills below at the level expected for a clinical student completing this rotation:
Student is able to (for skills not performed competently, please decribe in the comments section below):
1) Elicit a problem-oriented psychiatric patient history utilizing all available information sources (patient, family, community, old records), perform the relevant focused or complete physical examination, formulate an appropriate differential diagnosis, develop a final assessment and management plan for acute, emergent, and chronic psychiatric problems

2) Give a concise oral presentation of the patient, based on the history and physical examination in a 3-5 minute time frame
3) Document a Mental Status Exam, admission note and orders, SOAP progress notes, and discharge note/plan

Yes

2. Please evaluate the student in the following area (refer to syllabus – Learning Outcomes). Any additional comments can be provided in the comments section below.
Eliciting a Medical History in Psychiatry:
Takes an appropriate focused or comprehensive psychiatric patient history.

Patient identifying information provided. History of Present Illness.
Past Medical History.
Family and Social History.

Review of Systems.
Demonstrates the ability to write a thorough and/or focused psychiatric note.

Above Average

3. Please evaluate the student in the following area (refer to syllabus – Learning Outcomes). Any additional comments can be provided in the comments section below.
Performing Appropriate Physical Exam in Psychiatry:
Performs appropriate physical examination for a psychiatric patient.

Performs appropriate focused exam.
Performs appropriate comprehensive exam. Demonstrates appropriate technique and sequence. Interprets findings of the physical exam.

Average

4. Please evaluate the student in the following areas (refer to syllabus – Learning Outcomes). Any additional comments can be provided in the comments section below.
Clinical Reasoning in Psychiatry:
Presents the patient in an organized structure in oral and written manner.

Demonstrates broad knowledge base about disorders commonly presented psychiatric disorders. Demonstrates an active learning process (reads recent journals, seeks various sources). Develops Differential Diagnosis & Final Diagnosis.
Orders & Interprets Lab & Diagnostic Studies commonly used in the psychiatric setting.

Develops Appropriate Management Plan.
Provides adequate psychiatric care in children, adolescents, adults and the elderly.
Provides Appropriate Patient Education (including meds, discharge plans, culturally sensitive). Overall Clinical Knowledge and Reasoning for Psychiatric rotation.

Above Average

5. Please evaluate the student in the following area (refer to syllabus – Learning Outcomes). Any additional comments can be mentioned in the comments box below.
Professional Behavior:
Wears proper identification as a student.

Introduces self as a PA student to patients and staff.
Follows the appropriate schedule and attends all meetings (includes rounds, lectures).
Carries out assignments.
Wears appropriate attire and exhibits professional appearance.
Demonstrates professional behavior to patients and staff (including cultural sensitivity, patient rapport, interpersonal communication skills).
Demonstrates appropriate willingness to learn and accepts feedback.

Outstanding

6. Procedure Log Reviewed with Student. Yes

7. Performs clinical procedural skills competently as outlined in the Psychiatric Rotation Procedure Log. Above Average

8. Suggested Overall Grade: A

9. Comments (Student’s Strengths, Areas for Improvement, Suggestions).

Professionalism, ability to integrate into interdisciplinary team and exceptional interpersonal skills with patients and providers, constant work to increase he fund of knowledge but needs continue to work in it. Eager to learn, asks questions and ready to hear critical feedback

10. Are there specific areas that the PA program should focus more on? improve interviewing skills particularly acute psychiatric patients.

11. Please sign electronically by typing your name (first & last name, credentials) in the text box below. Please be sure to include your contact information.

Manasherov, Mikhail Assistant professor Icahn School of Medicine at Mount Sinai, Attending Psychiatrist of Department of Psychiatry at Elmhurst Hospital Center