History & Physical:

Psych QHC RH H&P #3 RE

 

Journal Article & Summary:

Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial

The article I chose to present was “Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial” because my patient was a 14-year-old patient with 3 reported past suicide attempts and was brought in for suicidal ideations. This article was done because there were no well-established, empirically supported treatments for decreasing suicide attempts or NSSIs in adolescents with elevated suicide risk. Dialectal behavioral therapy (DBT) has multiple components and it focuses on teaching skills for enhancing emotion regulation, distress tolerance, and building a life worth living. In this study, DBT was compared to individual and group supportive therapy (IGST) to evaluate efficacy for reducing suicide attempt. The trial had specific inclusion and exclusion criteria and there was a total of 173 participants 12-18 years of age with a prior lifetime suicidal attempt. The primary outcomes were suicide attempts, non-suicidal self-injury (NSSI), and self-harm which were assessed using the Suicide Attempt Self-Injury Interview (SASII). Participants were randomly assigned to either group and treatment was done over a 6-month duration and both groups had weekly individual and group psychotherapy, therapist consultation meeting, and parent contact as needed. Participants were followed up for one year. The study found significant advantages for DBT on all primary outcomes after treatment. Rates of self-harm decreased through 1-year follow up. Treatment completion rates were also higher for the DBT group than the IGST group. This study essentially supports DBT as being the first well-established, empirically supported treatments for decreasing suicide attempts, NSSI, and self-harm in high-risk youths.

 

Site Evaluation Presentation Summary:

For my site visit, I presented a 14YO Bangladeshi-American male patient that was brought in for suicidal ideations per guidance counselor. This patient reported 3 past suicide attempts and expressed suicidal ideations while in school that day. I had seen and interviewed this patient on my own and presented it to the attending in CPEP and he said the patient is considered high-risk and had to be admitted overnight for re-evaluation by the child psychiatrist the next morning. My site-evaluator asked questions about the patient’s reported suicide attempts because the history given by the patient about them sounded uncertain given that the parents said they did not know about any of those attempts. When CBT was discussed, I presented my article on Dialectal Behavioral Therapy and talked about how it would be good for my patient based on their history and family interactions. My site evaluator wanted to know specifics of what I’d focus on during therapy and what else could have been done for this patient. I was hesitant about having Prozac as a treatment given that, as an SSRI, it has reported adverse effect of suicidal ideations in children, but he told me it is something that needs to be monitored while on the medication and that it doesn’t mean you can’t have a trial with the medication.

 

Typhon:

Psych Typhon

 

Self Reflection:

Psychiatry was my first rotation, so I had no clue what to expect going in especially since it wasn’t in a clinic setting. My rotation was at CPEP at QHC I expected to see some chaos but was not sure what it would be like. I went into this rotation assuming I would not like it that much because it wasn’t a subject that I was that interested in when I was studying it during didactic, but what we read in books is in fact different than real life and this rotation taught me that. Every patient presented different than the other and that was interesting to see in person.

Actually seeing patients with schizophrenia and having acute psychotic episodes and getting to interview them is different than reading about them in our slides. When you read about hallucinations and delusions it’s just a definition or a one-line example. However, seeing these patients who are telling me what they’re seeing and hearing was intriguing. I got to interview patients who had such strange minds and their speech and thought content made me want to keep asking them questions to see what more they can say about themselves. Asking them as many questions as I can taught me a lot about how a schizophrenic patient is and it gave me a chance to see into their mind a bit.

One thing I found hard about patient interactions in psychiatry and I learned from talking to attendings about these patients, is that after spending some time with the patient and getting information/history from them, you can’t trust most of that information. Getting collateral information is such a huge component of any psych patient interaction. Therefore, I found myself asking “I wonder if this is what really happened” a lot when interviewing patients. When doing write-ups, I always had to question what to include or not because adding something that wasn’t true was not pertinent for the HPI, which is what I wrote most of the time on this rotation. This taught me to get comfortable with calling the family member, friend, partner, or whoever knows the patient well enough and getting the information I need about the patient to know what’s going on. The population I found the most difficult to interview were autistic patients because getting a history from them was tough and unfortunately, there was no way around that. I had to get almost everything on the patient from the aide that was with them.

Unfortunately, my preceptor was only there 2 of the 5 days I worked there but, when I worked alongside him those days, he pointed out things to pay attention to with certain patients and the specific questions that are more important than others when interviewing based on what the patient came in with. He reviewed 25 of the most common psychiatry medications with not just me, but also the other 3 PA students from Stony Brook rotating with me. Almost all of the attendings there were nice and willing to answer any questions I had. A couple of them would ask me questions randomly to test me or teach me about a medication or condition I might not know that well, or ask my differential diagnosis when I present a patient, which I appreciated. I also liked working alongside the social workers in CPEP because their questions for patients were not the same as a clinician’s questions, so it helped me learn about the patient in other aspects of their life besides their chief complaint and psych hx.

Experience wise, I got to see patients that were talking to someone that wasn’t there, patients getting restrained, patients who thought Donald Trump was waiting for them on the roof, patients that were very agitated and banging on the glass repeatedly, patients who have been physically or verbally abused, patients that are actively suicidal with a plan, patients that were sent by God, and more. It was a different thing every day and I got to take home a new experience almost every day. As you may have noticed, I actually ended up liking this rotation, even though I thought I wouldn’t, because I learned a lot from it, and that’s what matters.