Amoud University in Borama is located in the self‐declared state of Somaliland, in the Horn of Af... more Amoud University in Borama is located in the self‐declared state of Somaliland, in the Horn of Africa. Past conflicts and resulting economic hardship have led to a lack of local academic psychiatry faculty and resources. Amoud has been for some years partnering with voluntary faculty in the United Kingdom to teach psychiatry to its medical students through in‐person “teaching missions.” This was recently led by a Borama‐native psychiatry resident in Ethiopia. COVID‐19 added further hardships due to restrictions to travel and in‐person gatherings. These challenges also created the opportunity for the development of an innovative, international, hybrid (online onsite), self‐sustaining partnership model which has been successful in improving psychiatry teaching for undergraduate students in 2020–2021 and will continue in 2021–2022. An international, ‘online‐connected’ department of psychiatry comprising a primary care physician in Somaliland, three postgraduate trainees in Ethiopia and the United States, and three senior psychiatrists in the United Kingdom developed a local faculty‐led, hybrid‐delivered, dynamic curriculum (bedside teaching, in person and online lecturing) that adapted to the needs, resources, faith and culture of Somaliland. While 2020–2021 has been the pilot year for the program, the overall experience has been enriching for students and faculty, leading to valuable cross‐cultural conversations with impact on teaching and research. While learning about Somalilanders' and trauma, the program leads, also the authors of this article, have identified ways to harness the resilience and faith of students to bring about improvements in global mental health.
SUMMARYThe substantial strain that women are facing during the COVID-19 pandemic can affect their... more SUMMARYThe substantial strain that women are facing during the COVID-19 pandemic can affect their menstrual cycle and further impair their quality of life. In low- and middle-income countries, this strain is exacerbated by: cultural taboos and poor education related to menstruation; ‘period poverty’; unavailability of menstrual hygiene products; and poor hygiene facilities. We suggest actions that governments, healthcare professionals and individuals can take to address these factors and minimise the psychological impact of COVID-19 on women's physical and mental health.
Emphasizing how existential burdens can lead to psychiatric distress, as well as health care disp... more Emphasizing how existential burdens can lead to psychiatric distress, as well as health care disparity, poor treatment compliance, and worse therapeutic outcome.
The number of International Medical Graduate (IMG) physicians matching into categorical psychiatr... more The number of International Medical Graduate (IMG) physicians matching into categorical psychiatry decreased steadily over the past decade. The authors sought to understand if this trend was occurring in other specialties, if US IMG physicians and non-US IMG physicians were equally affected, and if certain regions of the USA were more affected by this decrease than others. Finally, the authors compared the proportion of foreign-born individuals within a US census region to the proportion of non-US IMG physicians within that region. The authors analyzed data from the National Resident Matching Program from the years 2014–2020. Statewide data was aggregated into nine geographic regions, as per the US Census Bureau. The number of foreign-born individuals within each US census region was calculated from the 2018 American Community Survey data. In comparison to eight other specialties, psychiatry saw the greatest decrease (46.3%) in IMG physicians matching into PGY-1 positions. Both US IMG physicians and non-US IMG physicians were equally affected. The percentage of IMG physicians decreased in each of the nine US census regions. In six out of nine geographic regions, non-US IMG physicians were under-represented when comparing their proportion to the number of foreign-born people that lived within that region. Decreasing numbers of IMG physicians in psychiatry training may have long-term implications for cultural competency, serving underserved populations, and fellowship recruitment. We advocate for program directors to recognize IMG physicians as an important source of diversity and to recruit residents that reflect the communities they serve.
Background: In the United States (USA), kratom has become popular for controlling withdrawal symp... more Background: In the United States (USA), kratom has become popular for controlling withdrawal symptoms from opioid cessation. Case studies have alluded to the occurrence of features of neonatal abstinence syndrome (NAS) in infants born to mothers who regularly used kratom. Materials and Methods: A comprehensive literature was conducted using Pubmed and Google Scholar with a combination of keywords. A total of 8 unique abstracts were identified and reviewed. Results: The reviewed papers suggest that infants exposed to kratom via the transplacental route exhibit symptoms such as breathing difficulties, irritability, jitteriness, muscle hypertonicity, and a high-pitched inconsolable cry, which are features of NAS. Though no treatment protocols exist for managing kratom withdrawal, the studies suggested symptomatic management of a hyper-adrenergic state. Some studies recommended using methadone, whereas others recommend the use of morphine, rooming-in, and close contact with the mother.
A large body of research indicates that ketamine is safe and well tolerated at sub-anesthetic dos... more A large body of research indicates that ketamine is safe and well tolerated at sub-anesthetic doses and shows potential as a novel antidepressant. However, the effect of single infusions of ketamine, although reliably replicated and effective in relieving depressive symptoms, is transient, with relapse occurring within 2 weeks of treatment. Recent studies have focused on identifying a safe and effective ketamine administration protocol for the rapid and sustained relief of depressive symptoms. A comprehensive literature search was conducted (for studies from January 2010 to April 2018 that administered intravenous ketamine in multiple infusions) and a total of 17 studies meeting criteria were included in this review. We enumerate principle points of studies that administered multiple infusions of ketamine and followed patients over a longer period of time. We also identify the pressing need for additional research to fill in the gaps that exist around appropriate dosage regimens and...
Background: Racial and ethnic minorities (such as Chinese-speaking (CS)) are known to have less e... more Background: Racial and ethnic minorities (such as Chinese-speaking (CS)) are known to have less equitable access to mental health services than Caucasians. These disparities have a powerful influence on minority groups that already endure a greater burden from mental health needs. Aim: The aim was to identify perceived provider barriers to care for CS patients. Methods: The study involved an 11-item web-based survey to multidisciplinary health professionals in the department of psychiatry at a 75-bed teaching community mental health center. Results: More than half the respondents agreed that there are disparities in the management of CS versus non-CS patients primarily due to the language barrier (46%). However, older participants and participants who worked fewer hours per week in patient care were less likely to agree (rho = −.27, p = .05 and rho = .33, p = .015, respectively) that these perceived difficulties prevented them from caring for these patients. Conclusion: The study re...
The shortcomings of existing antidepressants used in patients with treatment-resistant depression... more The shortcomings of existing antidepressants used in patients with treatment-resistant depression have evoked much interest in exploring novel yet cost-effective drugs that target N-methyl D-aspartate receptors. In addition to ketamine, evidence for the effectiveness of the antituberculosis drug D-cycloserine (DCS) in this realm has also been steadily accumulating. Systematic searches of the PubMed, Cochrane, and MEDLINE Plus databases were conducted to identify studies on the antidepressant effects of DCS. Results from one case series, four double-blinded trials, and two open-label studies comprising a total of 134 participants who had received DCS are summarized. These studies reported that DCS was safe and well tolerated, and four of them showed a reduction in depressive symptoms without psychomimetic and dissociative effects. We present the limited but convincing evidence to suggest the promising antidepressant properties of DCS when administered independently at high dose or as...
The Primary Care Companion For CNS Disorders, 2019
Objective To gain insight into the current prevalence of tobacco consumption in various forms amo... more Objective To gain insight into the current prevalence of tobacco consumption in various forms among female psychiatric inpatients and their visiting female relatives in Mumbai, India. Methods In this cross-sectional study, survey questionnaires were administered to 127 female inpatients and 110 of their visiting female relatives from July to October 2016. A total of 100 patients and 108 of their relatives completed responses. Additionally, a modified version of the Fagerström Test for Nicotine Dependence was incorporated into the survey to assess the level of nicotine dependence, with higher scores corresponding to higher levels of dependence. Results The rates of tobacco use were higher in the patients than in their relatives (χ² = 12.13, P = .0003). Patients had shorter periods of abstinence and lower World Health Organization Quality of Life Assessment parameters. Conclusions This study sheds light on certain data that may be utilized for future health programs and in the development of treatment plans for women with mental illness..
We describe two cases to emphasize the importance of recognizing symptoms of psychosis underlying... more We describe two cases to emphasize the importance of recognizing symptoms of psychosis underlying a constellation of neurotic symptoms, and to highlight the overlap and potential for misdiagnosis with personality and anxiety disorders. We also provide an overview of pseudoneurotic schizophrenia and familiarize readers about the challenges in making accurate diagnoses in light of this term used in the past. We refer to cases in the literature and point out the implications of this concept on diagnosis, management, and prognosis. Based on the management strategies deployed for the two cases described, we finally recommend that it is imperative to perform accurate and detailed assessments and take into consideration the evolution of the concept of pseudoneurotic schizophrenia to currently accepted DSM-V disorders, in order to effectively treat patients.
Ecstasy, a popular drug among the younger generation, the primary psychoactive component of which... more Ecstasy, a popular drug among the younger generation, the primary psychoactive component of which is 3,4-Methylenedioxymethamphetamine (MDMA), is rarely known to have acute psychiatric effects and when it does, it is usually short term. We describe a patient who presented to the emergency room in a psychotic state after using ecstasy recreationally. Given his aggressive behavior in the community and risk for self-harm, he was emergently hospitalized to ensure safety. He developed persistent psychotic symptoms (delusions) after one dose of recreational MDMA and the team had the opportunity to observe, monitor, and treat his psychosis. This case along with few other documented cases highlights the gaps in research about the chronic, persistent effects and long-term consequences of MDMA. It also suggests that neuropsychiatric symptoms may not be readily reversible after cessation of use. There is an emphasis on the need for physicians to inquire about MDMA use and include it in toxicol...
Past studies have evaluated the association of various comorbidities with bipolar disorder. This ... more Past studies have evaluated the association of various comorbidities with bipolar disorder. This study analyzes differences in the prevalence and association of medical and psychiatric comorbidities in bipolar patients by gender. A retrospective analysis was conducted using the Nationwide Inpatient Sample (2010⁻2014). Using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, we narrowed the study population to comprise those with a primary diagnosis of bipolar disorder and then obtained information about comorbidities. The differences in comorbidities by gender were quantified using chi-square tests and the logistic regression model (odds ratio (OR)). Hypertension (20.5%), asthma (12.5%) and hypothyroidism (8.1%) were the top medical comorbidities found in bipolar patients. Migraine and hypothyroidism were seen three times higher in females (OR = 3.074 and OR = 3.001; respectively). Females with bipolar disorder had higher odds of comorbid...
Psychiatric services (Washington, D.C.), Jan 20, 2018
This column describes the Internet System for Tracking Over-Prescribing (I-STOP), New York State&... more This column describes the Internet System for Tracking Over-Prescribing (I-STOP), New York State's prescription monitoring program, and its compatibility with HIPAA and Part 2 of Volume 42 of the Code of Federal Regulations (CFR). The authors review use of information that is permitted by I-STOP and CFR for health care operations, including disclosure, and present information from the state Bureau of Narcotics Enforcement about appropriate use of the program. Physicians are permitted, for example, to contact other prescribers in I-STOP, even without explicit permission from the patient, an area in which physicians need more training. Common clinical scenarios encountered while navigating I-STOP are described.
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation, Jan 2, 2017
A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identif... more A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identified as a major issue during the National Marrow Donor Program/Be The Match System Capacity Initiative. Work-related distress and work-life balance were noted to be potential barriers to recruitment/retention. This study examined these barriers and their association with career satisfaction across HCT disciplines. A cross-sectional, 90-item, web-based survey was administered to advanced practice providers, nurses, physicians, pharmacists, and social workers in 2015. Participants were recruited from membership lists of 6 professional groups. Burnout (measured with the Maslach Burnout Inventory subscales of emotional exhaustion and depersonalization) and moral distress (measured by Moral Distress Scale-Revised) were examined to identify work-related distress. Additional questions addressed demographics, work-life balance, and career satisfaction. Of 5759 HCT providers who received an indivi...
Amoud University in Borama is located in the self‐declared state of Somaliland, in the Horn of Af... more Amoud University in Borama is located in the self‐declared state of Somaliland, in the Horn of Africa. Past conflicts and resulting economic hardship have led to a lack of local academic psychiatry faculty and resources. Amoud has been for some years partnering with voluntary faculty in the United Kingdom to teach psychiatry to its medical students through in‐person “teaching missions.” This was recently led by a Borama‐native psychiatry resident in Ethiopia. COVID‐19 added further hardships due to restrictions to travel and in‐person gatherings. These challenges also created the opportunity for the development of an innovative, international, hybrid (online onsite), self‐sustaining partnership model which has been successful in improving psychiatry teaching for undergraduate students in 2020–2021 and will continue in 2021–2022. An international, ‘online‐connected’ department of psychiatry comprising a primary care physician in Somaliland, three postgraduate trainees in Ethiopia and the United States, and three senior psychiatrists in the United Kingdom developed a local faculty‐led, hybrid‐delivered, dynamic curriculum (bedside teaching, in person and online lecturing) that adapted to the needs, resources, faith and culture of Somaliland. While 2020–2021 has been the pilot year for the program, the overall experience has been enriching for students and faculty, leading to valuable cross‐cultural conversations with impact on teaching and research. While learning about Somalilanders' and trauma, the program leads, also the authors of this article, have identified ways to harness the resilience and faith of students to bring about improvements in global mental health.
SUMMARYThe substantial strain that women are facing during the COVID-19 pandemic can affect their... more SUMMARYThe substantial strain that women are facing during the COVID-19 pandemic can affect their menstrual cycle and further impair their quality of life. In low- and middle-income countries, this strain is exacerbated by: cultural taboos and poor education related to menstruation; ‘period poverty’; unavailability of menstrual hygiene products; and poor hygiene facilities. We suggest actions that governments, healthcare professionals and individuals can take to address these factors and minimise the psychological impact of COVID-19 on women's physical and mental health.
Emphasizing how existential burdens can lead to psychiatric distress, as well as health care disp... more Emphasizing how existential burdens can lead to psychiatric distress, as well as health care disparity, poor treatment compliance, and worse therapeutic outcome.
The number of International Medical Graduate (IMG) physicians matching into categorical psychiatr... more The number of International Medical Graduate (IMG) physicians matching into categorical psychiatry decreased steadily over the past decade. The authors sought to understand if this trend was occurring in other specialties, if US IMG physicians and non-US IMG physicians were equally affected, and if certain regions of the USA were more affected by this decrease than others. Finally, the authors compared the proportion of foreign-born individuals within a US census region to the proportion of non-US IMG physicians within that region. The authors analyzed data from the National Resident Matching Program from the years 2014–2020. Statewide data was aggregated into nine geographic regions, as per the US Census Bureau. The number of foreign-born individuals within each US census region was calculated from the 2018 American Community Survey data. In comparison to eight other specialties, psychiatry saw the greatest decrease (46.3%) in IMG physicians matching into PGY-1 positions. Both US IMG physicians and non-US IMG physicians were equally affected. The percentage of IMG physicians decreased in each of the nine US census regions. In six out of nine geographic regions, non-US IMG physicians were under-represented when comparing their proportion to the number of foreign-born people that lived within that region. Decreasing numbers of IMG physicians in psychiatry training may have long-term implications for cultural competency, serving underserved populations, and fellowship recruitment. We advocate for program directors to recognize IMG physicians as an important source of diversity and to recruit residents that reflect the communities they serve.
Background: In the United States (USA), kratom has become popular for controlling withdrawal symp... more Background: In the United States (USA), kratom has become popular for controlling withdrawal symptoms from opioid cessation. Case studies have alluded to the occurrence of features of neonatal abstinence syndrome (NAS) in infants born to mothers who regularly used kratom. Materials and Methods: A comprehensive literature was conducted using Pubmed and Google Scholar with a combination of keywords. A total of 8 unique abstracts were identified and reviewed. Results: The reviewed papers suggest that infants exposed to kratom via the transplacental route exhibit symptoms such as breathing difficulties, irritability, jitteriness, muscle hypertonicity, and a high-pitched inconsolable cry, which are features of NAS. Though no treatment protocols exist for managing kratom withdrawal, the studies suggested symptomatic management of a hyper-adrenergic state. Some studies recommended using methadone, whereas others recommend the use of morphine, rooming-in, and close contact with the mother.
A large body of research indicates that ketamine is safe and well tolerated at sub-anesthetic dos... more A large body of research indicates that ketamine is safe and well tolerated at sub-anesthetic doses and shows potential as a novel antidepressant. However, the effect of single infusions of ketamine, although reliably replicated and effective in relieving depressive symptoms, is transient, with relapse occurring within 2 weeks of treatment. Recent studies have focused on identifying a safe and effective ketamine administration protocol for the rapid and sustained relief of depressive symptoms. A comprehensive literature search was conducted (for studies from January 2010 to April 2018 that administered intravenous ketamine in multiple infusions) and a total of 17 studies meeting criteria were included in this review. We enumerate principle points of studies that administered multiple infusions of ketamine and followed patients over a longer period of time. We also identify the pressing need for additional research to fill in the gaps that exist around appropriate dosage regimens and...
Background: Racial and ethnic minorities (such as Chinese-speaking (CS)) are known to have less e... more Background: Racial and ethnic minorities (such as Chinese-speaking (CS)) are known to have less equitable access to mental health services than Caucasians. These disparities have a powerful influence on minority groups that already endure a greater burden from mental health needs. Aim: The aim was to identify perceived provider barriers to care for CS patients. Methods: The study involved an 11-item web-based survey to multidisciplinary health professionals in the department of psychiatry at a 75-bed teaching community mental health center. Results: More than half the respondents agreed that there are disparities in the management of CS versus non-CS patients primarily due to the language barrier (46%). However, older participants and participants who worked fewer hours per week in patient care were less likely to agree (rho = −.27, p = .05 and rho = .33, p = .015, respectively) that these perceived difficulties prevented them from caring for these patients. Conclusion: The study re...
The shortcomings of existing antidepressants used in patients with treatment-resistant depression... more The shortcomings of existing antidepressants used in patients with treatment-resistant depression have evoked much interest in exploring novel yet cost-effective drugs that target N-methyl D-aspartate receptors. In addition to ketamine, evidence for the effectiveness of the antituberculosis drug D-cycloserine (DCS) in this realm has also been steadily accumulating. Systematic searches of the PubMed, Cochrane, and MEDLINE Plus databases were conducted to identify studies on the antidepressant effects of DCS. Results from one case series, four double-blinded trials, and two open-label studies comprising a total of 134 participants who had received DCS are summarized. These studies reported that DCS was safe and well tolerated, and four of them showed a reduction in depressive symptoms without psychomimetic and dissociative effects. We present the limited but convincing evidence to suggest the promising antidepressant properties of DCS when administered independently at high dose or as...
The Primary Care Companion For CNS Disorders, 2019
Objective To gain insight into the current prevalence of tobacco consumption in various forms amo... more Objective To gain insight into the current prevalence of tobacco consumption in various forms among female psychiatric inpatients and their visiting female relatives in Mumbai, India. Methods In this cross-sectional study, survey questionnaires were administered to 127 female inpatients and 110 of their visiting female relatives from July to October 2016. A total of 100 patients and 108 of their relatives completed responses. Additionally, a modified version of the Fagerström Test for Nicotine Dependence was incorporated into the survey to assess the level of nicotine dependence, with higher scores corresponding to higher levels of dependence. Results The rates of tobacco use were higher in the patients than in their relatives (χ² = 12.13, P = .0003). Patients had shorter periods of abstinence and lower World Health Organization Quality of Life Assessment parameters. Conclusions This study sheds light on certain data that may be utilized for future health programs and in the development of treatment plans for women with mental illness..
We describe two cases to emphasize the importance of recognizing symptoms of psychosis underlying... more We describe two cases to emphasize the importance of recognizing symptoms of psychosis underlying a constellation of neurotic symptoms, and to highlight the overlap and potential for misdiagnosis with personality and anxiety disorders. We also provide an overview of pseudoneurotic schizophrenia and familiarize readers about the challenges in making accurate diagnoses in light of this term used in the past. We refer to cases in the literature and point out the implications of this concept on diagnosis, management, and prognosis. Based on the management strategies deployed for the two cases described, we finally recommend that it is imperative to perform accurate and detailed assessments and take into consideration the evolution of the concept of pseudoneurotic schizophrenia to currently accepted DSM-V disorders, in order to effectively treat patients.
Ecstasy, a popular drug among the younger generation, the primary psychoactive component of which... more Ecstasy, a popular drug among the younger generation, the primary psychoactive component of which is 3,4-Methylenedioxymethamphetamine (MDMA), is rarely known to have acute psychiatric effects and when it does, it is usually short term. We describe a patient who presented to the emergency room in a psychotic state after using ecstasy recreationally. Given his aggressive behavior in the community and risk for self-harm, he was emergently hospitalized to ensure safety. He developed persistent psychotic symptoms (delusions) after one dose of recreational MDMA and the team had the opportunity to observe, monitor, and treat his psychosis. This case along with few other documented cases highlights the gaps in research about the chronic, persistent effects and long-term consequences of MDMA. It also suggests that neuropsychiatric symptoms may not be readily reversible after cessation of use. There is an emphasis on the need for physicians to inquire about MDMA use and include it in toxicol...
Past studies have evaluated the association of various comorbidities with bipolar disorder. This ... more Past studies have evaluated the association of various comorbidities with bipolar disorder. This study analyzes differences in the prevalence and association of medical and psychiatric comorbidities in bipolar patients by gender. A retrospective analysis was conducted using the Nationwide Inpatient Sample (2010⁻2014). Using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, we narrowed the study population to comprise those with a primary diagnosis of bipolar disorder and then obtained information about comorbidities. The differences in comorbidities by gender were quantified using chi-square tests and the logistic regression model (odds ratio (OR)). Hypertension (20.5%), asthma (12.5%) and hypothyroidism (8.1%) were the top medical comorbidities found in bipolar patients. Migraine and hypothyroidism were seen three times higher in females (OR = 3.074 and OR = 3.001; respectively). Females with bipolar disorder had higher odds of comorbid...
Psychiatric services (Washington, D.C.), Jan 20, 2018
This column describes the Internet System for Tracking Over-Prescribing (I-STOP), New York State&... more This column describes the Internet System for Tracking Over-Prescribing (I-STOP), New York State's prescription monitoring program, and its compatibility with HIPAA and Part 2 of Volume 42 of the Code of Federal Regulations (CFR). The authors review use of information that is permitted by I-STOP and CFR for health care operations, including disclosure, and present information from the state Bureau of Narcotics Enforcement about appropriate use of the program. Physicians are permitted, for example, to contact other prescribers in I-STOP, even without explicit permission from the patient, an area in which physicians need more training. Common clinical scenarios encountered while navigating I-STOP are described.
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation, Jan 2, 2017
A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identif... more A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identified as a major issue during the National Marrow Donor Program/Be The Match System Capacity Initiative. Work-related distress and work-life balance were noted to be potential barriers to recruitment/retention. This study examined these barriers and their association with career satisfaction across HCT disciplines. A cross-sectional, 90-item, web-based survey was administered to advanced practice providers, nurses, physicians, pharmacists, and social workers in 2015. Participants were recruited from membership lists of 6 professional groups. Burnout (measured with the Maslach Burnout Inventory subscales of emotional exhaustion and depersonalization) and moral distress (measured by Moral Distress Scale-Revised) were examined to identify work-related distress. Additional questions addressed demographics, work-life balance, and career satisfaction. Of 5759 HCT providers who received an indivi...
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