Faculty Bibliography

Over the past three decades, the world of both amateur and professional sports has expanded greatly and become more complex. In part related to these changes - and relatively unknown to sports medicine practitioners - the field of sport psychiatry has steadily evolved and grown. This paper focuses on what these changes have been. A sport psychiatrist is a physician-psychiatrist who diagnoses and treats problems, symptoms and/or disorders associated with an athlete, with their family/significant others, with their team, or with their sport, including spectators/fans. The primary aims of the specialty are to (i) optimize health, (ii) improve athletic performance, and (iii) manage psychiatric symptoms or disorders. The training includes medical training to provide knowledge and skills unique to physicians; psychiatric training to provide knowledge and skills inherent in that field, and training and/or experience in sport psychiatry to provide knowledge and skills about psychiatric aspects of sports. The sport psychiatrist first makes an individual, family-systems and phenomenological diagnosis of the clinical situation. Based on this evaluation, he sets goals for not only the athlete, but also for significant others involved. He delivers treatment based on the psychiatric disorder or problem using a combination of medication, psychotherapy or self-help group interventions plus strategies targeted to specific sport performance issues. Evolution of the International Society of Sport Psychiatry as well as the field, including incorporation into school and professional team sports, is described along with a 'typical day' for a sport psychiatrist. Case examples, a training curriculum and core literature are included.

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study was funded by the National Institute of Mental Health to compare the effectiveness of drugs for schizophrenia. The focus here is not on its conclusions but on the knotty issues of design and methods, in order to support appropriate clinical interpretation of the conclusions, and on using the CATIE experience to indicate directions for improvement of future clinical trials. While many of the CATIE design and implementation decisions are excellent and serve as models for future research, other decisions resulted in a study with a large study group but inadequate power. Multiple treatment interventions, unbalanced randomization within and across clinical sites, and multiple secondary outcomes are among the issues that require even more serious consideration in future large multisite clinical trials. Moreover, it is crucial to clarify whether the intent of a study is to establish superiority of some treatments or to establish equivalence, for the appropriate designs and analyses differ in these situations. If the study is designed, as was CATIE, to demonstrate some treatments' superiority, statistically nonsignificant results should not be misinterpreted as evidence of "equivalence." For establishing either superiority or equivalence, future treatment comparisons might better be designed with fewer sites, more subjects per site, fewer treatments, and fewer outcomes, in order to have the power for definitively establishing superiority or equivalence at a lower cost.

This study presents a meta-analysis of the influence of several potentially biasing factors (eg industry support, extrapyramidal side effects) on efficacy of studies comparing second-generation antipsychotic (SGA) with first-generation antipsychotic (FGA) medications. We used the dataset from our previously published meta-analysis of 124 randomized controlled trials (RCTs) comparing SGAs with FGAs, to evaluate whether certain possible biases could influence the actual outcome on the total score of the Positive and Negative Syndrome Scale (PANSS), Brief Psychiatric Rating Scale (BPRS), and Clinical Global Impressions (CGI) scores. Industry sponsorship was determined by contact with authors or publication statement. We calculated whether (1) industry sponsorship, (2) study quality, (3) extrapyramidal symptoms (EPS) properties, or (4) prophylactic antiparkinsonian medications influenced SGA vs FGA efficacy for each drug and averaged overall by two Hedges and Olkin-based meta-analyses. The analysis found that none of the factors was significantly associated with a particular outcome. While industry-sponsored articles may conclude their medication to be more favorable than that of a competitor in an RCT, we found that the observed efficacy was not influenced by sponsorship. Many attribute the finding that SGAs appears to be more efficacious than FGAs to be a result of EPS-decreasing efficacy (or its measurement). We were unable to confirm that the drug's EPS properties or antiparkinsonian management altered actual efficacy.

BACKGROUND: Approximately 15% of patients with schizophrenia also meet DSM-IV criteria for obsessive-compulsive disorder (OCD) at some point in their illness, a rate considerably higher than in the general population. This study examined aripiprazole treatment of patients with comorbid schizophrenia and obsessive-compulsive symptoms (OCS) that did not meet full criteria for OCD. METHOD: Physically healthy adults aged 18 to 65 years with DSM-IV schizophrenia and a minimum score of 16 on the Yale-Brown Obsessive Compulsive Scale (YBOCS) were eligible to participate in this 6-week, open-label, flexible-dose trial of aripiprazole monotherapy. Patients currently taking another antipsychotic medication were concurrently down-titrated from their current antipsychotic and up-titrated with aripiprazole, starting with 15 mg/day. Coadministration of the 2 medications lasted from 7 to 14 days, until a stable therapeutic dose of 10 to 30 mg/day was reached. Subjects were recruited into the study, which was conducted at the Schizophrenia Clinic of Stanford University School of Medicine, between January 2005 and December 2006. RESULTS: Of 15 eligible patients, 7 completed the trial. All 7 had at least minimal improvement on the YBOCS, the Clinical Global Impressions (CGI) scale, and the Positive and Negative Syndrome Scale (PANSS). At week 6, the mean CGI-Improvement scale score was 2.3 (much improved). Mean PANSS scores decreased from 75 to 56, a mean decrease of 21%, (p < .05). On the YBOCS, 6 of 7 completers showed a change of greater than 35% from baseline to week 6. CONCLUSION: These results suggest that aripiprazole monotherapy can modestly improve the outcome for some schizophrenia patients with obsessive-compulsive symptoms. Further studies with aripiprazole under controlled conditions are indicated for this population of patients. Overall, even modest improvement in global functioning due to an improvement in an OCS component may be clinically meaningful for this difficult-to-treat subset of schizophrenia patients.

In summary, the journal editors' effort to restore faith in science by financial disclosure has been inadequate to the task. The editors could improve matters by demanding access to the raw data supporting claims for product safety and effectiveness. The recent emphasis on a detailed clinical trials registry anteceding the trial is clearly a breakthrough. The mandated clinical trial registries that include outcome data are even better. How well this works in terms of detailed public knowledge remains to be seen

How do we best teach clinical psychopharmacology to trainees and clinicians, so they not only increase their knowledge base, but even more importantly also learn to practice the most informed, evidence-based practice possible? This article attempts to answer this elusive question by compiling the individual and combined wisdom of 5 expert psychopharmacology teachers, each of whom draws on years of their own experiences as master educators. The topics covered include teaching clinical psychopharmacological competence in adult psychiatry residency training and in issues specific to both pediatric and geriatric populations, teaching physicians to improve clinical outcomes through continuing medical education, and new developments in adult-centered pedagogy and assessment. Although the focus of this article is on practical pearls found useful in teaching psychiatric residents and practicing physicians, the lessons learned are applicable to other groups of learners such as medical students, other trainees, and nonmedical clinicians. Our goal is to help educators produce competent psychopharmacology clinicians schooled in the latest evidence, capable of keeping up with new knowledge as it becomes available, and practicing both the art and science of expert clinical care