Educational Resource Column

Educational Resource Column

Psychiatry Resident/Fellow-Initiated and -Designed Multi-Modal Psychopharmacology Curriculum for Major Depression Kristina M. Deligiannidis, M.D., Ragy R. Girgis, M.D., Adam Lau, M.D., Richard Balon, M.D., Sidney Zisook, M.D. Psychiatric residency programs must train psychiatrists to be proficient in psychopharmacology, despite having a limited number of faculty who are student-centered, knowledgeable, and effective educators in psychopharmacology (1), as well as time constraints on those faculty who are available (2). Although almost all psychiatrists prescribe medications (3, 4), residency programs are not required to demonstrate their competency in clinical psychopharmacology (5). An assessment of psychopharmacology competency on American Board of Psychiatry and Neurology (ABPN) examinations suggests that residents are not being adequately trained in psychopharmacology (6). Psychopharmacology is traditionally taught through didactics and apprenticeship (5); these teaching methods have drawbacks, including large lecture formats with passive learning and small-group learning, with overemphasis on difficult-to-treat cases (2, 7). Therefore, the development of a multi-modal curriculum to support psychopharmacology education in U.S. adult psychiatry residency training programs that addresses these shortcomings would be an important step forward. Psychopharmacology Curricula and the Need for New Tools Suggested tools for teaching clinical psychopharmacology to trainees include lectures, conferences, case-based learning modules, problem-based learning (PBL), specialty clinics, journal clubs, games, the Internet, and other innovative modalities (2, 8, 9). Previous attempts to develop model Received August 12, 2010; revised January 25, 2011; accepted March 18, 2011. From the Center for Psychopharmacologic Research & Treatment, Univ. of Massachusetts Medical School, Worcester, MA; Dept. of Psychiatry, College of Physicians and Surgeons, Columbia University, New York State Psychiatric Institute, New York, NY; Dept. of Psychiatry, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, NY; Wayne State University School of Medicine, Detroit, MI; Dept. of Psychiatry, University of California, San Diego, La Jolla, CA. Correspondence: Kristina M. Deligiannidis, M.D., Univ. of Massachusetts Medical School, Worcester, MA; e-mail: [email protected] Copyright © 2012 Academic Psychiatry

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curricula in psychiatry training programs using these and other tools have generally not been received with much enthusiasm (10). A comprehensive review of 43 model curricula in psychiatry covering approximately two dozen topic areas reported that only the American Society for Clinical Psychopharmacology (ASCP) Model Psychopharmacology Curriculum had been used in more than two settings (11). Although the ASCP Model Psychopharmacology Curriculum has been described as “the most comprehensive curriculum development process in academic psychiatry” (11), it has not been as widely used as anticipated (10). Reasons for this may include its associated costs and the challenge of integrating the entire curriculum into an individual program’s curriculum (12). It may therefore be more feasible to create individual sections or curricula on major disorders (i.e., individual modules) for dissemination to residency programs. Accordingly, in 2006, the ASCP developed and fieldtested a Schizophrenia Module that served as a model for other major disorders (10). The Schizophrenia Module included lecture slides, video, vignettes, PBL scenarios, and pre- and post-module tests. Although none of the 14 residency programs that tested the curriculum used the module in the same manner, it was well received. Residents appreciated the quality of content and the interactive nature of presentations, cases, and video vignettes (10). Based on the results of the field test presented at the 2008 American Association of Directors of Psychiatric Residency Training (AADPRT) meeting, the consensus was for the development of additional modules on other important disease states such as mood, substance use, and anxiety disorders (10). Also, a group of educators at AADPRT and ASCP believed that more active involvement of residents and fellows in the next stage of development would maximize utilization by residency programs. Training directors were then asked to nominate residents or fellows to join the new “ASCP Resident and Fellow Committee (RFC) on Psychopharmacology;” 23 residents and fellows, representing 19 programs, joined the committee, joined by 4 senior faculty advisors who were members of both ASCP and AADPRT and were experienced educators in psychopharmacology. Given the number of sites involved as well as the success and enthusiasm surrounding the Schizophrenia Module curriculum, the ASCP RFC pursued the development of individual modules on 1) major depression; and 2) bipolar disorder. The remainder of this article describes Academic Psychiatry, 36:5, September-October 2012

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the development and structure of the Depression Module and discusses the advantages and limitations of this resource. Development, Description, and Suggested Uses of the Depression Module Curriculum and Its Components The curriculum was recently selected as a “Peer-Reviewed Model Curriculum” to be posted on the AADPRT Virtual Training Office/Model Curricula website. Also, the ASCP Curriculum Committee has recommended that it be posted on their website; in the meanwhile, it has provided a DVD with all 12 mini-module PowerPoint presentations, pre- and post-assessment questions, problem-based learning exercises, competency-based teaching cases, and Jeopardy-style learning games to all institutions and individuals who have purchased its most recent psychopharmacology curriculum (13). The Depression Module will be available for download at no cost to members of ASCP and AADPRT via those organization websites (http://www.ascpp.org/login.aspx? ReturnUrl5%2fsecured%2fdefault.aspx%3fPanelID%3d0& PanelID50 and http://www.aadprt.org/login.aspx). On the AADPRT website, the Module is located in the Virtual Training Office, under “Model Curricula.” The Depression Module workgroup performed a review of published ABPN, American Psychiatric Association (APA), AADPRT, and Accreditation Council for Graduate Medical Education (ACGME) core competencies and pracice guidelines to delineate the scope of the psychopharmacology curriculum to be developed. The Module was not intended to be a comprehensive, all-inclusive teaching resource, but rather to contain “bread-and-butter” topics of clinical importance for practicing psychiatrists, taken from the aforementioned source documents. Also, this curriculum was explicitly designed to allow residency programs to creatively apply the curriculum in a way that works best for the uniqueness of their programs. Materials to utilize each of these approaches are provided with the curriculum and are subsequently discussed. Twelve mini-modules were chosen to make up the Depression Module, each of which could be used as freestanding teaching sessions or collectively as one comprehensive curriculum. Each mini-module was created with an evidence-based PowerPoint presentation addressing an aspect of the clinical characteristics, diagnosis, or psychopharmacologic treatment of depression, and it served as the core psychopharmacology knowledgebase from which multimodal learning activities would stem. In addition to Academic Psychiatry, 36:5, September-October 2012

core neuropsychopharmacologic and clinical psychopharmacologic teachings, mini-modules on research findings from recent clinical trials and evidence-based medicine in psychiatry were incorporated to strengthen critical scientific literature review skills. See Table 1 for the mini-module teaching sessions. Problem- and group-based learning and alternative teaching exercises, as listed in Table 2, were developed for each mini-module to reinforce didactic learning objectives and extend learning beyond the scope of the slide-set. These modalities included: multiple-choice question (MCQ) banks, Jeopardy-style psychopharmacology quizzes, clinical vignettes with interactive learning exercises, and “sham” clinical scenarios designed to assess the ACGME core competencies of patient care, medical knowledge, communication, professionalism, system-based learning, and practice-based learning. These alternative teaching exercises and other ways by which to maximize the flexibility of this curriculum are described below in Table 3. The presentation can also be used for self-study by the residents, although we hope that this will not be the sole method of

TABLE 1. Components of the Depression Module Slide-Set (329 slides in total) Mini-Module 1: Historical and Epidemiological Highlights 2: Pathophysiology of Major Depression 3: Basic Phases of Antidepressant Treatment 4: Basic Antidepressant Treatment Approaches 5: Selecting an Antidepressant 6: Classes of Antidepressants 7: Treatment-Resistant Depression 8: Psychopharmacology in Special Populations 9: Sequenced Treatment Alternatives to Relieve Depression (STAR*D) 10: Suicide Risk and Assessment 11: Physician Depression and Suicide 12: Evidence-Based Medicine: Appraising the Evidence in Psychiatry

TABLE 2. Components of the Depression Module’s Alternative-Learning Materials • PowerPoint slide-set with video enhancements • Digital video excerpts • Multiple-choice question-and-answer bank • Jeopardy-style question-and-answer bank in a PowerPoint format for game use • Multi-stem problem/group-based learning questions/clinical scenarios • ACGME-style case-competency group exercises


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instruction and that the self-study would be as preparation for discussion or other teaching activity. For those programs with limited teaching hours, the core slide-set with video, comprising 329 slides, will take approximately 5.5 hours (if given 1 minute/slide). When used in this manner, the amount of additional teaching time will vary, based on the length of the mini-module and number of PBL exercises utilized. To enhance the Module’s utilization, a Program Director’s Suggested Use Guide was developed to lay out several potential uses of the curriculum.

The majority of residencies will find that the curriculum fits best into PGY-1 and -2 psychopharmacology teaching time in terms of content and scheduling, as junior residents require immediate training in psychopharmacology for their rotations. The curriculum may be integrated alongside concurrent psychotherapy training. For example, the slideset and the case-competency PBL exercises can be adapted for concurrent teaching of psychotherapy with psychopharmacology for residencies that have an integrated teaching approach.

TABLE 3. Depression-Module Curriculum Contents and Suggestions for Use Toolbox Contents

Suggestions for Use

Video-enhanced PowerPoint slide-set for lectures on clinical characteristics, diagnosis, and treatment of depression

Video excerpts from the American Foundation for Suicide Prevention Struggling in Silence (physician depression and suicide) Out of the Silence (medical student depression and suicide) Multiple-choice question (MCQ) and answer bank

Jeopardy-style question-and-answer bank in a PowerPoint format for game use Multi-stem problem/group-based learning; questions/clinical scenarios

ACGME-style case-competency group exercises

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These can be used in a traditional lecture format and/or provided to the residents for self-study. The presenters are encouraged to edit the PowerPoint slides liberally, substituting their own slides and providing case examples and opportunities for interaction. The video can be used as inserted into the PowerPoint slide-set, or used separately (see below). Can be used to facilitate discussion and or serve as stimulus for problem-based learning modules in Mini-Module 10 “Suicide Risk and Assessment” Video excerpts total approximately 10 minutes in duration These may be flexibly used as pre- or post-didactic questions. The questionbanks correspond to each Mini-Module topic/number. Also, if programs would like to use the Master MCQ Question Bank in its entirety, a separate Word file of questions/answers for the entire curriculum may be used for testing knowledge at the end of the Depression Module. These questions/answers test information that was presented in the didactic Depression Module master slide-set. They can be used at the end of the curriculum to assess knowledge across the Mini-Modules. The multi-stem problem-based learning (PBL) banks correspond to each MiniModule topic/number. Also, if programs would like to use the Master Multistem question-bank in its entirety, a separate Word file of Multi-stem questions/scenarios for the entire curriculum may be used for testing knowledge at the end of the Depression Module or separately to augment their own curriculum. Residents should be encouraged to go to the literature (especially evidencebased literature) before and after the session, independently and/or in groups, to explore the “answers” to the important questions posed in the exercise. Mini-Module 12: Evidence-Based Medicine: Appraising the Evidence in Psychiatry may be used as a resource or stand-alone didactic to further skills in critical literature review. The multi-stem PBL banks also serve as models to help the faculty develop their own PBL exercise appropriate to their goals, resources, and style. The ACGME-style case-competency group exercise banks correspond to each Mini-Module topic/number. Also, if programs would like to use the Master Case-Competencies question bank in its entirety, a separate Word file of cases for the entire curriculum may be used for testing knowledge at the end of the Depression Module or separately to augment their own curriculum. Some programs have found that a team approach to teaching may be helpful. Having two faculty members lead these sessions will help facilitate the PBL process and at the same time, allow assessment of individual resident competencies in real time. The Case-Competency banks also serve as models to help the faculty develop their own PBL exercise appropriate to their goals, resources, and style.


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Potential Advantages and Limitations of a Multi-Modal Psychopharmacology Curriculum in Depression The Module is divided into 12 mini-modules, allowing programs to adapt the Module to the time they have allotted for this subject. Rather than focusing on difficult-to-treat cases and “zebras,” the Module focuses on the “breadand-butter” of psychopharmacology for depression that is most clinically relevant for trainees, such as dosing strategies, side effects, and what to do when outcomes are not ideal (9, 14). A mini-module on psychopharmacology in special populations (e.g., child/adolescents, pregnancy/ postpartum, and geriatrics) was also included to address the needs of senior residents (14), making the Module a relevant teaching device for residents at all postgraduate levels. Also, whereas a core slide-set is provided as part of the Module, programs are given the option of emphasizing the other educational tools, such as the “sham” case scenarios, MCQ, and a Jeopardy-style game, allowing trainees to become active participants in their education. These more active learning tools are meant to not only engage trainees, but, more importantly, to move them from being people who “know” to people who “know how” (15). Furthermore, these tools encourage cooperative learning, an instructional strategy that is well suited for, and has been tested in, a variety of medical education settings (16). Finally, the lack of a basic understanding of neuroscientific principles is a hindrance to the proper understanding of psychopharmacology (2). The Module addresses this barrier by including background about the pathophysiology of depression. Another positive and unique aspect of this depression module is that the content and teaching modalities were developed by a group of highly-motivated and interested residents and fellows in psychiatry training programs. Material is generally better accepted by trainees when it is targeted toward their needs and focuses on the pragmatic aspects of psychopharmacology (14). However, although learner input to residency training has many advantages, residents are not senior-educators. Therefore, this module was designed from many ASCP RFC discussions under close supervision and mediation by master-educators and senior residency directors. Furthermore, although psychopharmacology curricula sometimes overlook the potential benefits of incorporating “play” into learning (8), we expect the Jeopardy-like exercise and other interactive teaching modalities will make learning fun. Finally, the mini-modules on the STAR*D trial and evidencebased medicine were included to introduce trainees to the importance of basing their practice of psychopharmacology Academic Psychiatry, 36:5, September-October 2012

on evidence whenever possible, and to become lifelong learners. The potential barriers to such practice have been discussed previously (17). However, the RFC does not believe that use of the Depression Module alone will affect competence in psychopharmacology, but that the use of this Model Curriculum will add to the armamentarium used in psychiatric residencies in achieving competence in psychiatry. Supervision is also critical, especially to help consolidate knowledge and clinical skills, and for introducing issues that cannot be taught in other formats, such as communicating and partnering with patients, and the managing of crises (9). Indeed, conducting “medication-management” sessions is no less multifaceted than conducting psychotherapy sessions (9)—dynamic issues are important, and trainees desire an understanding of them (14). The so-called “art of psychopharmacology” (2, 18) is partially addressed by the Depression Module, but often requires attention to detail that only individual supervision can provide. Finally, although the resident committee endeavored to choose tools by which to most effectively and efficiently teach psychopharmacology, they were unable to rely on an evidencebased application of these tools, which, to our knowledge, does not exist, and this is a limitation of this Model Curriculum and others. In conclusion, there is a substantial need for enhancing the means by which psychopharmacology is taught. The development of the Depression Module described in this report was a collaborative effort put forth by psychiatric trainees and master-educators who aimed to assemble a practical, inclusive, adaptable, and easily-modifiable instrument for the instruction of psychiatric trainees in the psychopharmacology of depression. We intend to survey training directors to learn whether and how the curriculum is being used, how helpful it has been, and how it can be improved, similar to the way a group of us solicited feedback on a previous psychopharmacology curriculum (10). When complemented with well supervised clinical care as part of a psychopharmacology training curriculum, the Depression Module and toolbox can contribute to the development of psychiatric trainees who are proficient in clinical psychopharmacology.

References 1. Dubovsky SL: Who is teaching psychopharmacology? Who should be teaching psychopharmacology? Acad Psychiatry 2005; 29:155–161 http://ap.psychiatryonline.org

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PSYCHOPHARMACOLOGY CURRICULUM FOR MAJOR DEPRESSION 2. Glick ID, Salzman C, Cohen BM, et al: Improving the pedagogy associated with the teaching of psychopharmacology. Acad Psychiatry 2007; 31:211–217 3. Appleton WS, Chien CP: American psychopharmacology: second-class status? Br J Psychiatry 1967; 113:637–641 4. Donovan SJ, Roose SP: Medication use during psychoanalysis: a survey. J Clin Psychiatry 1995; 56:177–178, discussion 179 5. Balon R: Teaching psychopharmacology: introduction. Acad Psychiatry 2005; 29:116–119 6. Juul D, Winstead DK, Sheiber SC: Assessment of psychopharmacology on the American Board of Psychiatry and Neurology examinations. Acad Psychiatry 2005; 29:211–214 7. Naranjo CA, Shulman RW, Ozdemir V: Development and evaluation of a clinical psychopharmacology educational curriculum. J Clin Pharmacol 1997; 37:474–479 8. Zisook S, Benjamin S, Balon R, et al: Alternate methods of teaching psychopharmacology. Acad Psychiatry 2005; 29: 141–154 9. Zisook S, Glick ID, Jefferson JW, et al: Teaching psychopharmacology: what works and what doesn’t. J Clin Psychopharmacol 2008; 28:96–100 10. Zisook S, Balon R, Benjamin S, et al: Psychopharmacology curriculum field test. Acad Psychiatry 2009; 33:358– 363

11. Wulsin LR, Kramer SI: Teaching psychopharmacology in the 21st century. Acad Psychiatry 2001; 25:102–106 12. Glick ID, Janowsky D, Zisook S: On Using the ASCP Model Curriculum for Psychopharmacology: Comments and an Update. Acad Psychiatry 2001; 25:237–238 13. Glick ID, Balon R, Citrome L, et al. (eds): Model Psychopharmacology Curriculum for Training Directors and Teachers of Psychopharmacology in Psychiatric Residency Programs, 6th Edition. Glen Oaks, CA, American Society of Clinical Psychopharmacology, 2010 14. Georgiopoulos AM, Huffman JC: Teaching psychopharmacology: two trainees’ perspectives. Acad Psychiatry 2005; 29: 167–175 15. Miller GE: The assessment of clinical skills/competence/performance. Acad Med 1990; 65(Suppl):S63–S67 16. Krych AJ, March CN, Bryan RE, et al: Reciprocal peer teaching: students teaching students in the gross anatomy laboratory. Clin Anat 2005; 18:296–301 17. van Dijk N, Hooft L, Wieringa-de Waard M: What are the barriers to residents’ practicing evidence-based medicine? a systematic review. Acad Med 2010; 85:1163–1170 18. Glick ID, Balon RJ, Ballon J, et al: Teaching pearls from the lost art of psychopharmacology. J Psychiatr Pract 2009; 15: 423–426

Call for Papers on Suicide Prevention, Evaluation, and Intervention Despite the serious public health impact and life-threatening nature of illnesses and conditions associated with suicide, they have received little attention in society and are poorly understood and profoundly stigmatized. Learning to understand and evaluate people at risk for self-harm is an important element of medical student and resident education. New evidence-based models for prevention of suicide are emerging, and these new models have inspired optimism. Integrating these new models is an exciting challenge for medical educators. To this aim, Academic Psychiatry is working with the Kubly Foundation to create a special issue of articles that support the development of novel curricula and innovative teaching in the important area of suicide prevention, evaluation, and intervention. In keeping with the overall mission of Academic Psychiatry, papers ideally will be evidence-based, drawing upon data and outcome measures, and/or involving multiple sites. Comprehensive reviews and case studies are also welcome. All submissions will be peer reviewed in keeping with the journal’s policy. Submissions are due by September 1, 2012. Submissions should be uploaded to ScholarOne Manuscripts (http://mc.manuscriptcentral.com/appiap). Please indicate in the cover letter that the submission is for this special issue. For more information, please visit our Web site at ap.psychiatryonline.org. Please direct questions on the submission process to Ms. Ann Tennier, Senior Editorial Associate, at 262-346-1461 or [email protected].

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