The Canadian Journal of Psychiatry

The authors describe an interdisciplinary mental health team operating out of the Bernalillo County Mental Health Center in Albuquerque, New Mexico. Psychiatric residents at the University of New Mexico are assigned to teams working in the community. In an attempt to evaluate this educational program a technique describing specific incidents in residents' performance which are judged to be effective or ineffective was used. Everyone had implicit and explicit expectations with the assignment to the treatment team and considerable change took place in the team and the resident. Conflict and breakdown in the usual team function occurred frequently. The lack of role definition and role conflict were serious problems. However, the overall effect was desirable, and this type of program may produce a new and necessary advance in providing services to the population at risk in addition to providing a new educational experience for psychiatric residents.

A scale of measuring interviewing skill is described. The process of development of the scale, including the establishment of inter-rater reliability, is briefly sketched.

Application of the scale to medical student performance in interviews revealed that capacity to diagnose and plan management has virtually no relationship to ability to carry out a ‘good’ interview.

A relatively new and increasingly popular method of teaching interpersonal skills has been described. The method has been in operation for the past year in the Department of Psychiatry at Queen's University. Evaluation by forty-five fourth-year medical students of the year 1970–71 points to a very favourable student reaction to this method.

This paper describes a study undertaken to determine the relationship of interviewing skills to age, educational level and intelligence in a class of paraprofessional mental health technicians. These technicians were trained at the U.S. Army Medical Field Service School at Fort Sam Houston, Texas in the fiscal year 1968.

The study indicates that skill in interviewing, as determined by scores obtained on an interview rating guide, are not significantly related to age, educational level or intelligence in the group investigated.

The methods of evaluating programs, residents and teachers are all interrelated. Although this may appear to be an over-inclusive statement, good training programs designed by competent teachers will produce competent residents. These residents in turn will become good teachers and clinicians. It is therefore in the interest of both residents and teachers to constantly evaluate each other and the programs.

The goal of residency training is to promote the acquisition of both theoretical and clinical skills. The final examination evaluates the resident's theoretical knowledge, but his clinical skills can only be evaluated in his day-to-day practice.

Recommendations: combine these evaluations at the end of training, allowing 50 per cent for the final theoretical examination and 50 per cent for his clinical work during his training.

Some steps to minimize the subjectivity of this clinical assessment follow:

1) Use the average of ratings from a number of supervisors.

2) The criteria to be evaluated should include theoretical knowledge, therapeutic abilities, interpersonal relations and initiative.

3) Periodic evaluations at regular intervals.

4) Feedback to the resident regarding his evaluation.

Taking into account the right and the duty of the teacher to evaluate his residents, and considering its aforementioned difficulties, it is essential that the resident also evaluate his teachers. This is a delicate but necessary task.

Criteria for evaluating teachers are:

1) Theoretical knowledge.

2) Clinical skills.

3) Interpersonal relationships.

4) Ability to communicate knowledge, both theoretical and clinical.

5) Motivation to teach.

6) Ability to inspire (‘feu sacre’).

7) Availability.

This continual evaluation by the residents of the department in which they are working will act as a constant stimulus for the improvement of programs, especially if it is assumed that the resident has a choice in determining his assignment.

To justify the assigning of 50 per cent of the assessment as clinical skills, a uniformity in the quality of training is necessary. This is seen as a uniformity in quality while maintaining differences in approach, and leads to the criteria for accreditation of hospitals.

Recommendations:

a) Formation of an autonomous committee responsible for accrediting the programs in various universities.

b) Plan for continuing research.

Vitamin B12 Deficiency

Among the many causes of organic psychoses are a number of processes which may be cured or arrested by the right treatment and by early recognition. This includes deficiency of vitamin B12. There is, therefore, a temptation to carry out sophisticated tests for vitamin B12 deficiency in all psychiatric patients. However, until cheaper and fully-automated techniques become available, routine vitamin B12 assays cannot be justified in psychiatric patients. At the present time a hemoglobin estimation and a careful inspection of the peripheral blood film by an experienced hematologist appear to be the most economic primary screening test for vitamin B12 deficiency. Nevertheless, psychiatrists should be alert to the possibility of vitamin B12 deficiency in patients with unexplained fatigue and in those with confusional states or dementia of unknown origin. Another presentation may be impotence which sometimes precedes other neurological manifestations of the disease. Even in patients who are not anemic or have no blood film abnormalities (which is uncommon) the possibility of missing cases of hypovitamin B12 deficiency can be further diminished by doing serum B12 assays in patients who are clinically at risk. For example, this includes post-gastrectomy patients, those with a familial history of pernicious anemia and those with an associated auto-immune disorder, such as thyroid disease.

Folic Acid Deficiency

The available evidence linking folate deficiency with psychiatric disorders is inconclusive. It is probable that the observed excess of folic acid deficiency in psychiatric patients can be explained on the basis of malnutrition, chronic physical illness, alcoholism or other drug usage. An important exception is brain damage and mental retardation in infants with inborn errors of folic acid metabolism. Further evaluation of folate deficiency is indicated, particularly in the affective disorders and in ambulatory, non-institutionalized, epileptic patients receiving anticonvulsant medication.

This is a report of recent developments in behaviour therapy in the treatment of phobias, observed while studying at the Institute of Psychiatry in London, England from July 1971 to May 1972. The modified flooding technique as practised by Marks and his team is less extreme than that employed by Stampfl. Furthermore it is more rapid and practical than Wolpe's systematic desensitization, while it is as efficient as this method in the treatment of specific phobias and surpasses it in the treatment of agoraphobia.

In specific phobias flooding in practice gives better results than flooding in imagination. In agoraphobia the superiority of one part of the treatment over the other has not yet been demonstrated. The importance of prolonged exposure to the phobic situation is now obvious.

This technique is not time consuming, the treatment is active, generally well accepted by the patients and improvement, both subjective and objective, is remarkable.

The urinary excretion of the main catecholamine metabolite, 3-methoxy-4-hydroxymandelic acid (VMA), was studied in thirteen patients before, during and after recovery from a depressive illness. The patients were classified independently into two diagnostic groups. Operational definitions of psychotic depression and neurotic depression were made, using diagnostic scales.

Taking the group as a whole there was no significant difference in VMA excretion throughout the periods of study. In four of the patients who showed psychomotor retardation the urinary VMA increased during hospitalization but did not reach statistical significance.

No difference was found in the mean values for VMA excretion in psychotic depressive patients compared with those who were neurotic.

Two hundred and eighteen chronic amphetamine users, ranging in age from thirteen to thirty years were interviewed to ascertain if common factors in backgrounds, life styles, and personalities exist. They were divided into six groups based on locale and sex, and important differences were noted. This essentially middle-class phenomenon is extremely destructive to these young people but it was quite obvious that the socio-psychological disturbance in most of them pre-dated the heavy drug use.

This investigation indicates that it is more difficult for people living in the isolation of remote areas and surrounded by dark forests and mountains to distinguish hearsay, fantasy, imagination and reality than it is for those who walk through illuminated city streets amidst noisy neighbours. A lonely Euro-Canadian farmer when asked about Sasquatches said, “When it is daylight I don't believe in them but at night when I am alone in the mountains or in the bush they could be real.”

It is also obvious that formal education is an important factor in determining whether a person has unwavering belief in mythology, and the higher the level of formal education the less a person believes in these phenomena.

Large numbers of patients with unwanted pregnancies are now being seen in areas where the abortion laws have been liberalized. A few frequently occurring psychologic mechanisms noted in these patients are described, and their significance for the consultant is noted.