My Fellowship sponsored by the World Psychiatry Association (WPA) commenced on the 4th of January 2010. I was introduced to the Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center, and a plan was put in place to enable me rotate through clinical and research units within the Department of Psychiatry as follows:
JANUARY - MARCH
A) Clinical Research Studies at the Child and Adolescent Bipolar (CABS) Clinic: I was introduced to two clinic research studies being conducted at the clinic – the Pittsburgh Bipolar Offspring Study (BIOS) and the Course and Outcome of Bipolar Youth Study (COBY). I observed intake and longitudinal follow up assessments of both studies using instruments such as the Structured Clinical Interview for DSM IV (SCID), Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime (KSADS –PL), Mania Rating Scale (MRS) and the Longitudinal Interval Follow Up Evaluation (LIFE). I also observed validation of assessments made by master’s levels clinicians with experienced child and adolescent psychiatrists.
B) Research Meetings: I began to attend weekly clinical research meetings with an expert group of MD’s, PhD’s, Masters level clinicians and statisticians. This continued through the course of the year and enabled me to gain a better understanding of the procedures involved in recruitment of study participants (subjects and controls), research instruments and methodology, data storage and data analysis. Under the supervision of Drs. Boris Birmaher and Tina Goldstein, I began to analyze and write up data from the BIOS study. The research questions aimed to determine the psychosocial functioning of children of parents with bipolar disorder as compared with children of community control parents.
C) Evidence Based Treatments at the CABS Clinic: I observed clinical assessments and treatments of bipolar patients using the latest evidence based treatments (pharmacotherapy, cognitive behavior therapy, dialectical behavior therapy and family therapy). I became familiar with the clinical and research diagnosis of Bipolar (BP) spectrum disorders especially BP NOS (not otherwise specified) , a diagnosis which is still controversial in many parts of the world.
D) Clinical Work: I obtained an institutional medical practice license for the state of Pennsylvania in March 2010. This enabled me to rotate through the Consultation Liaison unit at the Children’s Hospital Pittsburgh under the supervision of Drs. Roberto Ortiz-Aguayo and Viveca Meyer. This service involves the psychological management of patients with acute and chronic medical problems within a Medical hospital setting. My role included acute assessment of patients, formulating treatment plans, communicating with families and primary physicians, and arranging follow up mental health care when indicated. I also rotated through the Child and Adolescent Inpatient Unit under Dr. Gennady Berezkin where I had the opportunity to be involved in the acute stabilization of patients who were in need of a higher level of care. I worked with a multidisciplinary treatment team to facilitate this.
APRIL - JUNE
A) Women’s Behavioural Health Care: This was a four week rotation at a clinical research program for Women’s behavioural health under the supervision of Dr. Katherine Wisner. The program focused on mood disorders among women in the puerperium. I was introduced to planning and recruitment procedures for research participants, screening of post partum women for Depression using the Edinburgh Post Natal Depression Scale and full assessments for women who screened positive using the Structured Clinical Interview for DSM IV (SCID). I was exposed to another study which involved monitoring and follow up of mothers with Bipolar disorder who had been on anti-manic agents during pregnancy with the aim of determining the course and outcome of the disorder. I was also exposed to a third study - a randomized double blind clinical trial of Setraline vs Estrogen and placebo for women with post partum depression. I became involved in weekly monitoring of the study which included assessing mothers’ symptoms and infant developmental outcomes. During this period, I also had a brief introduction to bright light therapy for depressed post partum women. In the course of this rotation, i submitted an abstract for the annual Marcé Society Meeting, titled “Perinatal Mental Health Research: Harvesting the Potential” which was to be held in October 2010. This abstract looked at cross cultural differences comparing presentations of puerperal depression in Nigeria to the western world.
B) Other Activities: I had opportunities to participate in resident’s grand rounds, weekly didactics, journal clubs, workshops and conferences on the latest evidence based treatments for mood disorders. These included a workshop on suicidal spectrum behaviours which are commonly associated with mood disorders, and treatment strategies for emotionally dysregulated youth. I also attended some psychotherapy supervision meetings with Dr. Ellen Frank’s team.
JULY - SEPTEMBER
A) Partial Hospitalization Program: This rotation was carried out at an intermediate level of care for youth with emotional disorders within the community and supervised by Dr. Rameshwari Tumuluru. This level of care is currently not available in Nigeria and most of the developing world. Hence, I gained invaluable experience on the structure and workings of this type of service and how it can be modeled for the developing world setting.
B) Developmental Disorders Unit: This rotation took place at the John Merck unit of the Western Psychiatric Institute and Clinic which caters for the needs of children and adults with neuro- developmental disorders and intellectual disabilities. I gained experience in managing children and adults who have co- morbid neuro-developmental disorders or intellectual disability with mood and anxiety disorders in both inpatient and outpatient settings. My supervisors were Drs. Joseph Pierri, Kristina Johnson, and Russell Farr.
C) Crises Center: This rotation was carried out at the Resolve Crises Center of the Western Psychiatric Institute and Clinic. Here I spent two weeks observing the acute management of adults with emotional disorders in a crises situation under Dr. John Rozel.
D) Early Childhood Programs: I spent 4 weeks at a program which provides early interventions for children below the age of 5 years who suffer emotional disorders, or who were at increased risk for emotional disorders due to parental psychopathology. Here I gained experience on prevention techniques and the benefits of early interventions for high risk children under the supervision of Dr. Gautami Veeragandham
OCTOBER - DECEMBER
A) Completion of BIOS Write up: During the months of October to December, I completed a paper on the psychosocial functioning in offspring of bipolar parents as compared with community controls and submitted the paper to a peer reviewed journal for publication.
B) Participation in MARCÉ Conference: In the month of October I participated in the Marcé Perinatal mental health conference and presented my abstract.
Overall, my experience in the different facilities of the Western Psychiatric Institute of the University of Pittsburgh Medical Center helped me understand and gain experience in the presentation and management of mood disorders across the life span as well as insights into current important evidence based psycho-social treatments which are often neglected in my part of the world. The opportunity to rotate through clinical units provided insights into various levels of care currently unavailable in my country, and to work as part of a multidisciplinary team which are also rare in the developing world. Working with research data as part of research group provided training and mentoring in research instruments, methodology, statistical analyses and writing up papers for publication, as well as helping to understand better the link between research and clinical work.
As I return to Nigeria to continue teaching, research and clinical work at the University of Ibadan, and the University College Hospital, Ibadan, I would like to express my appreciation to the World Psychiatry Association and the University of Pittsburgh for this unique training opportunity. I hope to disseminate my new clinical and research knowledge and skills, as well as forge collaborations to carry out clinically and culturally relevant research in my environment.
Tolulope Bella MD
30th December 2010