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In this segment of Clinical Correlation, Dr. Renee Kohanski completes part 2 of her review of the most effective treatments for patients with severe anxiety. She also announces that, after almost 200 episodes, the Psychcast is taking an indefinite pause.

To reach Dr. Kohanski, email her at DocReneePodcast@gmail.com. To reach Dr. Lorenzo Norris, host of the Psychcast, email him at lnorris@mfa.gwu.edu.

Clinical Correlation was published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

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Craig Chepke, MD, speaks with Lorenzo Norris, MD, about changes he made to his practice during the COVID-19 pandemic, and plans to make some of those changes permanent.

Dr. Chepke is a psychiatrist in Huntersville, N.C., and adjunct associate professor at Atrium Health and adjunct assistant professor at the University of North Carolina at Chapel Hill. He disclosed serving as a consultant and speaker for Otsuka and Janssen, and as a speaker for Alkermes.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.

Take-home points

Dr. Chepke discussed his strategies for adapting his practice to the restrictions of the pandemic. He engaged in shared decision-making with patients when modifying his practice, including starting a drive-through pharmacotherapy clinic.
To ensure that patients continued to have access to treatments such as long-acting injectable antipsychotics and esketamine, Dr. Chepke created a system in which patients could drive up to his clinic to have the medication administered. Because esketamine requires a 2-hour monitoring period after administration, he adapted the safety protocol.
After patients received their intranasal spray dosage, they would complete the monitoring period in their car in the parking lot outside of his office, which was close enough to the clinic for Dr. Chepke to physically observe the patient, and to monitor vital signs wirelessly via a Bluetooth-enabled blood pressure cuff.
Throughout the pandemic, Dr. Chepke found ways to care for his patients’ physical and mental health. He also adopted technologies that help him monitor his patients' vital signs and glucose levels.
Especially while focusing on treatment-resistant psychiatric illness, Dr. Chepke invites family members to participate in evaluation and treatment. He uses this approach because he realizes that effective treatment must involve the system in which the individual exists.
Dr. Chepke and Dr. Norris discussed ways in which clinicians can extend hope to their patients through flexibility and innovation, especially throughout the pandemic. Providing hope to patients demonstrates belief in a better future.

Reference

Chepke C. Current Psychiatry. 2020 May;19(5):29-30.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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John “Jack” Rozel, MD, MSL, returns to the Psychcast to talk with Lorenzo Norris, MD, about American gun violence and steps clinicians can take to disrupt it.

Dr. Rozel is medical director of the resolve Crisis Network. He also serves as associate professor of psychiatry and adjunct professor of law at the University of Pittsburgh. Dr. Rozel is also past president of the American Association for Emergency Psychiatry. He has no disclosures.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.

Take-home points

Mass violence with guns is occurring with greater frequency and severity in the United States, compared with other countries. Mass shootings have been on the rise. In 2020 there were nearly 200 more mass shootings, compared with 2019.
The United States has a broad swath of firearm violence: Deaths by suicide account 60% of gun deaths, and the remaining 40% are deaths by homicide. Only 1%-2% of firearm homicides are completed in mass shootings – which are defined as an event in which four or more people are shot in an indiscriminate manner.
It is also a distinctly American problem that we have so many guns in our country. The United States has more civilian-held firearms (393 million) than the next 39 countries combined. Being an adult in the United States means being 25 times more likely to be the victim of a firearm homicide, compared with adults in any other country.
Dr. Norris and Dr. Rozel conclude that violence assessments must always cover suicide and homicide risk because they are related types of violence, especially when it comes to guns.

Summary

Suicide risk is increased by 100-fold when a new gun enters the home, and the risk peaks in the first days to weeks of ownership and then trails off. However, there is a measurable difference in risk of suicide in the 5 years after the purchase. Dr. Rozel emphasizes that it is essential to ask patients about acquisition of new guns, because as circumstances change as with the pandemic, people may feel the need to buy a gun.
Dr. Rozel presented a model for possibly reducing gun violence:
- Grievance: All violence starts with feeling like a victim; some people feel aggrieved after a disagreement or even a threat.
- The Pivot: This is a transition from simply having a grievance to violent ideation and wanting vengeance through violence. Perpetrators of violence shift from fantasy into research about planning and preparing to attack.
- Preparation: This stage includes acquiring weapons and, in some cases, tactical clothing. It also could include probing into their targets’ vulnerabilities, a “test attack,” and eventually the final attack.
- Breach: This entails a change in the safety of the potential victim.
- Attack: This stage encompasses perpetrating the attack.
Identifying a person at the grievance stage is the most effective place to intervene and potentially diffuse a violent situation by using motivational interviewing to enhance protective factors. Psychiatry’s greatest strength is meeting the aggressor where they are and hearing out the grievance.

References

Victor D and Taylor DB. A partial list of mass shootings in the United States in 2021. New York Times. 2021 Apr 16.

Kim NY. Gun violence spiked during pandemic, even as the deadliest mass shootings waned. Poynter.org. 2021 Mar 25.

Rozel JS and Mulvey EP. Annu Rev Clin Psychol. 2017 May 8;13:445-69.

Metzl JM et al. Har Rev Psychiatry. 2021 Jan-Feb 01;29(1):81-9.

Firearm access is a risk factor for suicide. Harvard School of Public Health.

National Council for Behavioral Health. Mass Violence in America: Causes, impacts, and solutions. 2019 Aug.

Gun Violence Archive

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In the first part of a two-part series on anxiety disorder, Dr. Kohanski shares what may be some surprising facts information about prescribing of the tried-and-true agents of anxiety, along with some clinical pearls.

Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

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Omar Sultan Haque, MD, PhD, talks with Lorenzo Norris, MD, about the need for medical schools to become responsive to physicians, medical students, and residents with mental disabilities.

Dr. Haque is a physician, social scientist, and philosopher who is affiliated with the department of global health and social medicine at Harvard Medical School, Boston. He disclosed founding Dignity Brain Health, a clinic that seeks to provide clinical care for patients struggling with major depressive disorder. Dr. Haque also serves as medical director of Dignity Brain Health.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.

Take-home points

Dr. Haque and colleagues recently published a perspective piece in the New England Journal of Medicine about the “double stigma” against mental disabilities, which the authors define as “psychiatric, psychological, learning, and developmental disorders that impair functioning,” including common diagnoses, such as attention deficit disorder and major depressive disorder.
Physicians and physicians-in-training, such as students and residents, face major challenges in disclosing mental disabilities, from fear of discrimination during the admissions process to stigma throughout training and licensure.
Medical leave is often the only suggested solution to an exacerbation of a disability, and this response is likely to instill fear in trainees, because taking leave will require future disclosure and worsen the double stigma. Reasonable accommodations could improve functioning and allow trainees to remain enrolled and on their desired academic path.
Dr. Haque recommends that medical schools and training programs have trained disability service providers (DSP) with specialized understanding of medical education and curricula who do not have conflicts of interest – as sometimes happens when they participate in other roles, such as serving as deans or professors within a medical school.
A continued challenge to disability disclosures are questions on medical licensing applications and renewals about past or current diagnoses or treatment for mental disabilities. Dr. Haque reminds listeners that, according to the American Disabilities Act, these questions about past and current diagnoses are illegal if the answers to those questions do not affect physicians’ current functioning.

Summary

Dr. Haque’s article offers several recommendations for medical schools, training programs, and licensing boards aimed at addressing the burden of the double stigma against mental disabilities within the culture of medical training and practice.
Medical schools should clearly communicate that applicants with disabilities are welcome as part of a larger commitment to diversity, and individuals with mental disabilities should be admitted and allowed to complete training.
Universities should hire medical school–specific disability service providers who understand medical education and are committed to parity for individuals with physical and mental disabilities.
Policies related to mental disabilities should be clearly publicized so that students and trainees know what to expect if they disclose a disability, and should create reasonable accommodations for those with mental disabilities instead of promoting medical leave as the only option.
Faculty members and administrators could publicly describe their own protected time for therapy and highlight the professional successes of people who were able to disclose their condition and get reasonable accommodations.
The Federation of State Medical Boards should enforce the ADA-based legal standard that questions about mental disabilities should be asked and answered only if they address current functional impairments that affect a physician’s ability to practice medicine safely.

References

Haque OS et al. N Engl J Med. 2021 Mar 11;384:888-9.

Wimsatt LA et al. Am J Prevent Med. 2015 Nov. 49(5):703-14.

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Géraldine Fauville, PhD, joins Lorenzo Norris, MD, to discuss some of the causes of Zoom fatigue and strategies that can make videoconferences productive.

Dr. Fauville is the lead researcher on the Zoom Exhaustion & Fatigue Scale project. She also is assistant professor in the department of education, communication, and learning at the University of Gothenburg (Sweden). Dr. Fauville has no disclosures.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.

Take-home points

Dr. Fauville started her research on Zoom fatigue in the Virtual Human Interaction Lab at Stanford (Calif.) University, founded by Jeremy N. Bailenson, PhD. The lab has pioneered research on the common but poorly understood phenomenon of Zoom fatigue.
Videoconferencing, often through Zoom, has allowed people to connect throughout the pandemic, but there are features of this modality that can contribute to stress, and for many, social anxiety.
Dr. Fauville and Dr. Norris discuss Zoom fatigue and which dynamics of videoconferencing contribute to a sense of anxiety, fatigue, and affect our general wellness in a society that has come to rely on videoconferencing as a primary form of communication and central to parts of our economy during the pandemic.
Dr. Fauville discusses how the size of faces on the screen and feeling observed activate anxiety and stress. Constant mirroring from seeing yourself reflected from the camera onto a screen can lead to self-judgment and negative emotions. Loss of traditional nonverbal communication and being forced to pay attention to verbal cues or exaggerate gestures can increase the cognitive load associated with conversations that occur via videoconference. Videoconferencing also restricts mobility, because people feel tethered to a small area within their camera’s view where they can be seen.

Summary

During an in-person meeting, people will stare at you while you’re speaking, but on videoconferencing it can feel as if all eyes are on you the whole time, which contributes to stress and social anxiety.
Dr. Fauville discusses the “large face” dynamic; if these conferences were real-life interactions, it would be like having a very large face just a few inches from ours, which can feel like an invasion of privacy. For the brain, having a face in close proximity to yours signals either a desire for intimacy or conflict.
- Recommendation: Minimize the videoconferencing application as much as possible and keep the size of the faces smaller.
Zoom and other platforms lead to “constant mirroring.” Seeing our own image can result in persistent self-evaluation and judgment, which can contribute to anxiety and negative emotions.
- Recommendation: Keep your camera on but hide self-view; doing so can combat this constant mirroring.
Videoconferencing has severely limited mobility during meetings, which make people feel trapped in the view of the camera.
- Recommendation: Using a standing desk allows for more freedom from the view of the camera. You can stretch your legs, walk around in the view of the camera, and create distance, especially if you have an external keyboard.
Nonverbal communication and behaviors are essential cues between humans. Videoconferencing that focuses on head and shoulders diminishes a large portion of body language. Videoconferences are more taxing for the brain than audio-only communication because people have to be even more in tune to the cues in speakers' verbal tones, and some nonverbal cues, such as nodding, become exaggerated.
- Recommendation: Organizations should create guidelines aimed at mitigating Zoom fatigue. Suggestions include allowing people to turn off their cameras for portions of meetings or didactics, having a mix of audio/telephone and video meetings, and assessing whether the information from some meetings can included in email messages or shared documents.
Dr. Fauville and colleagues created the Zoom Exhaustion & Fatigue Scale (ZEF Scale) to quantify the phenomenon. Fifteen items on the scale focus on five dimensions of Zoom fatigue, such as general, visual, emotional, social, and motivational fatigue. Part of the evaluation of Zoom fatigue should include examining how many videoconferences you have per day, the amount of time between each, and how long the conferences last.

References

Ramachandran V. Stanford researchers identify four causes for ‘Zoom fatigue’ and their simple fixes. Stanford News. 2020 Feb 23.

Fauville G et al. Zoom Exhaustion & Fatigue Scale. SSRN.com. 2021 Feb 23.

Bailenson JN. Nonverbal overload: A theoretical argument for the causes of Zoom fatigue. Technology, Mind & Behavior. 2021 Feb 23;2(1). doi: 10.1037/tmb0000030.

Zoom Exhaustion & Fatigue Scale survey: https://vhil.stanford.edu/zef/

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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In this week's installment of Clinical Correlation, Renee Kohanski, MD, unpacks the new Open Notes mandate.

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Guest host Vicki L. Ellingrod, PharmD, talks with Kristen M. Ward, PharmD, and Amy Pasternak, PharmD, about integrating pharmacogenomic testing into psychiatric practice.

Dr. Ellingrod is senior associate dean at the University of Michigan College of Pharmacy, Ann Arbor, and professor of psychiatry in the medical school. She is also section editor of the savvy psychopharmacology department in Current Psychiatry. Dr. Ellingrod has no relevant financial relationships to disclose.

Dr. Ward and Dr. Pasternak are clinical assistant professors of pharmacy at the University of Michigan. Dr. Ward and Dr. Pasternak report no relevant disclosures. Dr. Ward and Dr. Pasternak are team leads in the University of Michigan’s Precision Health Implementation Workgroup.

Take-home points

Pharmacogenomics is defined as the study of the relationship between genetic variations and how our body responds to medications.
Two common reasons for ordering pharmacogenomic testing are that a patient or clinician wants testing completed before starting the trial of a psychotropic medication and that there are concerns about nonresponse or loss of response to medications.
Common insurance criteria used to justify such testing include at least one failed medical trial; future use of a medication likely to be affected by genetic variants, such as metabolism through CYP2D6 or CYP2C19; or identification of human leukocyte antigen (HLA) variants before starting carbamazepine or oxcarbazepine.
Quality improvement and usability campaigns around pharmacogenomic testing include ensuring that testing results are readily available in the medical record.
Results should be searchable.
Alerts can be created for prescribers when they order a medication for which a patient has a relevant genetic variant.
After ordering testing, clinicians should document the patient’s medication response genotype and phenotype in the medical record so the information can be used for medications other than psychotropics.

Summary

Pharmacogenomic testing may be ordered for several reasons, including cases in which a patient or clinician wants information before switching to another medication or there are questions about failed medication trials.
For approximately 50% of individuals who undergo pharmacogenomic testing, there may not be a change in treatment plans, or the results might not be conclusive enough to affect treatment. However, pharmacogenomic testing is useful in reassuring and improving adherence in patients who experience somatic adverse effects to psychotropic medications and want to know whether those effects are related to their metabolism.
Getting insurance companies to cover pharmacogenetic testing can be tricky, and clinicians should be familiar with the criteria requested by insurers before ordering the tests. Many of the genetic-testing companies include a patient-assistance program to cover payment when insurance companies do not.
In the medical record, it’s important to document the patient's genotype and phenotype. The patient’s genotype affects their metabolism of medications beyond psychotropics.
Pharmacogenomic testing results can prevent serious adverse drug reactions. If testing comments on a patient’s carrier status for specific HLA subtypes implicated in drug metabolism, carbamazepine or other related medications should be added to the patient’s drug allergy list.
States requirements about informed consent for genetic testing vary, so any clinicians who order such tests should be informed about their local laws.

References

Ellingrod VL. Current Psychiatry. 2019 Apr;18(4):29-33.

Deardorff OG et al. Current Psychiatry. 2018 Jul;17(7):41-5.

Ellingrod VL and Ward KM. Current Psychiatry. 2018 Jan;17(1):43-6.

Bishop JR. Current Psychiatry. 2010 Sep;9(9):32-5.

Maruf AA et al. Can J Psychiatry. 2020 Aug;65(8):521-30.

National Institutes of Health. National Human Genome Research Institute. Genome Statute and Legislative Database.

Clinical Pharmacogenetics Implementation Consortium. CPIC guidelines..

Pharmacogenetics Knowledge Base.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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Lorenzo Norris, MD, speaks with Tonya Cross Hansel, PhD, about processing incidents such as the Jan. 6, 2021, siege on the Capitol, and determining how to foster recovery.

Dr. Hansel is an associate professor with the Tulane University School of Social Work in New Orleans. She has no conflicts of interest.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.

Take-home points

Dr. Hansel’s research focuses on measuring traumatic experiences and implementing systematic recovery initiatives that address negative symptoms by emphasizing individual and community strengths. The tendency to come together in times of vulnerability is a human instinct.
The Jan. 6 Capitol siege was a traumatic and polarizing event; in a Pew survey 1 week later, 37% of respondents expressed a strong negative emotion in response to the riot.
The unpreparedness of the U.S. Capitol Police and other law enforcement agencies led to fear and shock as much of the nation watched the breach unfold in real time on television.
A variety of groups attended the protest. Some groups were involved in domestic terrorism, and others were part of political groups who came protest their grievances against the government. Those who attended the event with the intent of engaging in violence and instilling fear are considered domestic terrorists.
Dr. Hansel said an event such as the insurrection wears on society by causing chronic stress, and one-time events such as the insurrection can lead to a prolonged state of anxiety.
Terrorism and violence are sometimes triggered by disenfranchisement when violence seems like the only way to make one’s voice heard. Disasters with an economic fallout, such as natural disasters or the ongoing COVID-19 pandemic, can result in greater disenfranchisement.
Prevention of future attacks and domestic terrorism must balance people’s ability to speak out and protest with an effort to avoid disenfranchisement. The way forward must also include addressing chronic fear.
Dr. Hansel suggests that building community over shared values is a powerful way to foster resilience after disaster. In the pandemic, we have all experienced sacrifice and hardship. When society moves beyond survival mode, efforts must be made to connect over our shared sense of loss.

References

Hartig H. In their own words: How Americans reacted to the rioting at the U.S. Capitol. Pew Research Center. 2021 Jan 15.

Pape RA and Ruby K. The Capitol rioters aren’t like other extremists. The Atlantic. 2021 Feb 2.

Ellis BH et al. Studies in Conflict & Terrorism. 2019 May 31. doi: 10.1080/1057610X.2019.1616929.

Hansel T et al. Traumatology. 2020;26(3):278-84.

Saltzman LY et al. Curr Psychiatry Rep. 2017 Jun 19. doi: 10.1007/s/1920-017-0786-6.

Hall BJ et al. PLoS One. 2015 Apr 24. doi 10.1371/journal.pone.0124782.

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One wouldn't think autism spectrum disorder belonged in the same universe as narcissistic personality disorder. Yet sometimes emotional disconnection and seeming lack of empathy leads to miscommunication. There is one key difference, however.

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Brian Holoyda, MD, MPH, MBA, conducts a Masterclass on the history of psychedelic research and how the renaissance of this drug class could affect psychiatric patients.

Dr. Holoyda, a forensic psychiatrist, practices in the San Francisco Bay Area. He also provides psychiatric consultations across the country. Dr. Holoyda has no disclosures.

Take-home points

The effects of psychedelics are dose dependent and difficult to predict. The impact of psychedelic treatment on violent behaviors was studied since the 1960s with varying results. More recent studies suggest that psychedelic use (excluding phencyclidine, or PCP) is associated with less violent crime.
Dr. Holoyda recommends that, before psychiatrists treat patients with psychedelic-assisted psychotherapy, patients should be screened for history of violence or aggression while using psychedelics (and in general) and a history of serious mental illness. Patients require informed consent about the risk of violence and interventions used to control aggressive behaviors.

Summary

In 1960, the Harvard Psilocybin Project included a study in the Concord (Mass.) Prison in which researchers hypothesized that using psychedelic-assisted psychotherapy in prisoners would reduce risk of violent recidivism. The original authors, including Timothy Leary, PhD, published varying results of the study – including that psychedelic use reduced recidivism. However, some argue the overly positive results from the first analysis were attributable to a halo effect. A recent reanalysis showed that the base rate for recidivism in the intervention group was 34%, and not significantly different from that of the control group.
Psychiatrists have continued to use psychedelic-assisted therapy for patients with psychopathology and treatment-resistant sexual offenders to investigate whether the transcendent experiences can change their personalities, including the development of insight and empathy.
Dr. Holoyda published a review of all published cases in medical literature discussing psychedelic use and violent behavior. Most of the cases were published in the 1960s-1970s, when psychedelics were viewed negatively as a product of the counterculture era.
More recent observational studies identified that psychedelics use is associated with a greater likelihood of carrying a firearm as well as intimate partner violence, but these newer studies are fraught, because PCP is sometimes classified as a psychedelic. Other epidemiological studies have identified reductions in violent behaviors associated with psychedelics use, compared with other illicit substances. Those reductions in violent behaviors include a lower probability of supervision failure, and a lower risk of intimate partner violence and drug distribution.
Peter S. Hendricks, PhD, and associates analyzed data from 225 million individuals who took the National Survey on Drug Use and Health from 2002 to 2014 with a focus on psychedelics use, excluding PCP. They found that a lifetime history of psychedelic use decreased the odds of theft, assault, and arrest for property and violent crime. Studies such as this suggest that individuals who favor psychedelics may be less prone to violent crime rather than a direct effect of psychedelics on decreasing violent crime.
As psychedelics enter the clinical sphere, clinicians must keep in mind that experiences on these agents are unpredictable. In a study of unmonitored psychedelic use, individuals report putting themselves or others at risk. Others reported behaving aggressively or violently, and others sought help at a hospital.
Before using psychedelics in a therapeutic environment, clinicians should assess patients’ past use and experience on psychedelics. They also should screen for history of “bad trips,” leading to aggression, agitation, paranoia, and risky behaviors. In clinical trials with psychedelics, individuals with history of bipolar and psychotic disorders have been excluded to reduce the risk of triggering an episode. For medicolegal protection, psychiatrists should engage in a thorough informed consent process before using psychedelic-assisted therapy.

References

Holoyda B. Psychiatric Serv. 2020;71(12): 1297-99.

Holoyda B. J Am Acad Psychiatry Law. 2020 Mar;48(1):87-97.

Hendricks PS et al. J Psychopharmacol. 2017 Oct 17. doi: 10.1177/0269881117735685.

Carbonaro TM et al. J Psychopharmacol. 2016;30(12):1268-78.

Metzner R. Reflections on the Concord prison project and the follow-up study. Bulletin of the Multidisciplinary Association for Psychedelic Studies/MAPS. Winter 1999/2000. 9(4).

Arendsen-Hein GW. LSD in the treatment of criminal psychopaths, in "Hallucinogenic Drugs and Their Psychotherapeutic Use." (London: H. K. Lewis & Co, 1963).

Leary T. Psyched Rev. 1969; 10:20-44.

Leary T and Metzner R. Brit J Soc Psychiatry. 1968;2:27-51.

Leary T et al. Psychother. 1965;2:61-72.

Doblin R. J Psychoactive Drugs. 1998; 30:419-26.

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Dost Öngür, MD, PhD, joins host Lorenzo Norris, MD, to discuss the emerging mental health effects of the pandemic.

Dr. Öngür is chief of the Center of Excellence in Psychotic Disorders at McLean Hospital in Belmont, Mass. He also serves as the William P. and Henry B. Test Professor of Psychiatry at Harvard Medical School, Boston. Dr. Öngür has no disclosures.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.

Take-home points

Without a doubt, the COVID-19 pandemic will have a lasting mental health impact on society.
Öngür discusses the role of trauma, grief, mourning, and social isolation during the pandemic.

Summary

One emerging mental health effect of the pandemic is lasting psychiatric symptoms after infection and inflammatory response, including anxiety, depression, insomnia, and fatigue.
Many individuals have lost loved ones or witnessed someone close to them experience severe illness and prolonged hospitalizations.
Early in the pandemic, in a 2020 Centers for Disease Control and Prevention representative survey, 30% of Americans reported symptoms of depression and anxiety, 13% reported increased substance use, and 11% thought about suicide.
Individuals report greater distress, substance use, and suicidal ideation in the United States, but deaths from suicide did not increase dramatically, compared with 2019. A recent study in JAMA Psychiatry noted, however, that emergency department visits for social and mental health emergencies such as suicide attempts, overdoses, and intimate partner violence were higher in mid-March through October 2020 during the COVID-19 pandemic, compared with the same period a year earlier.
One possible resilience factor for individuals with mental illness may be the protective nature of family ties. Though the shutdown led to social isolation and detachment from some networks, certain individuals came to rely more on nuclear relationships, such as family.
With the pandemic, mental illness and mental health treatment have entered the public consciousness and conversation more than ever before. After the pandemic, more people will need mental health services as the social effects continue to ripple for years to come.

References

Czeisler ME et al. Mental health, substance use, suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1049-1057.

Faust JS et al. Suicide deaths during the COVID-19 stay-at-home advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021 Jan 21;4(1):e2034273.

John A et al. Trends in suicide during the COVID-19 pandemic. BMJ. 2020;371:m452.

Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. Nat Hum Behav. 2021 Jan 15;5:229-38.

Holland KM et al. Trends in U.S. emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. 2020 Feb 3. doi: 10.1001/jamapsychiatry.2020.4402.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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In this week's installment of Clinical Correlation, Renee Kohanski, MD, offers some of her treasured nonpharmacologic pearls and discusses the power in practicing what we preach while forgiving our own human foibles.

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Pete Simi, PhD, joins host Lorenzo Norris, MD, to discuss some of the factors that lead people to join hate groups, and strategies that have enabled some to leave the life of extremism behind.

Dr. Simi, associate professor of sociology at Chapman University in Orange, Calif., has studied extremist groups and violence for more than 20 years. His research has received external funding from the National Institute of Justice, the Department of Homeland Security, the Department of Defense, the National Science Foundation, and the Harry F. Guggenheim Foundation.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. Dr. Norris has no disclosures.

Take-home points

Dr. Simi discusses how many of the White supremacists he studied live mundane, ordinary lives organized around extremist, violent beliefs. These individuals may be socialized in early life through exposure to beliefs consistent with White supremacy, such as racist ideas, slurs, and jokes, but they are not usually raised within a White supremacist family.
The biggest challenge of leaving White supremacy is finding a new overarching identity, which ultimately requires redefining one’s emotional habits when it comes to engaging with society. White supremacist programming not only includes hateful beliefs but an emotional orientation that influences how an individual interprets the world around them.
White supremacist violence and terrorism have long been a U.S. problem, and Dr. Simi said his awareness of the problem grew after the Oklahoma City bombing in 1995. Dr. Simi hopes that, through research and initiatives, the United States will address the root causes of White supremacist beliefs rather than focus on specific groups.

Summary

Dr. Simi first started studying White supremacists by evaluating their engagement on early Internet forums. Eventually, he made contact with a group that allowed him to observe their daily lives, including staying in their homes and attending collective events, such as music festivals. More recently, he has been evaluating and researching individuals who leave the White supremacist movement.
As with many individuals who find solace in extremist groups, the childhood and adolescence of those who become White supremacists usually contain adverse childhood experiences and instability, such as physical and emotional abuse, and substance use in the home. These events cultivate vulnerability to White supremacy, because these adolescents and young adults are searching for a stabilizing force.
In the Internet age, it’s much easier for vulnerable individuals to have chance encounters with extremist groups and beliefs, and even brief exposures are an opportunity for some to be recruited into White supremacist groups. A selling point of White supremacy is the sense of “fellowship” and “family,” which is attractive for individuals who feel disillusioned and isolated from society at large.
In Dr. Simi’s research, half of his sample participants of White supremacists reported mental health diagnoses and similarly high rates of suicidal ideation. Mental illness is not an excuse for the behaviors and beliefs, but an example of another vulnerability that makes these individuals susceptible to strong support groups that often hold extremist beliefs.

References

Simi P et al. Am Sociol Rev. 2017 Aug 29. doi: 10.1177/00031224177282719.

Bubolz BF and Simi P. Am Behav Sci. 2019. doi: 10.1177/0002764219831746.

Simi P et al. J Res Crime Delinquency. 2016. doi: 10.1177/002242781567312.

Windisch S et al. Terrorism Polit Violence. 2020. doi: 10.1080/09546553.2020.1767604.

Ask a researcher: Pete Simi. What domestic groups pose the largest threats? University of Nebraska, Omaha. 2021 Jan 14. National Counterterrorism Innovation, Technology, and Education Center. A U.S. Department of Homeland Security Center of Excellence.

McDonald-Gibson C. ‘Right now, people are pretty fragile.’ How coronavirus creates the perfect breeding ground for online extremism. Time. 2020 Mar 26.

Garcia-Navarro L. Masculinity and U.S. extremism: What makes young men vulnerable to toxic ideologies. NPR. 2019 Jan 27.

Life After Hate. Larry King Now. 2019 Jan 23.

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Frank Chen, MD, joins host Lorenzo Norris, MD, to discuss the impact of the COVID-19 pandemic on patients with schizophrenia.

Dr. Chen is the chief medical director for Houston Behavioral Healthcare Hospital and Houston Adult Psychiatry. He is a speaker for Alkermes and Otsuka. Dr. Chen has served on advisory boards for Alkermes, Intracellular Therapies, Otsuka, and Teva Pharmaceuticals.

Dr. Norris is associate dean of student affairs and administration at George Washington University. He has no disclosures.

Take-home points

Schizophrenia is associated with an increased risk of death from COVID-19, even when controlling for other medical comorbidities.
Individuals with schizophrenia have many biological and situational risk factors for COVID-19, including an elevated risk of metabolic syndrome from antipsychotic medications, higher rates of nicotine addiction, a greater likelihood of living in a group setting, limited access to medical care, and the underlying inflammatory state of schizophrenia.

Summary

An article published in JAMA Psychiatry in January 2021 evaluated a large cohort of patients in a New York health system and identified schizophrenia as the second most highly associated risk factor for 45-day mortality from COVID-19, after the risk factor of advanced age.
The study controlled for other medical comorbidities to avoid confounding the results. However, it is essential to remember that individuals with schizophrenia have environmental and biological factors that increase their risk of infection and complications from COVID-19, such as metabolic syndrome, cigarette smoking, limited access to health care, and living in a group or institutional setting.
Dr. Chen points out that many patients with schizophrenia already have skills to adapt to the stresses of the pandemic. For example, individuals with schizophrenia might already be accustomed to living with a certain level of fear and uncertainty inherent to their thought disorder. He also comments that negative symptoms make social distancing easier for individuals with schizophrenia than for other people.
Dr. Chen notes that telepsychiatry has been a boon to treating individuals with schizophrenia, because using this tool is almost like making a “home visit.” Telemedicine removes the barriers to care, such as transport and resistance to coming to the office.
Adaptation to telepsychiatry has varied among different patient populations. Dr. Chen says some of his “higher functioning” patients with more controlled and stable lives did not want to see their clinician via video. They preferred the “secure” and more private setting of an office.
Ultimately, psychological flexibility and ability to adapt influence the amount of stress people experience during crisis.

References

Nemani K et al. JAMA Psychiatry. 2021 Jan 27. doi: 10.1001/jamapsychiatry. 2020.4442.

Mazereel V et al. Lancet. 2021 Feb 3. doi: 10.1016/S2215-0366(2)30564-2.

Muruganandam P et al. Psychiatry Res. 2020 Jun 29. doi: 101016/j.psychres.2020.113265.

Kozloff N et al. Schizophr Bull. 2020 Jul;46(4):752-7.

Smith BM et al. J Contextual Behav Sci. 2020 Oct;18:162-74.

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We are still experiencing the direct hit in addition to the aftermath of the SARS-CoV-2 coronavirus, especially its devastating psychiatric impact. It's always darkest before dawn, isn't it? Let's lighten the path, shall we, in episode 12 of Clinical Correlation.

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John Koo, MD, and Scott A. Norton, MD, MPH, join host Lorenzo Norris, MD, for this special edition of the Psychcast. This is a crossover episode with our sister podcast, Dermatology Weekly.

Dr. Koo is a psychiatrist and a dermatologist at the University of California, San Francisco. He has no disclosures. Dr. Norton is a dermatologist with the Uniformed Services University of the Health Sciences in Bethesda, Md., and with George Washington University, Washington. He has no disclosures.

They are featured in an article on this topic online at MDedge.com/Psychiatry.

Dr. Norris is associate dean of student affairs and administration at George Washington University. He has no disclosures.

Take-home points

Delusional infestation or delusions of infestation, also known as delusional parasitosis, is a fixed false belief that one has an infestation of animate or inanimate pathogens, despite strong evidence against infestation. Common precipitants of delusional infestation include previous exposure to external or internal parasites, stress, and travel. The condition is more common among highly functional older women.
A recent study estimated the prevalence of delusional infestation as 1.9/100,000, though the condition is an area of limited study. Delusional infestation is poorly recognized by physicians, therapists, and families, which leads patients to search for an external cause of the symptoms and contributes to distress for patients and their loved ones.
Patients with delusional parasitosis often lack insight into their disease, and it can be difficult to persuade them to take the recommended treatment of antipsychotics.
Low-dose pimozide, a first-generation antipsychotic, is the most common treatment for delusional infestation, particularly because it does not have Food and Drug Administration approval as a treatment for psychosis. Therefore, patients are less biased against taking this medication.

Summary

Delusions of infestation are a monosymptomatic hypochondriacal psychosis in which the only delusion present is one of infestation, and patients do not have other symptoms of psychotic spectrum illness. Secondary delusions of infestation may occur in individuals who use drugs, such as methamphetamine or cocaine, or who have a primary psychotic disorder, such as schizophrenia.
Delusions of infestation is related to Morgellons disease, which is defined as a skin condition characterized by the presence of “threads” or filaments that patients believe are embedded in their skin and might be accompanied by stinging and itching sensations.
Patients with delusions of infestation usually present to a primary care physician or ED with symptoms of abnormal sensations of their skin, including crawling sensations. In addition, patients usually bring personal proof of their condition, such as a small bag of “specimens,” including pieces of lint, threads, or scabs. Some patients also bring in journals detailing the timing and associated factors of their symptoms.
Dr. Norton advises that physicians treating the patients with delusions of infestation should mentally prepare themselves against initial bias and set aside time for longer visits or several follow-up visits. Dr. Norton starts with the premise that the patient has an actual infestation or other underlying cause of their pruritus and performs a thorough, full-body exam for dermatologic conditions, and examines the materials patients bring with them using a double-headed microscope – so that he and the patient can look at the specimens together.
Dr. Koo often tells patients that they have Morgellons disease because it does not include the stigmatizing term of “delusional.” He reframes Morgellons as an infestation that cannot be cured by internal or external antiparasitic medications. He then pivots away from etiology to validation of their emotions and eventually to treatment.
Dr. Koo usually often starts treatment with pimozide because it is an antipsychotic with FDA approval for Tourette syndrome – not schizophrenia. This perceived absence of a connection of the medication to psychiatric illness allows patients to be more open to taking the medication.
For primary delusional infestation, Dr. Koo starts with pimozide. The dose, which is daily and taken orally, starts low at 0.5 mg and goes up by 0.5 mg every 2-4 weeks. The aim is to get up to 3 mg per day. Low doses of pimozide and other antipsychotics lead to decreased sensation of itching and formication. Dr. Koo refers to his treatment plan as a “trapezoid-like dosage strategy.” Once he gets the patient to 3 mg, he continues the medication until all the symptoms disappear and then continues the medication for an additional 3 months. Dr. Koo then slowly tapers the dosage over an additional few months.
The keys to successful treatment include communicating with patients and working collaboratively with them. This approach builds trust and rapport.

References

Brown GE et al. J Clin Exp Dermatol Res. 2014;5:6. doi: 10.4172/2155-9554.1000241.

Kohorst JJ et al. JAMA Dermatol. 2018 May 1;154(5):615-7.

Lepping P et al. J Am Acad Dermatol. 2017 Oct;77(4):778-9.

Middelveen MJ et al. Clin Cosmet Investig Dermatol. 2018;11:71-90.

Lepping P et al. Acta Derm Venereol. 2020 Sep 16. doi: 10.2340/00015555-3625.

Freudenmann RW et al. Br J Dermatol. 2012 Aug;167(2):247-51.

Wolf RC et al. Neuropsychobiology. 2020;79:335-44.

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George T. Grossberg, MD, conducts a Masterclass examining emerging treatment options for Alzheimer’s disease that are tied to the new research on the microbiome.

Dr. Grossberg is the Samuel W. Fordyce professor and director of geriatric psychiatry in the department of psychiatry and behavioral neuroscience at Saint Louis University.

He disclosed that he is a consultant for Acadia, Alkahest, Avanir, Axovant, Axsome Therapeutics, Biogen, BioXcel, Genentech, Karuna, Lundbeck, Novartis, Otsuka, Roche, and Takeda; receives research support from the National Institute on Aging, Janssen, and Genentech/Roche; performs safety monitoring for ANAVEX, EryDel, Intra-Cellular Therapies, Merck, and Newron; and serves on the data monitoring committee of ITI Therapeutics. Dr. Grossberg also serves on the speakers’ bureau of Acadia.

Take-home points

Dr. Grossberg discusses burgeoning research about treatment of Alzheimer’s disease (AD) by altering the microbiota using diet and medications.
The microbiome refers to the entirety of microorganisms that live throughout the body. Microbiota are those organisms that live within the gut. Dysbiosis refers to a microbial imbalance, which has been linked to numerous disorders, including inflammatory diseases, psychiatric illness, obesity, diabetes, and more recently, AD.
The gut-brain axis describes the impact of microbiota and GI tract health on the brain. Periodontal disease, as a marker of inflammation and as part of the microbiome, is linked to AD.
Increasing research into the role of the microbiome, inflammation, and AD has revealed promising treatments. Sodium oligomannate, a drug approved for mild to moderate AD in China, has been shown to slow the progression of AD by remodeling the microbiota and suppressing the production of specific amino acids that promote neuroinflammation.

Summary

The microbiota has many purposes, including digestion, communication with the immune system, generation of signaling peptides, refining vitamins, and producing antioxidants. Many factors influence the microbiome, including diet, use of antibiotics, exposure to breast milk as an infant, stress, and old age.
The gut microbiota can be altered by consuming “prebiotics,” which are food sources that influence the composition of the microbiota. These foods include fermented foods such as yogurt, kombucha, sauerkraut, and kimchi. The Mediterranean diet also has good sources of prebiotics.
Birthing method (C-section versus vaginal birth) also influences the microbiota; a recent study shows that an infant’s microbiota after C-section can be altered by giving them an early fecal transplantation from the mother.
As further proof of the link between periodontal disease and AD, a recent study identified the presence of Porphyromonas gingivalis, a bacteria that causes gum disease, in the brain in close proximity to the tau tangles of AD. Gingipain, the toxin secreted by this bacteria, is found in high concentrations in brains of individuals with AD.
Dr. Grossberg reviewed his “recipe” for AD prevention and treatment:
Recommend adequate activity in four spheres: Physical, mental, social, and spiritual.
Treat and control all cardiovascular risk factors, including smoking, obesity, diabetes, hypertension, and hyperlipidemia.
Recommend good oral hygiene based on the increasing research about the link of periodontal disease and AD.
Recommend dietary changes, including a prebiotic or probiotic, and the Mediterranean diet. Dietary changes may also include supplements such as curcumin, B-complex multivitamin, and vitamin E.
Control exposure to air pollution as possible.
Use a combination pharmacotherapy of an N-methyl-D-aspartate antagonist and a cholinesterase inhibitor for individuals with AD.

References

Jones ML et al. Gut Microbes. 2014 Jul 1;5(4):446-57.

Askarova S et al. Front Cell Infect Microbiol. 2020;10:104.

Beydoun MA et al. J Alzheimers Dis. 2020;75(1):157-72.

Wang X et al. Cell Res. 2019 Oct;29(10):787-803.

Korpela K et al. Cell. 2020 Oct 15;183(2):324-34.

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In episode 11 of Clinical Correlation, Dr. Kohanski offers more pearls to approaching that seemingly innocent chief complaint of insomnia. She welcomes listener commentary as always.

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Rebecca W. Brendel, MD, JD, and Allen R. Dyer, MD, PhD, join guest host Carol A. Bernstein, MD, to discuss the ethical challenges that have been occurring during the COVID-19 pandemic.

Dr. Brendel is director of law and ethics at the Center for Law, Brain, and Behavior at Massachusetts General Hospital, Boston. She also serves as director of the master of bioethics degree program at Harvard Medical School, Boston. Dr. Brendel has no disclosures.

Dr. Dyer is professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as vice chair for education at the school of medicine and health sciences. Dr. Dyer has no disclosures.

Dr. Bernstein, a past president of the American Psychiatric Association, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures.

Take-home points

Medical ethics often deal with decisions between doctors and patients, but during the COVID-19 pandemic, the medical community has been forced to reckon with ethics on a population scale. Examples of ethical challenges include issues of scarcity, justice, transparency, and navigating distrust of the medical system.
In the beginning of the pandemic, individuals such as Dr. Brendel and Dr. Dyer participated in ethical planning so that hospital systems would be prepared to deal with scarcity of resources that could result in some individuals going without lifesaving interventions. During times of scarcity, transparency and accountability are necessary, because the community will ask questions about the fairness and justice of specific outcomes.
The philosophy of utilitarianism is a reason-based decision-making model that strives to maximize the greatest good for the greatest number, and it has been commonly used as a template for ethical discussions during the pandemic. Yet, utilitarianism calculus is complicated by questions of how to define “good” and the challenge of accurately predicting the outcomes.

Summary

In situations of urgency, demand, and scarcity, ethics usually turns to utilitarianism with the intention of maximizing the greatest good for the greatest number. Inevitably, people or populations are harmed. Especially in the beginning of the COVID-19 pandemic, American society grappled with the issue of scarcity and allocation of medical resources, ranging from personal protective equipment, ventilators, medical staff, ICU space, and the vaccine.
Now we must think about the ethical decisions influencing COVID-19 vaccination, including weighing the risks and benefits of who gets the vaccine and when – and how certain vaccine schedules forestall the spread in the population. For example, institutionalized individuals are at great risk of contracting COVID-19, yet society debates the “good” of vaccinating elderly in nursing homes versus incarcerated individuals. Question of defining good and grappling with the consequences are present throughout the entire vaccination algorithm. Communities contend with the question of who in their ranks are essential workers: Health care workers? Teachers? Restaurant staff? Factory workers?
Justice and transparency are commonly discussed ethical principles, especially when we think about the algorithms created to allocate resources. Transparency is required to foster trust in the public health system, and actors within the system must demonstrate their accountability through being honest about the evidence behind policy decisions, following set parameters, and acknowledging historical reasons for distrust.
The pandemic has pushed society to think about the ethics of community solidarity and reflect on governmental and individual responsibility of protecting the health and well-being of the community. As the pandemic ravaged the U.S. economy and further disadvantaged already vulnerable communities, we must use this opportunity to reexamine the ethics of how health care is distributed in the United States, and work toward a just and equitable system.

References

Ethics and COVID10: Resource allocation and priority-setting. 2020 World Health Organization.

AMA Journal of Ethics. COVID-19 Ethics Resource Center.

Emanuel EJ et al. N Engl J Med. 2020 May 21. doi: 10.1056/NEJMsb2005114.

Dyer AR and Khin EK. Int Encycl Soc Behav Sci. 2015;63-70.

The principles of medical ethics with annotations especially applicable to psychiatry, 2013 edition. American Psychiatric Association.

American Psychiatric Association. Ethics.psychiatry.org.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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Ruth S. Shim, MD, MPH, joins Carol A. Bernstein, MD, to discuss how to understand systemic racism within psychiatric institutions and the implications for patient care.

Dr. Shim is the Luke & Grace Kim Professor in Cultural Psychiatry in the department of psychiatry and behavioral sciences at the University of California, Davis. She has no disclosures.

Take-home points

Dr. Shim discusses her editorial published by statnews about why she left the APA, and describes her frustration about what she sees as the APA’s failure to prioritize mental health inequity and structural racism within the organization.
Dr. Shim describes systemic racism and oppression as generational traumas that must be recognized and processed if our professional organizations and country are to move forward with equity. Psychiatry plays a role in healing societal trauma, so psychiatrists need to understand and address the damage of structural racism in our own system.

Summary

After psychiatry training, Dr. Shim became faculty at Morehouse School of Medicine, one of the few historically Black medical schools. During her clinical work in Atlanta, Dr. Shim noted the difference in health outcomes of inpatients at Emory University Hospital, which treated majority White patients, compared with those of Grady Memorial Hospital, which treated majority Black patients. This observation propelled her research into health disparities, which continues to inform her academic work.
Dr. Shim’s decision to leave the APA occurred during the presidential term of Altha J. Stewart, MD, who, even as the first African American president of the organization, was thwarted in her attempt to push the APA to focus attention and resources on addressing mental health disparities, inequity, and systemic racism within the organization and psychiatry, according to Dr. Shim.
Dr. Shim observes that systemic racism occurs when the structures of an organization, not individuals, perpetuate the inequity. An example within the APA is the disconnect and power disparity between the group’s executive leadership structure and its elected officials. This disconnect and power disparity stymie progressive voices and interventions, Dr. Shim said.
Addressing systemic racism within an organization is challenging because it may not be considered a problem by all members, and usually the leadership of an organization caters to its majority. As an example, Dr. Shim discussed the APA’s systematic attempt to reduce resources and cancel the Mental Health Services Conference (formerly Institute for Psychiatric Services, or IPS meeting), which focuses on health care delivery to the most vulnerable populations. As observed by Dr. Bernstein, the IPS meeting might have incurred financial losses, but investment in such a meeting demonstrated the APA’s concern for mental health equity. (The Mental Health Services Conference was not held in 2020 but is scheduled to be held virtually Oct. 7-8, 2021).

References

Shim RS and Vinson SY, eds. Social (In)Justice and Mental Health. Washington, D.C.: American Psychiatric Association Publishing, 2021.

Shim RS. Structural racism is why I’m leaving organized psychiatry. Statnews.com. 2020 Jul 1.

Marmot M et al. Lancet. 2008 Nov 8;372(9650):1661-9.

Okun T. White supremacy culture. Dismantlingracism.org.

APA apologizes for its support of racism in psychiatry. psychiatry.org. 2021 Jan 18.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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The Beatles aren't the first group to write about sleep and surely won't be the last. In these next two programs, Dr. Kohanski shares some of her pearls, pharmacologic and nonpharmacologic, on those gymnastic, jumping sheep.

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David H. Rosmarin, PhD, joins Lorenzo Norris, MD, to discuss how to think about the concept of denial and its role in the sociopolitical challenges of our society.

Dr. Rosmarin is a clinical psychologist and director of the spirituality and mental health program at McLean Hospital in Belmont, Mass. He also is an assistant professor of psychiatry at Harvard Medical School, Boston.

Dr. Rosmarin has no disclosures. Dr. Norris has no disclosures.

Take-home points

Denial is defined as a cognitive and emotional process by which a person avoids facing aspects of reality, especially when it is difficult to assimilate the details of reality into one’s current thinking.
Arguably, denial is a coping or defense mechanism meant to address the tension that arises from trying to change an individual’s current way of thinking and understanding of reality.
Another form of denial is choosing to focus only on one’s perception of reality and struggling to see the other side of an argument. We can see this form of denial play out in COVID-19 pandemic denial and in certain political narratives.
Denial in its most potent form causes individuals to disconnect from any conversation around the salient topic, which can make denial even worse.

Summary

Denial can be adaptive in its role of protecting a person's psyche. When the midbrain and limbic system are activated, the frontal lobe needs time to process and integrate the information. For example, people will deny the presence of an event they regret or fear until they have enough emotional capacity to integrate new facts into their current model of reality.
Yet, denial can be harmful when there are “side effects.” The classic example of pathologic denial is an individual who has experienced trauma, and through continued denial of its impact and poor integration of the event, starts to experience somatic symptoms. Dr. Rosmarin says the problem with denial is that people who are experiencing denial are often the last to recognize their need for treatment or an intervention.
Dr. Rosmarin discusses how, with certain topics, we must value and preserve relationships over persuading certain social contacts, such as family and friends, to overcome their denial. Validating emotions and finding the validity in a person's beliefs and grievances can go a long way toward preserving relationships that are challenged by denial of certain facts.

References

Rosmarin DH et al. Lancet Psychiatry. 2021 Feb;8(2):92-3.

Hall C and Pick D. Hist Workshop J. 2017 Oct;84(1):1-23.

Miller BL. JAMA. 2020 Dec 8;324(22):2255-6.

Rosmarin DH. Spirituality, Religion and Cognitive-Behavioral Therapy: A Guide for Clinicians. New York: Guilford Press, 2018.

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Guest host Eva Ritvo, MD, interviews Dorothy Otnow Lewis, MD, about her more than 40-year career in studying death row inmates as examined in the HBO documentary “Crazy, Not Insane.”

Dr. Lewis is clinical professor of psychiatry at Yale University, New Haven, Conn. She has no disclosures.

Dr. Ritvo is a psychiatrist in private practice in Miami Beach, Fla. She has no disclosures.

Take-home points

Dr. Lewis has an extensive archive of taped interviews with death row inmates that she has used to inform her work as an expert witness.
While doing her child psychiatry training at the Yale Child Study Center and sitting in at the juvenile court, she began to see that some of the children had psychiatric and neurologic problems that had not been addressed.
The parents of these children sometimes had psychotic or bipolar disorders. After seeing these themes, Dr. Lewis started a clinic at the court.
Dr. Lewis and her team were able to study approximately 15 inmates in four states, including Texas and Florida, both of which had the greatest number of condemned juveniles. One key theme that emerged is that all of the inmates had been sentenced to death as juveniles.
Eventually, the Supreme Court ended the death penalty for convicted killers who committed their crimes before age 18.
Digging deeper and asking more questions of child and adolescent patients who commit violent acts can help clinicians identify environmental stressors that might underlie behavior that is aggressive and antisocial. In some cases, the psychiatric and neurologic impairments identified are treatable.
Dr. Lewis would like to study whether identifying child abuse early might prevent future violence.

References

Yaeger CA, Lewis DO. Mental illness, neuropsychologic deficits, child abuse and violence. Child Adolesc Psychiatr Clin N Am. 2009;(4):793-813.

Lewis DO. Ethical Implications of what we know about violence. Child Adolesc Psychiatr Clin N Am. 2000 Oct 9(4):833-91.

Lewis DO et al. Ethics questions raised by the neuropsychiatric, neuropsychological, educational, developmental, and family characteristics of 18 juveniles awaiting execution in Texas. J Am Acad Psychiatry Law. 2004;32(4):408-29.

Griffith EEH et al. Re: Ethics questions raised by characteristics of 18 juveniles awaiting execution in Texas. J Am Acad Psychiatry Law. 2006;34(2):143-4.

Lewis DO et al. Some evidence of race bias in the diagnosis and treatment of the juvenile offender. Am J Orthopsychiatry. 1979 Jan;49(1):53-61.

Lewis DO. Guilty by Reason of Insanity: A Psychiatrist Explores the Minds of Killers. New York: Fawcett Columbine, 1998.

Roper v. Simmons, 543 U.S. 551 (2005).

Thompson v. Oklahoma, 487 U.S. 815 (1988) .

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In this week's installment, Dr. Renee Kohanski explores the identity crisis facing many physicians today.

Clinical Correlation is a bimonthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

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Regina James, MD, tells her personal story and discusses how to understand health equity with guest host Carol A. Bernstein, MD.

Dr. James is deputy medical director and chief of the division of diversity and health equity at the American Psychiatric Association. She also serves on the advisory board of The PACT group (Pan African Clinical Trials) and receives no income from the group.

Dr. Bernstein, a past president of the APA, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures.

Take-home points

The Robert Wood Johnson Foundation defines health equity as: “Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Equity embraces the idea of inclusiveness and evaluates a whole health care system instead of focusing only on individual marginalized communities. For example, it is essential to understand the social determinants that lead to groups being medically underserved and then to understand the impact of the medically underserved on the entire system.
Dr. James led a 20-year career in research and leadership within the National Institutes of Health, including the National Institute of Mental Health, the National Institute on Minority Health and Health Disparities, and the Eunice Shriver National Institute of Child Health and Human Development. She later transitioned to 2M, a research consulting agency, and then to the APA.
Within the APA, Dr. James has developed a 5-point strategic plan with the vision that all APA members will be culturally competent and sensitive, and able to provide mental health care for any individual regardless of age, race, gender, or sexual orientation.
The strategic plan focuses on raising awareness about mental health equity and destigmatization and leveraging the expertise of the APA membership in their communities. A cornerstone of the plan is an educational agenda, including materials on health equity in psychiatry and outreach to APA members and their community partners. In addition, Dr. James and her office partner with APA leadership to lobby the government for mental health equity and inclusion.
Dr. James describes structural racism as current policies within an organization that lead to racial inequalities. Separate from the Office of Diversity and Health Equity, the APA established a Presidential Task Force to Address Structural Racism Throughout Psychiatry to identify the scope and targets of structural racism within organized psychiatry, including the APA. It also seeks to identify how structural racism affects practicing psychiatrists and their patients.

References

Braveman P et al. What is health equity? Robert Wood Johnson Foundation. 2017 May 1.

American Psychiatric Association. Diversity and health equity.

American Psychiatric Association. Mental health disparities: Diverse populations.

APA Presidential Task Force to Address Structural Racism Throughout Psychiatry. https://www.psychiatry.org/psychiatrists/structural-racism-task-force

Rosenkranz KM et al. J Surg Education. 2020. doi: 10.1016/j.surg.2020.11.013.

Simonsen KA and Shim RS. Psychiatr Clin North Am. 2019 Sep;42(3):463-71.

Alves-Bradford J-M et al. Psychiatr Clin North Am. 2020 Sep;43(3):415-28.

Aggarwal NK et al. Patient Educ Couns. 2016 Feb;99(2):198-209.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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As we begin 2021, Renee Kohanski, MD, muses about the roller coaster journey she and her listeners have been on during the challenging times of 2020.

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Bradford L. Frank, MD, MPH, MBA, conducts a Masterclass on how to provide nursing home consultations for psychiatrists. The documents Dr. Frank refers to during this Masterclass are available at (https://bit.ly/3rWqfcK)

Dr. Frank is a board-certified geriatric psychiatrist who provides consultations for more than 30 nursing homes in North Dakota. He has no disclosures.

Take-home points

Dr. Frank reviews practical information about documentation, prescribing, and diagnoses for psychiatric clinicians who treat individuals living in nursing homes.
The Centers for Medicare & Medicaid Services has many rules and regulations governing the psychiatric treatment of individuals in nursing homes, including special mental status testing, a policy of gradual dose reduction, and restrictions on how long certain medications can be used.

Documentation

Even for geriatric patients who live in nursing homes, a full past psychiatric history, including substance abuse and social history, is essential to diagnosis and treatment. To obtain these histories, Dr. Frank sends documents to the nursing home to be completed ahead of time, and then, while he starts to make his differential diagnoses, he talks with the nursing staff about why they want the consultation.
The Brief Interview for Mental Status (BIMS) is a 15-item mental status exam mandated by the CMS during nursing home evaluations. A score of 13-15 indicates that a patient is cognitively intact, 8-12 indicates moderately impaired, and <8 is severe impairment. However, even patients with a BIMS score of 15 may still be diagnosed with moderate dementia when a more sensitive neuropsychiatric assessment is used. Patients should also complete a Patient Health Questionaire–9 and have labs done as they would in a clinic.
The assessment must also address gradual dose reduction using language from the CMS (see below).

Prescribing and medications

Gradual dose reduction is a CMS policy defined as “the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.” In collaboration with nursing home staff, prescribers must attempt to taper the doses of psychotropic medications during at least two quarters during the first year of the prescription and at least annually thereafter.
The Food and Drug Administration has provided a black-box warning for the use of atypical antipsychotics in geriatric patients with dementia, and their use in such patients is audited by the CMS. To avoid censure and low ratings, nursing home clinicians must prescribe antipsychotics only for psychotic symptoms, such as hallucinations and delusions, and not for “dementia” or “agitation.”
As-needed (PRN) antipsychotic medications can only be used for 14 days, and to extend the period another 14 days, the patient must be evaluated in person by the primary prescriber. PRN medications from other drug classes, such as benzodiazepines, can be used for longer without an exam, but their timeline must be specifically documented.
Psychiatrists are most commonly consulted in nursing homes for agitation, and antipsychotics are not supposed to be used solely for agitation. Dr. Frank recommends citalopram (maximum dose of 20 mg), then escitalopram, Nuedexta (dextromethorphan HBr and quinidine sulfate), and pimavanserin for agitation associated with Alzheimer's disease (AD).

Diagnosis

Research based on autopsy findings has concluded that mixed etiology dementia is the most common type of dementia. On autopsy, AD is concurrently found with either vascular dementia, as evidenced by cerebral infarcts, or Lewy body dementia. To use cognitive enhancers that are FDA approved only for AD, Dr. Frank will update the diagnosis to multiple etiologies with a severity specifier.
Frank discusses that nursing homes are reimbursed at a higher rate for the diagnoses of restlessness and agitation (R45.1), noncompliance (Z91.19), and wandering (V40.31), and these are helpful diagnoses because they describe behaviors. Nursing homes use ICD-10 codes to diagnoses dementia with or without behavioral disturbance. For psychosis not attributed to delirium or severe dementia, Dr. Frank uses psychotic disorder with delusions or hallucinations because of a known physiological condition (F06.2 and F06.0). Regulatory agencies recommend against use of the unspecified diagnoses.

References

Center for Clinical Standards and Quality/Survey & Certification Group. Centers for Medicare and Medicaid Services. 2016 Mar 25: 21-5.

Minimum Data Set – Version 3.0. Resident Assessment and Care Screening. Brief Inventory Mental Status exam: 7-8.

Bennett DA et al. Curr Alzheimer Res. 2012 Jul 9(6):646-63.

Yunusa I et al. JAMA Netw Open. 2019;2(3):e190828.

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Three of our favorite masterclasses back-to-back-to-back. The Psychcast will return with new content in 2021.

Bulimia nervosa (01:53) Episode 104
Telepsychiatry (12:58) Episode 111
Cannabis (39:17) Episode 137

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Richa Bhatia, MD, conducts a Masterclass on how to identify medical and neurologic illnesses that present with psychiatric symptoms and mimic psychiatric diagnoses.

Dr. Bhatia is a board-certified general and child and adolescent psychiatrist in private practice. She has no disclosures.

Take-home points

Psychiatric diagnoses are diagnoses of exclusion. Psychiatric clinicians must maintain a high level of clinical suspicion for medical and neurologic illnesses that present with psychiatric symptoms and mimic psychiatric diagnoses. When patients have a “strange” presentation of their psychiatric illness, including being out of the usual age range, a fast progression, or an unusual constellation of symptoms, clinicians should pursue a medical work-up and think broadly about other diagnoses that might mimic the psychiatric diagnosis.

Dr. Bhatia provides an overview of common medical and neurologic illnesses that mimic psychiatric diagnoses, including hypothyroidism, delirium, HIV/AIDS, Addison disease, autoimmune encephalitis, temporal lobe epilepsy, frontotemporal dementia, Wilson’s disease, and Parkinson’s disease.

Summary

Hypothyroidism is an endocrine disease that can mimic depression. The physical symptoms include constipation, edema, dry skin, hair loss, weight gain, and cold intolerance. Individuals with comorbid hypothyroidism and depression report inadequate response to antidepressants, so psychiatrists should check the patient’s thyroid-stimulating hormone or refer them to their primary care physician if they suspect hypothyroidism with elevated TSH.

Delirium is a common yet underdiagnosed syndrome that occurs secondary to medical illness and can produce an array of neuropsychiatric symptoms, including psychosis, irritability, and disorganized behaviors, which can lead to misdiagnosis as schizophrenia or mania. Delirium presents as an abrupt change in cognition with disorientation and significantly impaired attention. Hypoactive delirium presents with lethargy, apathy, and decreased alertness, and is often mistaken for depression in the hospital setting. Simple beside tests such as the Confusion Assessment Method can be used to quickly aid in diagnosing delirium.

HIV/AIDS can mimic psychiatric disease through direct effect on the nervous system, opportunistic disease, intracranial tumors, cerebral vascular disease, and medication adverse effects. HIV can mimic depression by causing neurovegetative symptoms; apathy, psychomotor slowing, and working memory deficits are more characteristic of the neuropsychiatric impairment from HIV rather than a primary depressive disorder. In late-stage HIV/AIDS, dementia can cause bizarre behaviors, delusions, and mood disturbance such as euphoria and irritability.

Addison disease is characterized by low blood pressure, hyperpigmentation, nausea, vomiting, weakness, fatigue, hypokalemia, and hyponatremia. Addisonian crisis can present with neuropsychiatric symptoms of delirium, anxiety, agitation, cognitive impairment, and auditory and visual hallucinations.

Autoimmune encephalitis, with anti–N-methyl-D-aspartate receptor encephalitis as the most common type, often masquerades as a primary psychotic symptom. Notable symptoms include subacute onset with fast progression and no clear prodrome, working memory impairment, agitation, or lethargy. Other presenting symptoms include focal neurologic deficits, new-onset or rapidly developing catatonia, fever, headaches, flu-like illness, and autonomic disturbance.

Temporal lobe epilepsy also can mimic a primary psychiatric disorder. The symptoms of seizure-like staring, blinking, lip-smacking, and behavioral arrest are precipitated by a sensation of fear or epigastric sensation and depersonalization, which can lead to misdiagnosis as a panic attack.

Frontotemporal dementia (FTD) can be mistaken for a primary psychiatric diagnosis in the initial stages. Hallmark symptoms include progressive behavioral change with disinhibition and a decline in executive functioning and language skills such as verbal learning and reasoning. FTD is the second most common dementia in people aged younger than 65 years. Patients with FTD struggle to give a history, and often lack a psychiatric history or exposure to psychotropic drugs. Clinicians should maintain a high degree of clinical suspicion for FTD in new-onset psychiatric syndromes in older individuals.

Stroke can lead to poststroke depression and anxiety, apathy, emotional lability, and personality changes. Depression after stroke, occurring hours to days after the insult, is associated with greater cognitive impairment and increased mortality. The diagnosis of poststroke depression is challenging because of impairments in language and cognition after stroke. Apathy can occur separately from depression and diminish recovery.

Wilson’s disease results in copper deposits in the brain and liver. The psychiatric symptoms, including psychosis, occur before neurologic changes. Parkinson’s disease also can result in depression-like symptoms, given the motor and neurovegetative symptoms from the neurodegeneration. Fatigue, psychomotor slowing with diminished facial expression, postural changes, and sleep disturbance are common conditions that can mimic depression.

References

Carroll VK. Current Psychiatry. 2009 Aug;8(8):43-54.

Welch KA and Carson AJ. Clin Med (Lond). 2018 Feb;18(1):80-7.

Scarioni M et al. Ann Neurol. 2020;87(6):950-61.

Evans DL et al. Neuropsychiatric manifestations of HIV-1 infection and AIDS, in “Neuropsychopharmacology: 5th Generation of Progress.” Philadelphia: Lippincott Williams & Wilkins, 2002, pp. 1281-99.

Deng P and Yeshokumar A. Psychiatric Times. 2020 Jan. (37):1.

Kumar A and Sharma S. Complex partial seizure, in “StatPearls [Internet].” Treasure Island, Fla.: StatPearls Publishing, 2020 Jan. (Updated 2020 Nov 20).

Rao V. Neuropsychiatry of stroke. Geriatric Workforce Program. Johns Hopkins Medicine.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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In this week's installment of Clinical Correlation, Dr. Renee Kohanski reminds listeners of our inherent desire to help one another and problem solve while cautioning against those who would place our most vulnerable populations at risk.

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Eliza W. Menninger, MD, spoke with Psychcast host Lorenzo Norris, MD, about how to help patients deal with anxiety related to the COVID-19 pandemic.

Dr. Menninger is medical director of the behavioral health partial hospital program at McLean Hospital in Belmont, Mass. She treats patients with major depression, bipolar disorder, schizophrenia, and schizoaffective disorder. Dr. Menninger also treats patients in McLean’s Schizophrenia and Bipolar Disorder Outpatient Clinic. She has no disclosures.

Dr. Norris has no disclosures.

Take-home points

Anxiety related to stress, fear, worry, and grief has spiked in all phases of the pandemic. Initially, we faced uncertainty not knowing how to adapt to restrictions, and we assumed that the adaptations would be short term. Six months into the pandemic, we’ve moved into questions about maintaining these adaptive processes over the long term.
As the medical director of a partial hospitalization program, Dr. Menninger created an acronym, “MASK,” to help people cope with the stress of the pandemic.
MASK stands for Make boundaries, Avoid the virus, Stay connected, Keep the faith.

Summary

Making boundaries refers to encouraging people to use similar behaviors from their past routines to maintain normalcy. For example, for people who work from home, Dr. Menninger suggests getting dressed and ready for work as though you’re actually going, and taking breaks from screens to reduce virtual platform fatigue. People are feeling socially and physically restricted by the pandemic, and she emphasizes going outside regularly. Boundaries that help delineate physical spaces and emotional responsibilities can alleviate the physical and mental clutter that compounds stress.
Avoiding the virus is a constant chore, so Dr. Menninger came up with a humorous song aimed at helping her patients remember their role in avoiding exposure to the coronavirus.
Staying connected means focusing on the social connection and feeling the presence of the other person instead of just sensing the temporary connection provided through the virtual platform. Dr. Menninger suggests imagining that the person with whom you’re connecting is in the room with you. Self-care through maintaining routines; exercising; maintaining healthy nutrition; seeking out humor; and enjoying art, music, and other stimuli helps people connect with themselves and others.
Keeping the faith means remembering that the pandemic will end, and we have the tools to build resilience in ourselves and patients. Dr. Menninger finds hope in the way her clinical staff has been creative to make a difference in the patients’ life amid the constant changes. She and Dr. Norris cite examples of patients using creativity to overcome overwhelming life circumstances, build on their strengths, and reframe the pandemic to find the silver lining.

Reference

Marcus PH et al. Current Psychiatry. 2020 Dec;19(12):28-33.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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Oliver Freudenreich, MD, talks with Lorenzo Norris, MD, about principles of pandemic management among patients with serious mental illness.

Dr. Freudenreich reported receiving grant or research support from Alkermes, Avanir, Janssen, and Otsuka. He has served as a consultant to the American Psychiatric Association, Alkermes, Janssen, Neurocrine, Novartis, and Roche.

Dr. Norris has no disclosures.

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In this week's installment of Clinical Correlation, Dr. Renee Kohanski tackles the very difficult and painful realities of a postelection country.

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This week, we revisit four shows that offer guidance to clinicians for addressing the mental health fallout from COVID-19.

Lisa W. Coyne, PhD, founder of the McLean OCD Institute for Children and Adolescents in Belmont, Mass., focuses on helping children and adolescents with anxiety and obsessive-compulsive disorder. She disclosed receiving royalties from New Harbinger and Little Brown Publishing.

Christine Moutier, MD, describes interventions that can prevent patients from ending their lives by suicide. She is chief medical officer of the American Foundation for Suicide Prevention. Dr. Moutier reported no disclosures.

Sanjay Gupta, MD, offers a Masterclass on how to determine which medication works best for geriatric patients with symptoms of dementia. Dr. Gupta, chief medical officer at BryLin Hospital in Buffalo, N.Y., disclosed serving on the speakers’ bureaus of AbbVie, Acadia, Alkermes, Intra-Cellular Therapies, Janssen, and Otsuka.

Peter Yellowlees, MBBS, MD, wraps up the podcast with perspective about permanent changes that could be in the offing to the practice of psychiatry because of the pandemic. He is a professor of psychiatry at the University of California, Davis. Dr. Yellowlees has no disclosures.

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Diana M. Martinez, MD, conducts a Masterclass on marijuana’s effects on psychiatric disorders.

Dr. Martinez, a professor of psychiatry at Columbia University, New York, specializes in addiction research. She disclosed receiving medication (cannabis) from Tilray for one study and has no other financial relationships with this company.

Take-home points

The use of cannabis, recreationally and medically, has been a controversial topic for ages, and the classification of cannabis as a schedule I controlled substance has made it all the more difficult to research and meaningfully understand its harms and benefits.
Based on information from the National Academies of Sciences publication Health Effects of Marijuana: An Evidence Review and Research Agenda, Dr. Martinez presents a sweeping overview of the role of cannabis in two domains: Its ability to worsen psychiatric symptoms, and its role in causing psychiatric disorders.
The cannabis plant has 100 cannabinoids. The two most commonly studied are tetrahydrocannabinol (THC), which creates the "high," and cannabidiol (CBD), which does not create a high and has many subjective effects.
Cannabis is researched and used in several forms, including the smoked plant or flower form, and prescription cannabinoids based on THC – namely dronabinol (Marinol), nabilone (Cesamet), and CBD.
Research suggests that both benefits and risks are tied to using cannabis and cannabinoids.
Clinicians should have rational discussions with their patients about the use of cannabis. If patients are no longer responding to psychiatric treatment, and the clinician wants to talk about their cannabis use, it is important to understand the common reasons patients use cannabis, including for chronic pain, anxiety, and insomnia.

Benefits

There is substantial evidence supporting the use of cannabis and cannabinoids for the treatment of chronic pain. Most studies evaluated the smoked or vaporized form. Research suggests a dose of 5-20 mg of oral THC is about as effective as 50-120 mg of codeine, although there are few head-to-head studies to reinforce this finding.
Cannabis will likely have a role in the pain treatment armamentarium. The risks of use include intoxication and development of an addiction.
Cannabinoids may have a role in achieving abstinence from addiction to cannabis and other substances.
THC in the form of cannabinoids shows some promise for its use in disorders such as PTSD and obsessive-compulsive disorder, but larger controlled studies are needed. In addition, cannabinoids have an effect when combined with other behavioral interventions, such as exposure therapy.

Risks

There is substantial evidence that cannabis has a moderate to large association with increased risk of developing psychotic spectrum disorders in a dose-dependent fashion, particularly in patients who are genetically vulnerable.
Moderate evidence suggests that cannabis causes increased symptoms of mania and hypomania in people with bipolar disorder who use it regularly.
Cannabis can cause addiction. About 9% of people who use it will develop a substance use disorder, and the risk of developing a substance use disorder increases to 17% in people who start using cannabis in their teenage years. Frequent cannabis use is associated with withdrawal symptoms, such as irritability, sleep problems, cravings, decreased appetite, and restlessness.

References

National Academies of Sciences, Engineering, and Medicine. Health Effects of Marijuana: An Evidence Review and Research Agenda. Washington, DC: National Academies Press, 2017.

Whiting PF et al. JAMA. 2015;313(24):2456-73.

Fischer B et al. Am J Public Health. 2017 Jul 12. doi: 10.2105/AJPH.2017.303818.

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In this week's installment of Clinical Correlation, Renée Kohanski, MD, ponders the loss of professional courtesy and the larger implications of medicine-shifting paradigms.

Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

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Lisa W. Coyne, PhD, spoke with Psychcast host Lorenzo Norris, MD, about strategies that can be used to help children and adolescents deal with anxiety and obsessive-compulsive disorder amid COVID-19.

Dr. Coyne, a clinical psychologist, is founder of the McLean OCD Institute for Children and Adolescents in Belmont, Mass. She also is director with the New England Center for OCD and Anxiety in Cambridge, Mass. Dr. Coyne disclosed receiving royalties from New Harbinger and Little Brown Publishing.

Dr. Norris has no disclosures.

Take-home points

Much of the anxiety experienced by some children and adolescents is caused by uncertainty about the future.
Some children and adolescents also are watching cases of COVID-19 tick up across the country and are concerned about the mixed messages they are receiving from adults.
- Different cultures exist around belief in science.
Rates of anxiety in general are on the rise as are demands for more mental health services.
- Clinicians are supporting each other to support their patients.
Anxiety in young patients might present as disruptions in sleep and appetite. Look for an increase in oppositional behavior. Young patients with anxiety also might resist going to bed.
Clinicians also are seeing increases in depressed mood and nonsuicidal self-injury.
Acceptance and commitment therapy, a type of cognitive-behavioral therapy that is exposure based, is a strategy that can be used to help patients develop psychological flexibility and put distance between themselves and their thoughts.

References

Mazza MT with foreword by Coyne LW. The ACT Workbook for OCD: Mindfulness, Acceptance, and Exposure Skills to Live Well With Obsessive-Compulsive Disorder. Oakland, Calif.: New Harbinger Publications, 2020.

Allmann AE et al. Acceptance and commitment therapy-enhanced exposures for children and adolescents. Exposure Therapy for Children and Adolescents with Obsessive-Compulsive Disorder: Clinician’s Guide to Integrated Treatment. Academic Press, 2020.

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*** There is a transcript available for this episodes at https://www.medscape.com/viewarticle/940969

Yuan Chang Leong, PhD, spoke with Psychcast host Lorenzo Norris, MD, about his research into the neural underpinnings of right- and left-leaning individuals.

Dr. Leong is a postdoctoral scholar in cognitive neuroscience at the University of California, Berkeley. He has no disclosures.

Dr. Norris has no disclosures.

Take-home points

Dr. Leong and colleagues looked for further evidence of “neural polarization,” which is defined as divergent brain activity based on conversative versus liberal political attitudes.
The prefrontal cortex is the part of the frontal lobe responsible for executive and higher-order brain function that makes sense and organizes what a person is seeing, hearing, and experiencing.
Participants were shown news clips about immigration policy and their brain activity showed differences in activity of their dorsomedial prefrontal cortex (DMPFC), which is active in interpreting narrative content. The findings suggest there is a neural basis for the way in which individuals with different political attitudes interpret political information and news.
The research suggests that words related to threat, morality, emotions, anger, and differentiation/community drive neural polarization.

Summary

Dr. Leong and colleagues asked participants to watch news clips about immigration policy while undergoing functional MRI with the goal of identifying the neural correlates of neural polarization, which is thought to parallel the behavioral aspects of political polarization.
Dr. Leong and colleagues identified an association of divergence in connectivity to the DMPFC to the ventral striatum, a structure involved in reward processing and sensing the valence and tone of information. Their study, published in the Proceeding of the National Academy of Sciences, suggests that information from the ventral striatum is transmitted differently to the DMPFC between groups.
The findings suggest that our political beliefs might influence our interpretation of other information, as the DMPFC helps humans interpret narrative content.
Dr. Leong pointed out that this study provides evidence about why it is so difficult to bridge the partisan divide. He also discussed the psychology of social identity theory and how any categorization of people makes individuals think along the lines of in-group and out-group, and how the human drive is to protect the in-group.

References

Leong YC et al. PNAS. 2020 Oct 20. doi: 10.1073/pnas.2008530117.

McLeod S. Social identity theory. Simply Psychology. Updated 2019.

University of Texas, Austin. Ethics unwrapped. In-group/out-group (video).

Brooks M. Brain imaging reveals a neural basis for partisan politics. Medscape.com. 2020 Oct 27.

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Renee Kohanski, MD, discusses managing difficult referrals from trusted colleagues.

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Christine Moutier, MD, joins Lorenzo Norris, MD, to discuss how clinicians can scale up interventions to reduce suicide rates amid the pandemic.

Dr. Moutier is chief medical officer of the American Foundation for Suicide Prevention. She reported no disclosures.

Dr. Norris also reported no disclosures.

Take-home points

Death by suicide is a health outcome, which means that there is always a place to intervene, whether clinically, socially, or through research.
Risks for suicide during the pandemic are known to increase; however, it is not a foregone conclusion that suicide deaths will rise during or afterward.
Mental health diagnoses are a risk factor for suicide, and there will be interplay with stressors such as unemployment, financial stress, grief, and socioeconomic disparities.
The basics of suicide prevention include screening for suicidal ideation at behavioral health appointments. If a change in risk is identified, clinicians should use a patient-centered intervention, such as a safety plan.

Summary

The U.S. suicide rate has risen by 35% from 1999 to 2018, and the rates of suicide are particularly increasing in middle-aged populations as well as among youths of color.
Evidence-based efforts are underway to mitigate suicide deaths through national suicide prevention plans. Yet, everyone has a role to play in suicide prevention, since part of prevention includes reducing stigma related to conversations about mental health and asking about crises and suicidal thoughts.
In behavioral health settings, routine screening should be implemented for suicidal ideation and deterioration in any aspect of mental health. Asking about suicidal ideation is the bare minimum, and not all patients will admit to suicidal ideation when asked. Other risk factors for suicide include acute stressors such as decompensation and losses of relationships and employment.
Most individuals with suicidal thoughts do not need to be psychiatrically hospitalized. Suicidal thoughts, as symptoms of a mental illness, can be treated with interventions other than hospitalization. The goal is to maintain safety and respond appropriately.
In-office interventions include creating a safety plan or adding to an existing plan.
As a silver lining, the pandemic has normalized conversations about mental health and reduced stigma around mental health experiences. Dr. Moutier discusses how, as the pandemic set in, the AFSP experienced a notable increase in requests for education about mental health and suicide prevention.

References

Moutier C. JAMA Psychiatry. 2020 Oct 16. https://bit.ly/34AF0Zq.

Chung DT et al. https://bit.ly/31RYxm9.

American Foundation for Suicide Prevention: https://bit.ly/2HK3S8j

Policy priorities: https://bit.ly/37IvO78

Safety plan worksheet: https://bit.ly/2HK3Vkv

Centers for Disease Control and Prevention suicide risk factors: https://bit.ly/3jyMu3i

Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest.

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Philip Resnik, PhD, returns to the Psychcast, this time with his research partner and wife, Rebecca Resnik, PsyD, to discuss the interface between language, psychiatry, psychology, and health.

Dr. Philip Resnik appeared on the show previously to discuss artificial intelligence, natural language processing, and mental illness. He is a professor in the department of linguistics at the University of Maryland, College Park, and has a joint appointment with the university’s Institute for Advanced Computer Studies.

Dr. Philip Resnik has disclosed being an adviser for Converseon, a social media analysis firm; FiscalNote, a government relationship management platform; and SoloSegment, which specializes in enterprise website optimization. Some of the work Dr. Philip Resnik discusses has been supported by an Amazon AWS Machine Learning Research Award.

Dr. Rebecca Resnik is a licensed psychologist in private practice who specializes in neuropsychological assessment. In 2014, she served as cofounder of the Computational Linguistics and Clinical Psychology workshop at the North American Association for Computational Linguistics. She continues to serve as a workshop organizer and clinical consultant to the cross-disciplinary community. She has no disclosures.

Dr. Norris disclosed having no conflicts of interest.

Take-home points

Dr. Rebecca Resnik and Dr. Philip Resnik are interested in finding measurable, observable features to apply to the assessment of psychological and psychiatric diagnoses. They point out that finding an objective measure is essential for scaling up mental health evaluations and treatment.
Natural language processing (NLP) is focused on analyzing language content. NLP technology has generated tools such as Siri, Alexa, and Google Translate, and NLP allows computers to do things more intelligently with human language.
Individuals are using machine learning and NLP to analyze language data sets to evaluate diagnostic criteria. The goal is to create or use language sets that can be analyzed outside of the clinic.
Dr. Rebecca Resnik imagines a world where a patient gives a “language sample” to an app or an avatar that would be evaluated by NLP that would, in turn, offer some overarching hypotheses about the person. So much of evaluations is trying to home in on the correct signal, explicit and implicit, from the patient. In addition, neuropsychiatric tests/scales are standardized against a limited scope of the population, so NLP would be matched to the individual.
Dr. Philip Resnik looks at signals in text and speech content, acoustics, microexpressions, and even biometric data. Machine learning can process and distill a huge amount of data with various signals more easily than any human.
Dr. Rebecca Resnik revisits the idea of clinical white space, which is the “space” or the time between clinical encounters, and this is where decompensation and high-risk suicidal behaviors occur. She suggests that NLP software could be used to fill this white space by using apps to collect text samples from patients, and the software would analyze the samples and warn of patients who are at risk of decompensation or suicide. If clinicians were to use text or speech samples from people’s smart technology, we could assess an individual's risk in the moment and use nudge-type interventions to prevent suicide.
Finally, Dr. Philip Resnik emphasizes that there are technologists who have the skills and technology that is on the verge of helping clinicians, but the key to progress is collaborating with clinicians.

References

Resnik P et al. J Analytical Psychol. 2020 Sep 10. doi: 10.111/sltb.12674.

Coppersmith G et al. Biomed Inform Insights. 2018;10:1178222618792860.

Zirikly A et al. CLPsych 2019 shared task: Predicting the degree of suicide risk in Reddit posts. Proceedings of the Sixth Workshop on Computational Linguistics and Clinical Psychology. 2019 Jun 16.

Yoo DW et al. JMIR Mental Health. 2020;7(8):e16969.

American Medical Informatics Association and Mental Health: https://www.amia.org/mental-health-informatics-working-group

Selanikio J. The big-data revolution in health care. TEDxAustin. 2013 Feb.

CLPsych: Computational Linguistics and Clinical Psychology Workshop. 2019 Program.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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Dr. Renee Kohanski discusses how important personal and professional development is among physicians in the workplace. Is your current job worth it?

Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast

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Sanjay Gupta, MD, conducts a Masterclass on treating geriatric patients with symptoms of dementia, particularly amid the restrictions tied to COVID-19.

Dr. Gupta is chief medical officer at BryLin Hospital in Buffalo, N.Y. He is also is a clinical professor in the department of psychiatry at the State University of New York, Syracuse, and is affiliated with SUNY at Buffalo. Dr. Gupta attends at 8-10 nursing homes.

He disclosed serving on the speakers’ bureaus of AbbVie, Acadia, Alkermes, Intra-Cellular Therapies, Janssen, and Otsuka.

Take-home points

Common neuropsychiatric symptoms in patients with dementia include agitation, aggression, delusions, insomnia, anxiety, and depression. One-third of community-dwelling elders and between 60%-80% of nursing facility patients have these neuropsychiatric symptoms.
The most common medication class Dr. Gupta uses is antipsychotics. The use of these medications in individuals with dementia is off label. The Food and Drug Administration maintains a black-box warning on the use of antipsychotics for geriatric patients because of the increased risk of sudden death.
Risperidone is supported by the most data, then olanzapine, then aripiprazole, and finally quetiapine. Quetiapine has very limited data to support its efficacy. Most antipsychotics have modest efficacy data for their use in this population. The riskiest adverse effects are cardiovascular adverse events, which are higher in risperidone.
Dr. Gupta starts risperidone at a low dose of 0.25 mg taken by mouth b.i.d. and titrates to a maximum dose of 2 mg/24 hours. The starting dose for olanzapine is 2.5 mg up to a maximum dose of 10 mg. The starting dose of aripiprazole is 1 mg, and maximum dose 5 mg or less.
Selective serotonin reuptake inhibitors (most commonly sertraline or citalopram), the atypical antidepressant mirtazapine, and anticonvulsants (valproic acid) are also used for agitation in dementia but there is limited evidence for their efficacy. Melatonin and trazodone have a positive effect on sleep that can have downstream improvement on aggressive behaviors.

Summary

To choose an effective treatment, it’s essential to obtain a detailed history of the symptoms from patients and collateral, such as relatives and staff members from the facility. Staff members can be educated about what information is most important to the clinician, or they may provide vague information, such as “the patient is confused.” Specific symptoms that can be used guide treatment include the presence of disorganized thoughts, delusions and paranoia, or visual and/or auditory hallucinations; the timing of the behavior (day vs. night); and patterns of aggressive behaviors.
Dr. Gupta emphasizes that it’s important to rule out delirium as the cause of agitation by evaluating underlying medical issues with laboratory evaluations, and when possible, a physical exam.
Antipsychotics work best in the context of aggression driven by paranoia and/or delusions of persecution. Antipsychotics seem to work less well for general agitation that may be driven by triggers that need to be uncovered through investigation of the history and environment. Reasons for agitation and aggression might include sensory or activity deprivation, difficulty emptying bladder or bowels, or depression and loneliness, both of which are prevalent during the pandemic.
Adverse effects of antipsychotics will be greater in older adults, and include sedation, gait problems that increase the risk of falls, and extrapyramidal or Parkinsonian symptoms. In a geriatric patient, tardive dyskinesia can occur with as little as 1 month of exposure to an antipsychotic, compared with 3 months in younger adults.
Before starting an antipsychotic, the clinician must obtain informed consent from the health-care proxy and inform them that using antipsychotics in a patient with dementia is a non–FDA-approved treatment with a black-box warning.
Gradual dose reduction, a Medicare policy about the use of psychotropic medications within nursing homes, is defined as “stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.” Dr. Gupta addresses this policy by assessing which medications are essential and often stopping some medications once the patient is started on antipsychotics.

References

Steinberg M, Lyketsos CG. Am J Psychiatry. 2012 Sep;169(9):900-6.

Maher AR et al. JAMA. 2011 Sep 28;306(12):1359-69.

Schneider LS et al. JAMA. 2005 Oct 19;294(15):1934-43.

Seitz DP et al. Cochrane Database Sys Rev. 2001 Feb 16;(12):CD0089.

Ballard C et al. Cochrane Database Sys Rev. 2006 Jan 25. doi: 10.1002/14651858.

Ballard C, Waite J. Cochrane Database Sys Rev. 2006 Jan 25;(1):CD003476.

Department of Health & Human Services. State Operations Manual Surveyor Guidance Revisions Related to Psychosocial Harm in Nursing Homes. CMS.gov. 2016 Mar 25.

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David Henry, MD, host of the Blood & Cancer podcast, joins Psychcast host Lorenzo Norris, MD, to discuss steps clinicians can take to alleviate the distress associated with receiving a diagnosis of cancer.

Dr. Henry is clinical professor of medicine at the University of Pennsylvania, Philadelphia. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures.

Take-home points

Cancer patients have always been susceptible to developing depression and anxiety after receiving their distressing diagnoses. During the COVID-19 pandemic, the risk for depression and anxiety are even greater because patients face separation from their oncology treatment teams and for some, delays in treatment.
Major depressive disorder (MDD) occurs in up to one-third of cancer patients, and any depressive disorder can be seen in about half.
Another concern is how to screen for depression in the context of cancer. Dr. Norris suggests using the Patient Health Questionnaire–2 (PHQ-2) screener, or the question: “Are you sad or depressed?” Answering those questions can give patients the opportunity to open up about their emotions.
Signs of depression in cancer include nonadherence to treatment, changes in mood and anxiety affecting daily functioning at home or work, and demoralization, which is defined as helplessness, isolation, and despair in the face of overwhelming stressors.

Summary

An emotional upset, such as disbelief, despair, or even denial, might occur immediately after receiving a cancer diagnosis. A depressive disorder, however, is a persistently depressed, sad mood with changes in functioning that affect the patient, his/her family, and even engagement with treatment.
Findings of studies about the prevalence of depression in patients with cancer vary depending on the type of screening and/or diagnostic tool used. In general, the prevalence of MDD is up to 38%, and the prevalence of any depressive disorder is up to 58%. The prevalence of depression is even greater in patients with advanced cancer. In the general population, the 12-month prevalence of MDD is 6%, and the lifetime prevalence is 16%.
It’s useful to think about stress along a continuum of diagnoses ranging from a normal expected stress syndrome, an adjustment disorder, MDD triggered by the event, depression secondary to a general medical condition as can occur in central nervous system and pancreatic cancer, or even a substance-induced mood disorder from either prescribed medications or perhaps a form of coping that has turned maladaptive.
Cognitive-behavioral therapy (CBT) can be explained as examining the way thoughts influence emotions and behavior. When using CBT with cancer patients, a good place to start is checking in on their understanding of their diagnosis, their prognosis, and current and future treatments. The goal is to see whether they have unnecessary cognitive distortions that may be affecting their emotions and behaviors. During periods of extreme stress, CBT can help patients by emphasizing the use of adaptive thoughts, and identifying maladaptive thoughts and behaviors as opportunities for intervention.
To screen for depression, it may be enough to ask: “Are you depressed?” As a screening tool, the PHQ-2 asks only two questions: “Over the last 2 weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things, or been feeling down, depressed or hopeless? The PHQ-2 score ranges from 1 to 6, and even at the lowest score, it has a sensitivity and specificity of 90.6% and 65.4%, respectively, in detecting any depressive disorder.

References

Krebber AMH et al. Psycho-oncology. 2014 Feb;23(2)121-30.

Walker J et al. Ann Oncol. 2013 Apr 1;24(4):895-900.

Trinidad AC et al. Psychiatr Ann. 2011;4(9):439-42.

Daniels S. J Adv Pract Oncol. 2015 Jan-Feb;6(1):54-6.

Other resources

PHQ-2: https://www.hiv.uw.edu/page/mental-health-screening/phq-2

National Cancer Institute: Depression–Health Professional Version: https://www.cancer.gov/about-cancer/coping/feelings/depression-hp-pdq

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Dr. Renee Kohanski, MD, uses a proverb to discuss how she talks to patients about face masks, and how she talks to patients with face masks on. What's hiding behind the mask?

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Psychcast host Lorenzo Norris, MD, talks with members of the Group for the Advancement of Psychiatry’s Media Committee about how to help patients navigate the uncertainties associated with educating K-12 and college students during the pandemic. The discussion is moderated by Jack Drescher, MD.

Dr. Norris is assistant professor of psychiatry and behavioral sciences and assistant dean of student affairs at George Washington University in Washington. He also serves as medical director of psychiatric and behavioral sciences at George Washington University Hospital. Dr. Norris has no conflicts of interest.

Dr. Drescher is clinical professor of psychiatry at Columbia University in New York, adjunct professor at New York University, and a training and supervising psychoanalyst at the William Alanson White Institute. He has no conflicts of interest.

Joining Dr. Norris and Dr. Drescher are Carol Bernstein, MD; Jeffrey Freedman, MD; Gail Saltz, MD; and Peter Kramer, MD. None of the guests have a conflict of interest.

Summary

Questions about school reopenings are fraught with uncertainty for children, parents, and teachers, with concerns for safety as well as the quality of the school experience. Constant communication between parents and schools with families is warranted; however, without a clear plan, too much communication can generate anxiety.
The pandemic and school reopenings affect most sectors of society, including the economy, and vulnerable and elderly populations. The pandemic puts pressure on families because the distribution of work often is in the home.
Women in particular are struggling with the ongoing need to manage work demands with those tied to their children’s school schedules.
School reopening plans have ramifications for the workplace as parents struggle to meet their usual schedule and productivity standards.
School reopening is another aspect of the pandemic that underscores class and financial disparities, because some school systems can afford widespread testing to keep children in school. These decisions, in turn, have a ripple effect on parents' ability to return to work.
School reopenings also affect young adults at colleges and universities. The social milieu of college targets the development of young adults as they accomplish social and emotional milestones by interacting with peers. Yet, to reopen safely, colleges have been forced to change their structure and limit social interactions between students and faculty. In addition, college is a common time and place for mental illnesses to surface or be exacerbated in young people; it’s unclear whether there will be enough mental health services for this group, which is now under even more stress. Colleges are trying to fill the mental health gap by using adjunctive tools, such as apps, and broader telehealth and virtual psychotherapy services.
Children at every age are facing developmental challenges, including a "failure to launch." Presently, 52% of young adults reside with one or both of their parents, the largest proportion since the Great Depression.

References

Bushwick S. Schools have no good options for reopening during COVID-19. Scientific American. 2020 Sep 5.

Simpson BW. The important and elusive science behind safely reopening schools. https://www.jhsph.edu/covid-19/articles/the-important-and-elusive-science-behind-safely-reopening-schools.html. Johns Hopkins School of Public Health. 2020 Aug 14.

Johns Hopkins School Reopening Plan Tracker. https://bioethics.jhu.edu/research-and-outreach/projects/eschool-initiative/school-policy-tracker/.

Fry R et al. A majority of young adults in the United States live with their parents for the first time since the Great Depression. Pew Research Center. FACTTANK: News in the Numbers. 2020 Sep 4.

Marcus J and Gold J. Colleges are getting ready to blame their students: As campuses reopen without adequate testing, universities fault young people for a lack of personal responsibility. The Atlantic. 2020 Jul 21.

Will M. Keeping COVID-19 rates low in schools: Advice from an expert. Education Week. 2020 Sep 28.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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Richard Balon, MD, returns to the Psychcast, this time to conduct a Masterclass on the impact of marijuana use on patients, particularly adolescents.

Dr. Balon is professor of clinical psychiatry and anesthesiology and associate chair of education at Wayne State University in Detroit. He has no disclosures.

Take-home points

Marijuana remains a controversial topic as potential legalization looms large in public policy and various groups espouse the positive benefits of marijuana.
Current marijuana formulations are more potent than formulations used in previous years. Formulations used today have a higher tetrahydrocannabinol content, with up to 80% THC content achieved through artificial selection.
Clinicians are rightly concerned about the well-established negative effects of marijuana on specific populations, particularly adolescents. They also worry about the effect of marijuana on brain development, which could affect educational outcomes, and the significant risk of developing psychosis and/or schizophrenia after using marijuana.
Newer research on marijuana use is also suggesting other negative health outcomes, including a potential link between marijuana use and an increased risk of developing various types of cancer.

Summary

Research over the past 20 years has elucidated the negative effects of marijuana on brain health and development. Marijuana use undermines cognitive function, including executive function and educational outcomes. Longitudinal and twin studies show a decline in the IQ of adolescents who have used marijuana. This is congruent with other established research and public health guidelines urging individuals to avoid the use of psychoactive drugs before the brain finishes maturing at approximately age 25 years.
In 2016, Nora D. Volkow, MD, director of the National Institute on Drug Abuse, and other leading investigators in the field published a review of the literature discussing the impact of marijuana cognitive capacity, amotivational syndrome, and the risk of psychosis. Ample evidence based on neuropsychological testing demonstrates a negative impact of marijuana on learning and working memory. Cannabis amotivational syndrome manifests as apathy, reduced concentration, and an inability to follow routines or master new material. Evidence demonstrates that long-term heavy cannabis use is associated with educational underachievement and impaired motivation.
Marijuana use is considered a preventable risk factor for the development of psychosis and schizophrenia. Any use of marijuana is estimated to double the risk of schizophrenia, accounting for 8%-14% of cases, and those at greatest risk include adolescents who start at an early age, engage in heavy use, and use high-potency THC.
There is limited evidence about the effect of marijuana on PTSD, and a study using a large Veterans Affairs database suggests that marijuana may worsen PTSD symptoms and increase the risk of violence.
A well-established physical outcome of heavy cannabis use is cannabis hyperemesis, defined as recurrent nausea, vomiting, and cramping abdominal pain tied to marijuana use.
- The symptoms may improve temporarily by taking a hot shower or bath.
Though more research is required, low-strength evidence suggests that regular marijuana use may be associated with development of testicular germ cell tumors. The association of marijuana use with lung and oral cancer is unclear, partly because marijuana smokers often also smoke cigarettes.
- Given that we know the smoke in cigarettes is a major risk factor for heart disease, the same concerns must be investigated for individuals who smoke only marijuana.

References

Fischer B et al. Am J Public Health. 2017 Jul 12;107(8):e1-12.

Volkow ND et al. JAMA Psychiatry. 2016;73(3):292-7.

Lorenzetti V et al. Eur Neuropsychopharmacol. 2020 Jul;36:169-80.

Fried P et al. CMAJ. 2002 Apr 2;166(7):887-91.

Meier MH et al. Addiction. 2017 Jul;113:257-65.

McAlaney J et al. Eur Addict Res. 2020 May 6;1-8.

Ben Amar M, Potvin S. J Psychoactive Drugs. 2007;39:131-42.

Wilkinson ST et al. J Clin Psychiatry. 2015 Sep;76(9):1174-80.

Steenkamp MM et al. Depress Anxiety. 2017 Mar;34(3):207-16.

Chocron Y et al. BMJ. 2019;366:l4336.

Ghasemiesfe M et al. JAMA Netw Open. 2019;2(11):e1916318.

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Introducing Clinical Correlation, a new podcast drop from the Psychcast.

Renee Kohanski, MD, began producing observational segments for the Psychcast since its inception in April 2018. Clinical Correlation episodes will be published on Mondays twice per month.

In this first edition, Dr. Kohanski recalls a poignant moment during her training when her mentor and then director, Donald Morgan, MD (https://bit.ly/35PAqY6), reconsidered his opinion prior to testifying in a court of law based on a simple question from a trainee. For Dr. Kohanski, this moment emphasized the importance of honest and open conversations.

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Jeffrey R. Strawn, MD, talks with host Lorenzo Norris, MD, about assisting children and adolescents with anxiety and anxiety disorders, particularly during the COVID-19 pandemic.

Dr. Strawn, a previous Psychcast guest, discusses ways for mental health clinicians to think about proportionate anxiety versus anxiety that is severe, continual, and persistent. He is director of the anxiety disorders research program at Cincinnati Children’s Hospital Medical Center and an associate professor of psychiatry at the University of Cincinnati.

Dr. Strawn has received research support from several pharmaceutical companies and from the National Institute of Mental Health. He also has received royalties from Springer.

Dr. Norris is assistant dean of student affairs, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He has no conflicts of interest.

Take-home points

Anxiety is a normal emotional reaction critical to survival. Yet, when the emotions become extreme, anxiety can negatively affect day-to-day functioning.
With any event that may cause stress, the anxiety should be expected and proportional to the event.
Clinicians and parents can support children and adolescents by pointing out different emotional reactions and discussing them to promote self-awareness, as well as maintaining routines while also acknowledging the loss of normalcy.
Clinicians should keep in mind several dimensions of the child-parent relationship and how they interact with the ever-changing home and schooling environment. The dimensions to be considered include: Flexibility versus control, which is a spectrum that ranges from rigid to chaotic, and cohesion and support, which ranges from disengaged to enmeshed.

Summary

If the triggering event is severe, persistent, and uncertain, such as the COVID-19 pandemic, the anxiety may last and become an anxiety disorder, which results in functional impairment.
Anxiety (not yet a disorder) may provoke changes in emotions and behaviors, such as irritability, frustration, poor sleep, and so on, that are proportional and expected to the major changes produced by the pandemic. So, parents and clinicians need to monitor for impact on functioning.
Clinicians and parents can support children by pointing out different emotional reactions and discussing them to promote self-awareness. Adults should acknowledge that children are going through loss and trauma and be open to discussing how life is different now but not lose sight of the future. Parents will have to balance trying to keep normalcy in place where possible and discussing when life feels far from the norm.
In his clinical practice, Dr. Strawn has noticed more reports of irritability and frustration. These emotions need to be evaluated but not necessarily pathologized. Those emotions likely arise from the drastic changes in home environment. Also parents now have more opportunity to observe their children in the learning environment.
The pandemic has come with certain benefits, such as more time at home together allowing families time to slow down and engage in different, more fulfilling activities. Yet, the pandemic has created chronic and variable stressors that can negatively affect physical and mental health. This combination of the dark and light has the potential to foster resilience as we reflect on our vulnerabilities and strengths. But we must also think about how to inoculate ourselves against loneliness, and the risks of how social distancing and societal discord may fray our social fabric.

References

Strawn JR. Current Psychiatry. 2020 May;19(5):9-10.

Brooks D. The pandemic of fear and agony. New York Times. 2020 Apr 9.

Delgado SV, Strawn JR. Difficult Psychiatric Consultations: An Integrated Approach. New York: Springer, 2013.

Strawn JR et al. Depress Anxiety. 2012;29(11):939-47.

Strawn JR et al. Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-39.

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Psychcast host Lorenzo Norris, MD, talks with Peter Yellowlees, MBBS, MD, about the changes to clinical practice forced by the COVID-19 pandemic and the likelihood that many of these changes are here to stay.

Dr. Yellowlees is a professor of psychiatry and chief wellness officer at the University of California, Davis. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures.

Take-home points

Prior to the COVID-19 pandemic, 1%-2% of psychiatric consultations occurred on telepsychiatry modalities. During the pandemic, however, telepsychiatry has become the norm for psychiatric patient encounters.
With the pandemic, the federal government relaxed many regulations that limited the use of telehealth.
For many, telepsychiatry is now a preferred modality, because it confers high patient satisfaction, and many view it as more egalitarian, convenient, and less intimidating. Some even consider it more private, because the patient does not have to come to the office, and they can remain in a safe personal space.
Telepsychiatry can be used within a hybrid model, where a patient can see the psychiatrist in person, using video, and the modality changes based on the needs of the patient and the clinician.
Telehealth has expanded access to care to many populations, so the American Psychiatric Association and other professional associations are lobbying the federal government to keep certain telehealth regulations relaxed beyond the pandemic.

Summary

Dr. Yellowlees sees telepsychiatry as the return of the home visit because the tool allows the clinician to see how the patient lives. He believes telepsychiatry fosters even more intimacy in the clinical relationship because of the extra distances created through the virtual space. In hybrid relationships, there are the physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. But the virtual space is convenient and provides a sense of physical and emotional space between the clinician and patient – which can make it easier to share intense emotions.
The textbook that Dr. Yellowlees wrote with Jay H. Shore, MD, MPH, “Telepsychiatry and Health Technologies: A guide for mental health professionals,” includes a chapter on clinical skills for seeing patients over video. Dr. Yellowlees points out that trainees need instruction about the work flow and clinical process, but most are savvy about how they should present themselves on screen.
- Dos and don’ts: The clinical space for teleconferencing for both the clinician and the patient must be private and secure. Ensure that everyone in either room is introduced. The webcam should be placed on top of the computer screen so that eye contact is maintained.
- The clinician’s head should take up two-thirds of the screen. Use picture in picture setting, so you can monitor your body language during the session.
The APA and other professional associations are lobbying the federal government to keep certain telehealth regulations relaxed beyond the pandemic. The changes would include removing the geographic restrictions on licensing, maintaining parity of reimbursement between telehealth and in-person visits, removing frequency limitations on telehealth services in nursing homes and inpatient settings, finalizing regulatory changes to the Ryan Haight Act, and allowing prescribers to continue to prescribe controlled substances without an initial in-person visit.

References

Yellowlees P, Shore JH. Telepsychiatry and Health Technologies: A guide for mental health professionals (Washington: American Psychiatric Association Publishing, 2018).

Yellowlees P. Physician Well-Being: Cases and Solutions (Washington: American Psychiatric Association Publishing, 2020).

Support for Permanent Expansion of Telehealth Regulations After COVID-19. American Psychiatric Association. 2020.

Telepsychiatry Toolkit. American Psychiatric Association

American Telemedicine Association

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Psychcast host Lorenzo Norris, MD, meets Renee Kohanski, MD, to announce the launch of Clinical Correlation.

In Clinical Correlation, which will be released every other Monday, starting Sept. 14, Dr. Kohanski will expand on her “Dr. RK” segment and explore issues of interest to the practicing psychiatrist. And later, we will revisit four of Dr. Kohanski’s “Best of” segments.

Next week, Dr. Norris will return with an interview with Peter Yellowlees, MD, about clinicians’ embrace of telepsychiatry during the pandemic. They also discuss whether many of the COVID-19–related changes – including those tied to reimbursement – are here to stay.

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Anique K. Forrester, MD, joins host Lorenzo Norris, MD, to discuss the importance of continuing to work in academic medicine.

Dr. Forrester is assistant professor at the University of Maryland, Baltimore. She also serves as director of the consultation-liaison psychiatry fellowship at the university.

Dr. Norris and Dr. Forrester have no conflicts of interest.

Take-home points

Dr. Forrester recently wrote an article in the New England Journal of Medicine discussing minority underrepresentation in academic medicine and the persistent labor of love required to stay in departments that do not explicitly value diversity.
Underrepresented minority colleagues leave for many reasons, and Dr. Forrester highlights the issues of invisibility, lack of mentorship and support, and burden of microaggressions.
Dr. Forrester focused her article on why she stays in academic medicine, feeling that it is critical her voice is heard; she knows her presence has changed the tone and outcome of issues. As she says: “One of the things about representation is that someone has to be there to represent.”

Summary

Staying in academic medicine with the presence of systemic racism is a difficult road; however, Dr. Forrester has stayed because of her desire to educate and mold the future of trainees.
Underrepresented minority (URM) colleagues leave for many reasons, and Dr. Forrester highlights the issues of invisibility, lack of mentorship and support, and burden of microaggressions. The late Chester Pierce, MD, a psychiatrist and the first African American full professor at Massachusetts General Hospital, Boston, coined the term “microaggression” to describe subtle slights or snubs directed at minority and historically stigmatized groups. The cumulative effect of microaggressions is toxic and can lead to self-doubt, damaged self-esteem, and momentum that pushes a URM colleague to leave.
When a URM colleague leaves a department, there is a short-lived conversation about what could have been done differently to retain them.
Forrester speaks of the “double hit” that occurs when a URM colleague leaves because it is not just the loss of a colleague, but the additional connection about the shared sense of mission and about progressing conversations about equity and diversity in the department.
Medical trainees at every level benefit from a diverse core faculty because such diversity provides different perspectives to situations and thus might also provoke an alternative response that is essential to growth. Research has also shown that patient outcomes improve in the presence of diverse medical teams.
Dr. Forrester talks about using self-reflection to identify one’s core mission as the commitment to stay in academic medicine and/or an underrepresented department. When we are stressed, it’s instinctive to be reactive to negative situations. Identifying one’s intention for being in academic medicine in the first place can reinforce the strength to stay and reach out for support.

References

Forester A. N Engl J Med. 2020 Jul 23;383:e24.

DeAngelis T. Unmasking ‘racial microaggressions.’ American Psychological Association. Monitor on Psychology. 2009;40(2):42.

Galinsky AD et al. Perspect Psychol Sci. 2015 Nov;10(6):742-8.

Gomez LE, Bernet P. J Nat Med Assoc. 2009 Aug;111(4):383-92.

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Philip Resnik, PhD, joins host Lorenzo Norris, MD, to discuss the use of AI and natural language processing to help clinicians identify patterns in the behaviors of patients with mental illness.

Dr. Resnik is a professor in the department of linguistics at the University of Maryland, College Park. He also has a joint appointment with the university’s Institute for Advanced Computer Studies.

Dr. Resnik has disclosed being an adviser for Converseon, a social media analysis firm; FiscalNote, a government relationship management platform; and SoloSegment, which specializes in enterprise website optimization. Some of the work Dr. Resnik discusses has been supported by an Amazon AWS Machine Learning Research Award.

Dr. Norris disclosed having no conflicts of interest.

And don’t miss the “Dr. RK” segment, with Renee Kohanski, MD.

Take-home points

Artificial intelligence (AI) refers to the effort to get computers to develop capabilities that humans would consider intelligent when people do them. For example, a “smart” thermostat learns patterns of behaviors and changes the temperature accordingly.
Natural language processing (NLP), an AI approach, focuses on the content of language from the words used and looks for cues within the content. NLP technology allows computers to do things more intelligently with human language, and NLP has generated technologies such as Siri, Alexa, and Google Translate.
Much of clinical work is focused on language, and clinicians look for cues within the content. Dr. Resnik is a technologist who believes that NLP can help facilitate clinical progress, especially in the face of a shortage of mental health clinicians and the limited amount of time that clinicians are able to spend with their patients.
Research aimed at using machine learning and NLP to analyze social media and other types of online presence to evaluate for suicide risk and the presence of mood disorders is underway.
Dr. Resnik imagines an ecosystem in which computers and humans balance their efforts, with each “brain” doing what they are best at; he believes in technology’s ability to save us time so we can prioritize our efforts.

Summary

A common example of NLP is automatic dictation and transcription software embedded in medical records. Dr. Resnik thinks of technology as an enabler and augmentation strategy.
Resnik and his wife, Rebecca Resnik, PsyD, completed a study using NLP to automatically detect clusters of language in the writing samples of college students. NLP software evaluated the natural patterns of language that might correlate with vegetative and somatic symptoms of depression and social isolation. His team was able to home in on language themes specific to college students that suggest specific symptoms of depression.
Another example of NLP in mental health is using predictive modeling, taking in data, and then making a prediction about a pertinent variable to understand mental health outcomes. For example, Glen Coppersmith, PhD, and associates evaluated social media posts with NLP software and concluded that analysis of language in social media posts can accurately identify individuals at risk of suicide and facilitate earlier interventions.
Resnik imagines a future in which speech and language samples are used to give a point-of-care evaluation of a patient’s mood and suicide risk.
“Clinical white space” is all the “space” (for example, the time between clinical encounters) and this is where decompensation occurs. Resnik suggests that NLP software could be used to fill this white space by using apps to collect text samples from patients. Software would analyze the samples and warn of patients who are at risk of decompensation or suicide.
Barriers to using this technology include engaging the technologists and clinicians, and accessing data samples because of privacy concerns, especially because HIPPA was written before the emergence of mega data.

References

Coppersmith G et al. Natural Language Processing of Social Media as Screening for Suicide Risk. Biomed Inform Insights. 2018 Aug 27. doi: 10.1177/1178222618792860.

Zirikly A et al. CLPsych 2019 Shared Task: Predicting the Degree of Suicide Risk in Reddit Posts. In Proceedings of the Sixth Workshop on Computational Linguistics and Clinical Psychology. 2019 Jun 6. 24-33.

Lynn V et al. CLPsych 2018 Shared Task: Predicting Current and Future Psychological Health from Childhood Essays. In Proceedings of the Fifth Workshop on Computational Linguistics and Clinical Psychology: From Keyboard to Clinic. 2018. 37-46.

Selanikio J. The big-data revolution in health care. TEDx talk.

Graham S et al. Artificial Intelligence for Mental Health and Mental Illnesses: An Overview. Curr Psychiatry Rep. 2019 Nov 7;21(11):116. doi: 10.1007/s11920-019-1094-0.

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Abigail Kay, MD, MS, joins host Lorenzo Norris, MD, to discuss the treatment of patients with substance use disorders.

Dr. Kay is an addiction psychiatrist at Thomas Jefferson University Hospital in Philadelphia and is associate dean of academic affairs and medical student education at Sidney Kimmel Medical College. Dr. Norris is assistant dean of student affairs, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington.

Dr. Kay disclosed no conflicts of interest for the past year. Before that, she reported receiving payment from the American Society of Addiction Medicine, through a grant from the Substance Abuse and Mental Health Services Administration, to teach a free training to clinicians to be certified to prescribe buprenorphine. Dr. Norris, who also serves as medical director of psychiatric and behavioral sciences at George Washington University Hospital, disclosed no conflicts.

Take-home points

Substance use disorders have genetic and environmental factors. The genetic component is sometimes overlooked because the environmental factor – the exposure to using a substance – is heavily focused as the only trigger for addiction.
Methadone is a pure agonist at the mu-opioid receptor so the higher dose the greater the effect. The average dose of methadone to achieve blocking of cravings, withdrawal, and opiate intoxication is 80-120 mg.
Buprenorphine is a partial agonist: At low doses, it acts as an agonist, and at high doses it acts as an antagonist with quite high affinity for the receptor. As a partial agonist, it has a ceiling effect with more than 90% of opiate receptors occupied at 24 mg.
Dr. Kay suggests a helpful rule of thumb is to assume that, if patients have an addiction, there’s a 50/50 chance that they have another psychiatric disorder and vice versa. With this in mind, all patients with substance use disorder should be evaluated for comorbid psychiatric disorders and underlying medical conditions.

Summary

Dr. Kay breaks down human cognition into the primitive brain and thoughtful brain. The primitive brain keeps us alive by preferentially focusing on sleeping, drinking, and eating. Addiction to a drug hijacks the primitive brain, making it prioritize the substance of choice above all else.
Methadone is the “gold-standard” treatment for opioid use disorder in the sense that all treatments are compared with its efficacy and mechanism of action. Methadone is a pure agonist at the mu-opioid receptor, meaning the higher dose the greater the effect; the average dose of methadone is 80-120 mg. The goal of treatment is to achieve a blocking dose, meaning a dose that blocks the craving, the withdrawal, and the high if people were to use illicit opiates on top of their methadone. Methadone is administered only at federally approved sites, and one advantage is that additional services, such as counseling, can be offered on site after daily administration.
Buprenorphine as a partial agonist can play both “roles” on the mu-opioid receptor. At low doses, it acts as an agonist, and at high doses, it acts as an antagonist with quite high affinity for the receptor. In addition, as a partial agonist buprenorphine has a ceiling effect: At 24 mg of buprenorphine occupies 92% of opiate receptors and at 32 mg only an additional 1% of receptors are occupied. Buprenorphine must be administered when the person is already in withdrawal, because its affinity to the receptor dislodges other opiates from the mu receptor thus precipitating withdrawal. Buprenorphine works well for individuals who would require an average 40-60 mg of methadone to achieve their blocking dose. Because of the ceiling effect, some individuals continue to crave opiates while on buprenorphine. This means that, despite the greater convenience offered by buprenorphine, it is not the treatment of choice for everyone.
Naltrexone is a pure opioid antagonist requiring 10-14 days of abstinence from opiates to prevent precipitating opioid withdrawal. Naltrexone can be given as a once-monthly injection to address cravings. The greatest risk with naltrexone is that, after 1 month of treatment, people lose their tolerance and are at risk of opioid overdose if they return to their previous amount of use.

References

Volkow ND. Hum Genet. 2012 Jun;131(6):773-7.

Volkow ND, Blanco C. J Clin Invest. 2020 Jan 2;130(1):10-3.

SAMHSA.gov. Overview of MAT: https://www.samhsa.gov/medication-assisted-treatment/treatment.

Jones HE et al. N Engl J Med. 2010;363:2320-31.

Kay A et al. J Addict Dis. 2010 Apr;29(2):139-63.

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Derek M. Griffith, PhD, joints host Lorenzo Norris, MD, to discuss different ways to look at men’s health within the context of COVID-19.

Dr. Griffith is founder and director of the Center for Research on Men’s Health at Vanderbilt University, Nashville, Tenn. He also serves as professor of medicine, health, and society at the university. Neither Dr. Griffith nor Dr. Norris have disclosures.

And do not miss Renee Kohanski, MD, who offers a message of hope in the “Dr. RK” segment.

Take-home points

The confluence of the COVID-19 pandemic, the death of civil rights leader Rep. John Lewis, and the death of Herman Cain from COVID-19 requires us to reflect on race, gender, personal identity, and our own vulnerability.
Sometimes denial in the form of thinking “that won’t happen to me” is a trope within masculinity, especially black masculinity, and can lead to men delaying preventive treatments and interventions, which makes them more vulnerable to excess morbidity and mortality from preventable diseases.
- Some research suggests that men are more likely to suffer severe effects of COVID-19 than women.
Personal preference and agency are hallmarks of the American ethos, and those attitudes made it difficult to accept new and challenging information during the beginning of the COVID-19 pandemic. Ironically, this fierce autonomy is celebrated and demonized in the male identity and will have an effect on their behavior in the environment. In terms of mental health, we must consider how schemas influence behavior, and one’s ability to take in and act on relevant information.
Any singular lens is limited when discussing an issue as complex as the current pandemic. Many perspectives must be examined if we are to work toward an effective solution. While society is examining COVID-19 morbidity and mortality through the lens of race, we may miss other essential perspectives, such as place, gender, age, etc.
In a situation such as the COVID-19 pandemic, we must manage complexity by asking the hard questions. Dr. Norris asked Dr. Griffith to identify what factor in the pandemic we are missing from our current perspectives. Dr. Griffith suggested that our society continues to assume that we know more about COVID-19 than we actually know. Several times throughout the pandemic, we have assumed that we have it “figured out,” only to be shown that the SARS-CoV-2 virus is more unpredictable than we realize.
Race, gender, age, and health disparities also will be at play when it comes time to test and administer a COVID-19 vaccine.

References

Griffith DM et al. Prev Chronic Dis. 2020;17:E63.

Griffith DM et al. The COVID-19 elephant and the blind men of race, place, and gender. Gender & COVID-19.org. 2020 Jul 26.

Elder K and Griffith DM. Am J Public Health. 2016 Jul;106(7):1157. doi: 10.2105/AJPH.2016.303237.

Peters JW. Will Herman Cain’s death change Republican views on the virus and masks? New York Times. 2020 Jul 30.

Cain H. This is Herman Cain!: My Journey to the White House. New York: Threshold Editions, 2011.

Sharma G et al. JACC Case Rep. 2020 Jul 15;2(9):1407-10.

Baker P et al. Lancet. 2020 Jun;395(10241):1886-8.

Indini A et al. Crit Rev Oncol Hematol. 2020 Sep;153:103059.

Chowkwanyun M and Reed AL. Racial disparities and COVID-19 – Caution and context. N Engl J Med. 2020 Jul 16;383:201-3.

Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. Updated 2020 Jul 24.

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Episode 128 interview:

Philip G. Janicak, MD, joins MDedge Psychiatry Editor in Chief Lorenzo Norris, MD, to discuss device-based therapies for psychiatric patients.

Dr. Janicak is adjunct professor of psychiatry and behavioral sciences at Northwestern University in Chicago. He serves as an unpaid consultant to Neuronetics and has a financial relationship with Otsuka. Dr. Norris, medical director of psychiatric and behavioral services at George Washington University Hospital in Washington, has no disclosures.

Take-home points

Therapeutic neuromodulation, including electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS), refers to the use of device-based therapies that alter neurocircuitry implicated in the pathophysiology of psychiatric disorders. Most available evidence is from studies in major depressive disorder, though more research is emerging for bipolar disorder and other diagnoses
The advantage of TMS is minimal cognitive adverse effects, compared with ECT. Dr. Janicak recommends ECT over TMS when a patient requires inpatient psychiatric treatment, is acutely suicidal, has psychotic features, or is not taking care of basic needs.

Summary

TMS originated in England when Anthony T. Barker, PhD, began using TMS as a probe for the peripheral and central nervous systems. Imaging studies showed that, in the context of depression, the left dorsolateral prefrontal cortex had less metabolism and blood flow, and when TMS was applied, those phenomena were reversed. One large randomized, controlled trial showed that TMS treatment could lead to remission of depression and had a durable effect for most patients in the study.
The recent goal of TMS research has been to improve the efficacy and decrease the length of treatment from 4-6 weeks of daily treatments to 1-2 weeks.
In 2018, deep TMS (dTMS) was cleared by the Food and Drug Administration for the treatment of obsessive-compulsive disorder after first- and second-line pharmacologic and psychotherapeutic treatments. In dTMS, the medial prefrontal cortex and the anterior cingulate cortex are targeted.
Several studies suggest the pro-cognitive effects of TMS, and Dr. Janicak hopes that TMS might be on the radar as treatment for mild cognitive impairment.
TMS also is being used in combination with psychotherapy, such as cognitive-behavioral therapy, under the theory that TMS enhances the activity of the neurocircuitry and potentiates the effect of the psychotherapy.

References

Janicak PG. What’s new in transcranial magnetic stimulation. Current Psychiatry. 2019 Mar;18(3):10-6.

Dunner DL et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: Durability of benefit over a 1-year follow-up period. J Clin Psychiatry. 2014;75(12):1394-1401.

Janicak PG and Dokucu ME. Transcranial magnetic stimulation for the treatment of major depression. Neuropsychiatr Dis Treat. 2015;11:1549-60.

Vidrine R. Integrating deep transcranial stimulation into the OCD treatment algorithm. Psychiatric Times. 2020 Apr 7.

Marra HLD et al. TMS in mild cognitive impairment. Behav Neurol. 2015;2015:287843. doi: 10.1155/2015/287843.

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Dmitry M. Arbuck, MD, joins host Lorenzo Norris, MD, to discuss ways psychiatrists can help patients with treatment-resistant chronic pain.

Dr. Arbuck is clinical assistant professor of psychiatry and medicine at Indiana University, Indianapolis. Dr. Arbuck also serves as president and medical director of Indiana Polyclinic, a multispecialty pain management facility, and is an associate editor of Current Psychiatry.

Both Dr. Arbuck and Dr. Norris disclosed having no conflicts of interest.

And do not miss the “Dr. RK” segment, where Renee Kohanski, MD, discusses part 2 of her examination of the constructs of medicine.

Take-home points

Acute and chronic pain are mediated by different mechanisms and therefore must be treated differently. Acute pain is caused by tissue damage leading to nociception, and it should heal. Chronic pain is the chronification of acute pain and more of an emotional state with sensations of pain without clear tissue damage.
Many neurotransmitters are involved in pain, including dopamine, serotonin, norepinephrine, and the opioid system.
- The levels of neurotransmitters will change as the pain (emotional and physical) thresholds change.
- When patients with borderline personality disorder cut themselves, dopamine increases, and the patients, in turn, feel better. Likewise, when patients with PTSD reexperience negative events, this causes an increase in dopamine to protect against stress.
Psychiatrists are particularly well positioned to help those with chronic pain because trauma and emotions are central to the perception of emotional and physical pain. Emotional trauma also influences the severity and chronicity of pain.
Currently, pharmacogenetics are more of a general guide for clinicians than specific practice guidelines. But they can inform patients and physicians about drug metabolism and expression of receptors in difficult-to-treat patients.

Summary

Chronic pain can be understood as emotions colored by nociception, while acute pain is the tissue damage and subsequent nociception causing pain. Opioids suppress the nociception of pain and are appropriate in acute pain. However, opioids should be used only in the normal time of healing in acute pain. If their use is extended, opioids can cause hyperalgesia, thus worsening chronic pain.
Many forms of chronic pain, such as fibromyalgia and chronic back pain, do not have tissue damage. The sensations of physical pain and the compounding emotional pain are mediated by central pain sensitization. The theory behind central pain sensitization helps explain why medications such as SSRIs, serotonin-norepinephrine reuptake inhibitors, and antipsychotics can come into play in chronic pain treatment.
In some patients, there can be dopaminergic hyperactivity in chronic pain. Dr. Arbuck conceptualizes dopamine as a defensive neurotransmitter. Dopamine is secreted in response to fear and can result in a physical response, such as weakness in the legs, but it also leads to emotional consequences, such as dissociation. Dopamine is also secreted with emotionally painful stimuli, such as trauma, so an event such as a sexual assault that results in a physical and emotional injury may produce substantial dopamine secretion. When the defense becomes chronic, excessive dopamine secretion can be pathological.
Pharmacogenetics inform clinicians about a patient’s ability to benefit from medications by looking at the presence of specific alleles for enzymes that metabolize medications and for receptors upon which medications act. Currently, Dr. Arbuck uses pharmacogenetics in specific indications, such as for patients with a seemingly treatment-resistant condition or with excessive adverse effects from medications.
The pharmacogenetics results are meant to help physicians and patients understand the body’s role in medications.
Psychiatry needs to look more into the medical aspects of mental health, and training in psychiatry needs to be more biological in nature.

References

Arbuck DM. Current Psychiatry. 2020 Jan;19(1):25-9;31.

Clauw DJ. JAMA. 2014;311(15):1547-55.

Nijs J et al. Expert Opin Pharmacother. 2014 Aug;15(12):1671-83.

Dale R and Stacey B. Med Clin North Am. 2016 Jan;100(1):55-64.

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Roger S. McIntyre, MD, returns the Psychcast, this time to talk with host Lorenzo Norris, MD, about the mental health hazards of COVID-19 and what clinicians can do to help protect patients.

Dr. McIntyre is professor of psychiatry and pharmacology, and head of the mood disorders psychopharmacology unit at the University Health Network at the University of Toronto.

He disclosed receiving research or grants from the Stanley Medical Research Institute and the CIHR/GACD/National Natural Science Foundation of China. Dr. McIntyre also disclosed receiving consultation/speaker fees from several pharmaceutical companies. Dr. Norris has no disclosures.

Take-home points

Uncertainty tied to the COVID-19 pandemic threatens to undermine mental health and exacerbate problems for those with mental illness.
U.S. suicide rates, which were already rising after the Great Recession of 2007-2009, are likely to climb further because of the impact of COVID-19.
Clinicians can take steps to prevent some of the negative mental health outcomes tied to the pandemic.

Summary

COVID-19 presents a triple threat to patients' mental health.
- The fear of viral infection is a mental health hazard.
- The financial shock that COVID-19 has had on the economy has not been seen since the Great Depression. Links between suicide and unemployment are powerful. In a study published in World Psychiatry, McIntyre and colleagues found associations between COVID-19 and major depression, PTSD, binge alcohol use, and substance use disorders.
  - French social scientist Emile Durheim, PhD described the link between suicide and unemployment.
- Quarantining affects mental health, and there is nothing like COVID-19 in the history books.
  - The Toronto experience with severe acute respiratory syndrome in 2003 offers lessons about the devastating impact of quarantining on mental health.
“Deaths of despair” in the form of suicides have been on the increase in the United States. From the Great Recession, researchers found that for every 1% increase in unemployment, there is a commensurate 1% increase in suicide.
- U.S. unemployment stood at 8%-9% during the Great Recession, and now those percentages are much higher. Dr. McIntyre and his team projected that an unemployment rate of 14%-20% would lead to an additional 8,000-10,000 suicides could occur each year for the next 2 years. That’s in addition to the current number of approximately 50,000 suicides annually.
- Express Scripts, a pharmacy benefits manager, recently reported a 40% increase in prescriptions for anxiety-related medications. This suggests that people are distressed.
Clinicians should take an aspirational approach to addressing these issues by pivoting to virtual platforms to increase patients’ access to care.
- Create medical homes that are HIPAA compliant.
- Look toward evidence-based models such as those found in Japan. That country found that, for every 0.2% increase in GDP spending on mental health care right after the Great Recession, the suicide rate fell by 1%.
- Encourage patients to structure the day and avoid consuming too much news or participating on social media.
  - Two studies conducted in China found that people who spent more than 2-3 hours a day on news consumption were more likely to report clinical levels of depression, anxiety, and insomnia.
  - Social media consumption has been associated with many adverse mental health outcomes, including loneliness. People who spent more than 3 hours a day were more likely to experience depression.
- Support programs for small-business people; jobs enhance resilience.
- Target the “basics” of self-care, such as getting enough sleep and engaging with others.

References

McIntyre RS, Lee Y. Psychiatry Res. 2020 May 19. doi: 10.1016/j.psychres.2020.113104.

McIntyre RS, Lee Y. World Psychiatry. 2020 Jun;19(2):250-1.

Shanahan L et al. Am J Public Health. 2012 Jun;109(6):854-8.

Kang S, Chua HC. CMAJ. 2004 Mar 2;170(5):811-2.

Express Scripts. America’s State of Mind Report. 2020 Apr 16.

Lee Y et al. Psychiatry Clin Neurosci. 2020 Jul 1. doi: 10.1111/pch.13101.

Hao F et al. Brain Behav Immun. 2020 Jul;87:100-6.

Tan W et al. Brain Behav Immun. 2020 Jul;87:84-92.

Wang C et al. Brain Behav Immun. 2020 Jul;87:40-8.

Harvey SB et al. Am J Psychiatry. 2018 Jan 1;175(1):28-36.

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Jack Rozel, MD, MSL, returns to the Psychcast, this time to discuss with host Lorenzo Norris, MD, how to think about guns, gun violence, and the intersection with mental health.

Dr. Rozel is medical director of resolve crisis services at the University of Pittsburgh Medical Center/Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis – rather than sell a gun. Dr. Norris has no disclosures.

Take-home points

In the United States, more guns were sold in the month leading up to the COVID-19 pandemic than were ever sold in 1 month since gun sales were recorded.
Suicide risk with a new gun in the home peaks in the first days to weeks of ownership and then trails off, but there is a measurable difference in risk of suicide in the 5 years after the purchase.
Any surge in gun sales leads to greater accidental deaths and homicides from firearms.
Rozel reminds clinicians to ask their patients (again) about guns. A good question to start is: “Are there guns in the home or new guns in the home?” He also asks about gun storage and the number of guns. Dr. Rozel goes through the basics of gun safety, such as handling a gun only while sober; securing the gun in a locked box unless the owner/responsible adult is holding it; using a responsible means to carry the gun, such as a holster; and not handling the gun like a toy.
- If a patient is under financial pressure, the clinician might gently suggest that a way to remove some of that pressure might be to sell a weapon to a licensed gun dealer.

Summary

It is likely that fear and uncertainty of the future with broad social disorder are influencing gun sales. Most of the gun sales during the pandemic are to new gun owners.
Unfortunately, the increase in gun sales tracks with other major risks for suicide, such as unemployment and unstable housing, which might get worse during the COVID-19 pandemic.
During this period of unstable employment and house, people might be moving to different houses, or relatives and friends might be moving in. With this fluidity, it is essential to inquire about guns in the home where they are staying or whether new people brought in guns. Dr. Rozel also explores who is in the house with the patient and checks in about the home environment regarding arguments and abuse, especially as tensions run high during pandemic shutdowns.
- Make gentle assumptions by asking questions such as: “How do you store your guns?”
- Get a sense of how safe the patient’s environment is while conducting telehealth, and be aware of patients’ social determinants of health issues.
As psychiatrists, it is our role to talk to patients about how their mental health influences their safety. If a patient is experiencing acute symptoms of their illness or perhaps has relapsed on substances, then it is imperative to ask about gun safety and whether the gun should be temporarily moved from the house.

References

Rozel J. Clinical Psychiatry News. 2020 Apr 2.

Harvard School of Public Health. Means Matter: Firearm Access is a Risk Factor for Suicide

Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.10.1001/jamapsychiatry.2020.1060.

Rand Corporation. Gun Policy in America.

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This week, we decided to revisit three of the Psychcast episodes that examined various aspects of COVID-19. First, you will hear excerpts from the interview that host Lorenzo Norris, MD, did with Sheldon H. Preskorn, MD, on educating patients about SARS-CoV-2 and the disease. Next, Jay H. Shore, MD, MPH, conducts a Masterclass lecture on factors to consider while using telepsychiatry during the pandemic.

And later, guest host Jacqueline Posada, MD, talks with Lynne S. Gots, PhD, about using cognitive-behavior therapy to treat patients with anxiety.

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Thomas Abt, JD, spoke with Nick Andrews about his talk at the TEDMED 2020 conference in Boston.

Mr. Abt (@Abt_Thomas), senior fellow at the Council on Criminal Justice, discussed his evidence-based and community-informed strategies for reducing urban violence. Mr. Abt earned an undergraduate degree in economics from the University of Michigan in Ann Arbor, and a law degree from Georgetown University in Washington. Mr. Abt also worked as a prosecutor in the Manhattan District Attorney’s office in New York, and as a teacher in Washington. He has no conflicts of interest.

Summary

Mr. Abt said the three fundamental principles of focus, balance, and fairness are central to interventions for reducing urban violence. This means focusing on people and places in which urban violence is concentrated, balancing between positive and negative incentives to reduce violence, and facilitating trust between the state and its citizens to foster a sense of fairness.

Mr. Abt’s book, “Bleeding Out: The Devastating Consequences of Urban Violence - And a Bold New Plan for Peace in the Streets” is a compilation of 10- 12 strategies using evidence-based interventions. Mr. Abt promotes strategies informed by data and vetted by communities.

Success stories can be found with deterrence in Boston; and Oakland, Calif; and Cincinnati; and Indianapolis; and with cognitive-behavioral therapy (CBT) in Chicago. Those strategies have not been brought to scale or sustained over time.
The “Becoming a Man” program in Chicago is one the most promising examples of the power of CBT. The program focuses on at-risk youth in high school and teaches strategies for conflict resolution, interpersonal problem-solving skills, anger management, and future orientation.
The program has three components: vigorous youth engagement; an intensive “man’s work” educational program delving into positive masculine identity; and a CBT component.
- CBT is only part of the success, and Mr. Abt argues that a clinical component is necessary when working with groups with traumatic backgrounds. A psychotherapy modality is required to meaningfully alter the impulsive, automatic responses that can lead to violence.
- Street outreach workers, public health officials, and police officials have responded positively to the book. Criticism has come from political extremes.
Conventional narratives about urban violence suggest that it is rooted in poverty or culture, or social and economic injustice. Yet research about urban violence suggests reducing violence must focus on urban violence itself and not on ancillary topics. Structural and historical factors, such as racism and de jure and de facto segregation, have produced high rates of urban violence, but we can’t start over in a span of a few years to address those generational problems. Mr. Abt focuses on identifying interventions that target reducing violence, which has its own ripple effects on structural injustice.
Abt emphasizes that urban violence is a concentrated problem with larger effects. The solutions need to be direct and focused so that the effect of the interventions is not diluted and able to be applied in multiple communities. The solutions direct and focused approaches so that the effect of the interventions is not diluted and able to be applied in multiple communities.

References

Abt T. Bleeding Out: The Devastating Consequences of Urban Violence – And a Bold New Plan for Peace in the Streets. (Basic Books, 2019).

Obbie M. This man says his anti-violence plan would save 12,000 lives. The Atlantic.

University of Chicago. Urban Labs. Becoming a Man program.

Heller SB et al. Thinking, Fast and Slow? Some Field Experiments to Reduce Crime and Dropout in Chicago. National Bureau of Economic Research. Working Paper 21178. May 2015. Revised August 2016.

Medscape Psychcast bonus episode transcript: Click Here.

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Igor Galynker, MD, returns to the Psychcast, this time to discuss his most recent work on suicidal crisis syndrome with host Lorenzo Norris, MD.

Dr. Galynker is professor of psychiatry and director of the Galynker Research and Prevention Laboratory at the Icahn School of Medicine at Mount Sinai, New York. He reported receiving funding from the National Institute of Mental Health and the American Foundation for Suicide Prevention. Dr. Norris has no disclosures.

Take-home points

Suicide crisis syndrome (SCS) is a state or syndrome that develops shortly before a suicide attempt. Since the last Psychcast with Dr. Galynker, SCS has been replicated in several cohorts and countries.
SCS has been refined to three primary factors instead of five. The factors of SCS include a state of entrapment which includes cognitive rigidity and flooding, insomnia/agitation, and social withdrawal.
New data are emerging about how to treat the acute syndrome with medications, because patients are not susceptible to psychotherapy or even safety planning in this state of mind.
Galynker and colleagues have validated the suicide crisis narrative model and have found that the clinician’s response to the narrative is predictive of risk of suicide.

Summary

In SCS, the two primary factors are a sense of entrapment and cognitive rigidity followed by insomnia or agitation and social withdrawal.
The state of entrapment is characterized by frantic hopelessness with a sense of being trapped in a life situation that is painful, intolerable, and feeling that all escapes are blocked. Cognitive rigidity and dyscontrol can include ruminative flooding associated with headache or head pressure, and inability to suppress the ruminative thoughts. Cognitive rigidity, like psychosis, can make it difficult to engage in psychotherapy.
SCS needs to be treated with medications such as an antipsychotic for cognitive rigidity, a benzodiazepine for the frantic hopelessness and sense of agitation, and something that targets the emotional pain.
- Antidepressants might make SCS worse because they can increase anxiety.
The accompanying narrative crisis model of suicide behavior includes five components: High-risk traits, stressful life events, a narrative of hopelessness and failure, the suicide crisis syndrome, and then suicide attempt. Clinicians can think of the long-term risk factors for suicide as vulnerable traits such as fearlessness, perfectionism, insecure attachment, and childhood abuse. When these vulnerable individuals have stressful life events, they enter a subacute phase in which they create a life narrative that tells a story of falling short of their goals, feeling humiliation, being a burden to others, and being unable to achieve future goals, all of which lead to social withdrawal.
SCS is treated with medications and means restriction, and the narrative is treated with cognitive restructuring through specific forms of psychotherapy.
Three clinician emotions triggered by a suicidal patient’s narrative are predictive of risk of suicide death. The first emotion is clinician distress and dread. The second is anxious overinvolvement, which is similar to a rescue fantasy with false hope. The third is a sense of distancing and resignation that the patient is going to kill themselves. Clinicians must be trained to listen to their own emotional reactions to a patient's suicidal narrative of how they arrived at this state to detect this risk.
Using emotions and something like the SCS is important for suicide prevention, because only one-third of people report suicidal ideation. Sometimes the burden of EMR documentation or checkboxes can get in the way of accurately assessing a patient’s risk. This type of work requires awareness of emotions and managing them to make sure they are attuned to the patient. Other emotions, such as fatigue and burnout, can interfere with the risk assessment.

References

Cohen LJ et al. Suicide Life Threat Behav. 2019 Apr;49(2):413-22.

Hawes M et al. Compr Psychiatry. 2017 Jan;72:88-96.

Galynker I et al. Depress Anxiety. 2017 Feb;34(2):147-58.

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Lorenzo Norris, MD, spoke with Sheldon H. Preskorn, MD, about how to best educate patients about coronavirus.

Dr. Preskorn is a professor in the department of psychiatry at the University of Kansas School of Medicine–Wichita. Neither Dr. Norris nor Dr. Preskorn have any relevant financial relationships to disclose.

Take-home points

Coronavirus 2019 (COVID-19) is the disease process caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
SARS-CoV-2 is different from the previous SARS-type coronaviruses and is having a greater impact on society as a pandemic for three reasons: It’s highly transmissible person to person, it can be spread by infected individuals who are asymptomatic or presymptomatic, and it has a high level of morbidity but a lower level of mortality.
Psychiatrists work with vulnerable populations, including older adults and individuals with medical comorbidities that put them at risk for COVID-19.
Psychiatrists must understand the pertinent facts about COVID-19 to help their patients who are suffering the consequences of social distancing, a shuttered economy, and changes in their daily lives from COVID-19.

Summary

While coronaviruses are known to cause the common cold, some are more medically serious – and even lethal – based on their ability to cause a severe acute respiratory syndrome (SARS). SARS-CoV-2 is one in a line of several coronaviruses to make the leap from animals to humans and cause a severe acute respiratory syndrome with devastating effects.
Previous coronaviruses include SARS-CoV-1, which caused an illness referred to as “SARS” that had a mortality rate close to a 10%, and MERS-CoV, which caused Middle East respiratory syndrome (MERS) and had an even higher mortality rate. The high mortality rate of these SARS-type coronaviruses is thought to be why they did not transition from epidemic to pandemic.
SARS-CoV-2 is different from the previous SARS-type coronaviruses and is having a greater impact on society as a pandemic for three reasons: It’s highly transmissible from person to person, it can be spread by infected individuals who are asymptomatic or presymptomatic, and it has a high level of morbidity but a lower level of mortality.
In terms of transmissibility, each person infected can infect up to six additional people and individuals can spread the virus even while asymptomatic or presymptomatic. This is why wearing a mask and engaging in social distancing are essential to slowing the spread of COVID-19.
SARS-CoV-2 is more lethal than influenza and is especially dangerous for certain populations, such as older adults and those with multiple medical comorbidities, including chronic pulmonary obstructive disease, hypertension, diabetes, obesity, and being immunocompromised. In the United States, 80% of COVID-19 deaths are in people older than age 65 years.
Psychiatrists must understand these pertinent facts about COVID-19 to help their patients who are suffering the consequences of social distancing, a shuttered economy, and changes in their daily lives from COVID-19.
Psychotropic medications that can lead to metabolic syndrome, such as second-generation antipsychotics, may put patients with serious mental illness at risk of worse outcomes if infected with COVID-19.
Ultimately, psychiatrists are medical doctors who are helping treat the secondary mental health effects of the COVID-19 pandemic, so we have a responsibility to have a working knowledge of the epidemiology and basic science of the virus to help our patients.

References

Preskorn SH. Coronavirus Disease 2019: The first wave and beyond. Psychiatr Times. 2020 Apr 28.

Preskorn SH. COVID-19: Protecting the vulnerable and opening the economy. Psychiatr Times. 2020 May 6.

Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Older adults.

National Institute of Allergy and Infectious Diseases. Coronaviruses.

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SPECIAL: Lorenzo Norris, MD, welcomes fourth-year psychiatry resident Brandon C. Newsome, MD, for a discussion on race relations as a physician in the wake of the death of George Floyd, who was killed when a white police officer kneeled on his neck during an arrest.

Dr. Newsome was raised in Alabama and currently lives in Boston. He shares his experiences with Dr. Norris in an important conversation.

The pair discuss what their patients are experiencing and what they're experiencing as black physicians.

Dr. Norris is a consultation-liaison psychiatrist and medical school dean affiliated with George Washington University, Washington (@GWSMHS). Dr. Newsome will begin a fellowship in July at Children’s National Hospital (@ChildrensNatl).

References

American Medical Association (@AmerMedicalAssn) 2020 statement on police brutality (2020)

American Psychiatric Association (@APAPsychiatric) statement

National Medical Association (@NationalMedAssn) statement

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Candrice R. Heath, MD, and Nicole B. Washington, DO, MPH, spoke with Psychcast host Lorenzo Norris, MD, about physician mental health.

Dr. Heath is affiliated with Temple University Hospital, Philadelphia. She has no disclosures.

Dr. Washington disclosed serving as chief medical officer and founder of Elocin Psychiatric Services, a telemedicine company that provides care to physicians. Dr. Norris is a consultation-liaison psychiatrist and medical school dean affiliated with George Washington University, Washington. He has no disclosures.

And stick around for Renee Kohanski, MD, who talks about expectations.

Take-home points

Physicians often delay seeking mental health treatment. Compared with the general population, the risk of suicide is 2.27 times higher in female physicians and 1.4 times higher in male physicians.
The COVID-19 pandemic has created additional risk factors for all physicians, including those on the front lines and others whose clinical practices and home lives have changed because of the pandemic.
Prevention and mitigation of mental illness start with understanding your own risk factors and stressors and trying to address them before they become overwhelming.

Summary

During the best of times, physicians are at risk for anxiety, depression, and substance use disorders. The syndromes of demoralization and burnout should be seen as prodromes to clinical diagnoses, such as major depressive disorder. An estimated 300-400 physicians die from suicide each year.
Prevention of mental illness starts with identifying one’s stressors, such as balancing personal and professional demands on time; knowing one’s risk factors, such as a history of substance use and previous episodes of distress or psychiatric diagnoses; and thinking about the phases of disaster response. When it comes to the COVID-19 pandemic, are you surging with adrenaline, hitting a plateau, or experiencing a decline?
Dr. Washington suggests that her patients focus on what they can control in their lives, because uncertainty and loss of control of our usual routines contribute to stress, anxiety, and fatigue. It is also helpful to reflect on past periods of hardship and resilience to identify strengths and previous strategies used to overcome challenges.
Physicians who are not on the front lines are experiencing different forms of hardship, such as financial stress from furloughs and loss of patient volume. There may also be guilt about not addressing the pandemic in the same way as frontline physicians. Even without direct patient care of COVID-19, it must be acknowledged that the impact of the pandemic is everywhere.
Most physicians delay seeking mental health treatment. This may particularly occur for physicians with better “lifestyles,” such as dermatologists, who some may view as suffering less. This pandemic is a reminder that all physicians need to take care of themselves, regardless of specialty.
We are all adjusting to the “new normal,” so in times like this, it is helpful to seek practices such as mindfulness and “radical acceptance,” the latter of which is part of dialectical behavior therapy.
- Accepting reality with judging and setting expectations at a realistic level can help prevent suffering.

References

Phases of disaster timeline: https://www.samhsa.gov/dtac/recovering-disasters/phases-disaster
American Psychiatric Association Well-being Toolkit: https://www.psychiatry.org/psychiatrists/practice/well-being-and-burnout/well-being-resources
Radical acceptance by Tara Brach, PhD: https://www.youtube.com/watch?v=_K35O3G82L4
Facts about physician suicide: https://www.acgme.org/Portals/0/PDFs/ten%20facts%20about%20physician%20suicide.pdf

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Bill Scheidler, MD, is assistant clinical professor of psychiatry at the University of North Carolina, Chapel Hill. He also is associate training director for the consultation-liaison fellowship at UNC and is a lead consultant at UNC Hospitals Hillsborough.

Dr. Scheidler spoke with host Lorenzo Norris, MD, about how to think through patients’ decision-making capacity in medical (rather than psychiatric) hospitals. Neither Dr. Scheidler nor Dr. Norris have disclosures.

Take-home points

Decision-making capacity (DMC) is essential to informed consent, which is providing patients with the information necessary to make an informed decision about medical or surgical care.
- Standards differ, depending on the U.S. state.
DMC has four components, as defined by Paul Appelbaum, MD, and colleagues:
- The ability to make and communicate a consistent choice
- The ability to understand the information provided about medical conditions and decisions
- The ability to appreciate the consequences of a choice
- The ability to reason through the decision
In the sliding-scale model of DMC, not all decisions carry the same weight. The assessment evaluates the risk-benefit ratio of a particular decision, and the bar for capacity depends on the ratio.
When a patient lacks capacity and treatment over objection is pursued, the outcome is highly dependent on the hospital and state laws. Clinicians should confer with their risk management and legal team.

Summary

A capacity assessment usually is implicit in the process of informed consent because clinicians usually are assessing whether the patient truly understands what they are consenting to.
In the legal literature, “capacity” and “competency” are used interchangeably, but in the medical field they are different. It is easier to refer to adjudicated competency in which a judge legally determines a person’s ability to make decisions. Usually, a person lacking adjudicated competency has a guardian to guide their decisions.
In contrast, DMC is time and decision specific. A DMC assessment includes evaluation of the four components of capacity, including making a consistent choice, understanding the medical condition and decision, appreciating the risks, and using intact reasoning.
It is a low bar of DMC for a decision that has a high benefit and low risk (e.g., a blood draw or an x-ray). An intervention that is high risk and low benefit, such as an experimental treatment, would require the highest bar of capacity for consent. The lowest bar for DMC is when the patient decides who should make medical decisions for them.
In capacity assessments, clinicians must remember that a patient’s desire for a certain outcome does not translate into DMC. In these impassioned cases, clinicians need to stick to the four components of capacity in their assessment. The presence of mental illness does not preclude DMC. It is helpful to consider whether the person’s psychosis or symptoms of their disorder are influencing the decision.
If a patient lacks capacity, a surrogate decision maker should be identified. With a surrogate decision maker, it’s more likely the patient’s wishes will be honored. The surrogate decision maker hierarchy differs state by state.
Implicit in most DMC assessments are several questions, including: What do we do next if the person lacks capacity? Treatment over objection and the outcome are highly dependent on the hospital and state laws, so clinicians need to confer with their risk management and legal team. Usually, there are specific legal statutes to guide how to proceed if a patient's incapacity puts them at danger of harm.
When treatment over objection is the only option, teams must consider whether treatment can be delayed, and what the alternative treatments should be. The mechanisms for keeping people in the hospital are usually are coercive.

References

Appelbaum PS. N Engl J Med. 2007;357(18):1834-40.

Appelbaum PS, Grisso T. N Engl J Med. 1988;319(25):1635‐8.

Wynn S. Decisions by surrogates: An overview of surrogate consent laws in the United States. American Bar Association. 2014 Oct 1.

Centers for Disease Control and Prevention. Legal authorities for quarantine and isolation.

National Conference on State Legislatures. State quarantine and isolation statutes.

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Renae Beaumont, PhD, assistant professor of clinical psychology at New York–Presbyterian/Weill Cornell Medical Center, spoke with host Lorenzo Norris, MD, about the Secret Agent Society.

The Secret Agent Society is a video gaming–based therapy program aimed at helping children with a range of social and emotional challenges learn the social skills required to make and keep friends. The program also helps children feel happier, calmer, and braver. Dr. Beaumont disclosed her role as creator of the Secret Agent Society program. Dr. Norris has no disclosures.

Take-home points

The Secret Agent Society is a video gaming–based program that helps children detect how another person is feeling through the interpretation of facial expressions, body language, and vocal tone; use skills to socially engage; and to internally detect their own emotions.
Secret Agent Society is meant to engage children. It can be used during clinical/therapy sessions to stimulate discussion as well as at home with parents. The indicated age range is 8-12 years, and it is useful for children with autism and with average intellectual functioning.

Summary

The Secret Agent Society video game has four levels. Level one is about detecting emotions from facial expressions, vocal recognition, and body language. Level two is about detecting personal emotions and using scales to identify the components and range of emotions. Levels three and four are about navigating common social challenges in real time, from losing in a game to collaborating in a group project and learning calming techniques for themselves. To encourage practical application, there is a secret agent journal section where participants can chronicle how they used their skills.
Beaumont initially developed the game to help children who are on the autism spectrum. For many children on the spectrum, social skills are not innate, but can be taught and developed into life skills to help children meet their potential.
Parents might be conflicted about encouraging their children to play video games. It’s important to consider the evidence behind the game and the age and skills of the research participants. In general, parents should favor video games that teach skills, have educational context, and allow parental involvement. Now that much of social interaction is over the virtual sphere and social media, games and exercises that teach social skills over these mediums help build skills early.
The Secret Agent Society is meant to engage children. It can be used during a clinical/therapy to stimulate discussion and at home with parents. The game is also a helpful adjunct for psychological services offered online. The indicated age range is 8-12 years, as well as for children with autism and within average age intellectual functioning. New research is showing that the game may also be effective for children with social anxiety and ADHD.
Gameplay can be integrated into what a clinician is already doing, or the Social Skills Training Institute offers online training for clinicians that would be helpful when using the game to treat patients with multiple comorbidities.
Therapeutic gaming is useful during social distancing because it builds coping skills and helps children feel more in control of their emotions and actions.

References

Einfeld SL et al. J Intel Dev Disabil. 2018;43(1):29-39.

Sofronoff K et al. Develop Disabil. 2015 Apr 28. doi: 10.1177/1088357615583467.

Beaumont R, Sofronoff K. J Child Psychol Psychiatry. 2008 Jul;49(7):743-53.

Dr. Renae Beaumont’s TEDx Talk: https://www.youtube.com/watch?v=KQVv2hKipYQ

Secret Agent Society/Social Skills Training Institute: https://www.sst-institute.net/

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Frederick S. Barrett, PhD, is affiliated with the Center for Psychedelic & Consciousness Research (@JHPsychedelics) at Johns Hopkins University, Baltimore (@Hopkins Medicine).

Dr. Barrett spoke with Nick Andrews (@Nick_Andrews_) at @TEDMED 2020, about the research that has been conducted by the Center for Psychedelic & Consciousness Research on the impact of psychedelics, or hallucinogens, on psychiatric disorders. He has no disclosures.

Take-home points

Dr. Barrett transitioned into neuroscience research through his interest in the effect of music on human emotions and the brain.
Until 1970, psychedelics such as psilocybin were widely used in clinical research, with more than 1,000 academic papers published about their use. For example, psychedelics were used as a model for schizophrenia and helped identify the role of serotonin in psychosis. They were also studied to treat addiction and as a treatment for existential anxiety in cancer. In 1970, psychedelics were deemed illegal by the Controlled Substances Act which brought the United States in compliance with the 1971 Convention on Psychotropic Substances.
- Roland R. Griffiths, PhD, and a group at Johns Hopkins have led the way in reestablishing clinical research using psychedelics.
- Enthusiasm at the lab is borne out by the potential that this research might help many people.
Institutional concerns also are at work because of the “rich and sordid history” of these compounds.
In the next 10 years, Dr. Barrett would like to have a clear understanding of the effect size of psychedelics on mood and substance use disorders.
Psychedelic agents have a novel therapeutic quality: Studies support that a few or even one exposure to a psychedelic compound has a short-term biological effect and can lead to a long-lasting therapeutic effect, such as remission of mood disorder or change in personality characteristics. The clinical outcomes are mediated by the intensity of the psychedelic experience.

Summary

The Center for Psychedelic & Consciousness Research is working to discern which medical indications have the most promise for being treated with psychedelics. Its goal is a balanced and rational approach to psychedelic research and subsequent treatment considering the societal and political contexts around these drugs.
Dr. Barrett trained in music education and psychology and has been a musician all this life. He moved into neuroscience during graduate school and used music as a tool to study emotions and the brain.
Music, meditation, and psychedelics have the similar flow component that inspires converging research questions and a desire to analyze the brain and understand this experience that is central to consciousness.
Music is fundamental to the human experience, and it is exciting to try to describe the neural circuitry of how music affects the brain and emotions.
Music is useful in therapy because it can regulate emotions. There has long been an overlap of the use of psychedelics and music in therapy. A prime example of this is guided imagery and music (GIM), which is a specialized form of therapy that arose out of work done by Helen Bonny, PhD, a nurse, music therapist, and concert violinist. Bonny developed a protocol for using music to regulate emotions during psychedelic experiences.
In the next 10 years, Dr. Barrett would like to have a clear understanding of the effect size of psychedelics on mood and substance use disorders.
It will be interesting to see whether and how psychedelics are efficacious in treating an array of substance use disorders. If effective, they would be a single-use treatment for addiction to substances that interact with diverse neural circuits.

References

Barrett FS et al. Sci Rep. 2020 Feb 10. doi: 10.1038/S41598-020-59282-y.

Barrett FS, Griffiths RR. Curr Top Behav Neurosci. 2018;36:393-430.

Barrett FS et al. Int Rev Psychiatry. 2018;30(4):350‐62.

Griffiths RR et al. J Psychopharmacol. 2018 Jan;32(1):49-69.

Barrett FS, Janata P. Neuropsychologia. 2016 Oct;91;234-46.

Johnson MW et al. Am J Drug Alcohol Abuse. 2017 Jan;43(1):55-60.

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Anne Marie Albano, PhD, professor of medical psychology and psychiatry at Columbia University, New York, and director of the Youth Anxiety Center at New York–Presbyterian Hospital, discusses strategies for treating childhood, youth, and young adult anxiety with Nick Andrews.

Dr. Albano (@AnneMarieAlbano), who also is director of Modern Minds, an anxiety and depression program in Charleston, S.C., spoke with Nick (@Nick_Andrews_) at @TEDMed 2020.

Dr. Albano has no conflicts of interest.

Take-home points

Early identification of activity avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance.
Parents should validate that facing anxiety is difficult and that the child might be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears rather than to accommodating and enabling.
In 2008, Dr. Albano and colleagues published a randomized, controlled trial in the New England Journal of Medicine showing that sertraline, cognitive-behavioral therapy, or a combination of both are all more effective treatments for anxiety than placebo. The treatment effect degrades over time as the developmental challenges change, so children will need booster sessions or must return to treatment.
Young adults sometimes misinterpret “normal” emotions of apprehension with overwhelming anxiety that disincentivizes them to engage in activities. Therapy teaches children to “ride the wave” of anxiety and continue to move toward new experiences.
Dr. Albano is currently developing a program that uses virtual reality to role-play difficult developmental experiences that cause anxiety and help young adults learn how to advocate for themselves and problem-solve through anxiety.

Summary

Dr. Albano noticed that, when parents do not push children to participate or let them get out of activities, this can exacerbate the child’s anxiety. Early identification of avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance.
As a strategy, parents can offer children a choice of activities and push for the child to choose one of them. Parents should validate that facing anxiety is difficult and the child may be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears instead of accommodating and enabling.
The psychotherapy treatments focus on “riding the wave” of emotions that come with new or intimidating experiences and pushing toward exposures. Young adults sometimes misinterpret “normal” emotions of apprehension with overwhelming anxiety, and this confusion disincentivizes engaging in activities.
Dr. Albano has always integrated parents into treatment. Working with parents means finding the balance between the parents swooping in to help or rescue the child with coaching, setting limits, and pushing children toward experiences that will be exposures to anxiety.
The biggest challenge is the extent to which technology tethers parents to children and builds dependency.
More research needs to be done on what types of children progress with specific types of treatment, how long to stay in treatment, how to transition out of treatment, and when to offer booster sessions. Dr. Albano wants to expand treatment out of clinics and to the places in the community where anxiety happens and is at risk of hindering child development.

References

Walkup JT et al. N Engl J Med. 2008 Dec 25;359(26):2753-66.

Kagan ER et al. Child Psychiatry Hum Dev. 2020 Apr 6. doi: 10.1007/s10578-020-009883-w.

Hoffman LJet al. Current Psychiatry Rep. 2018 Mar 27. doi: 10.1007/s11920-018-0888-R.

Chen A. For kids with anxiety, parents learn to let them face their fears. NPR. Morning Edition. 2019 Apr 15.

McGuire JF et al. Depress Anxiety. 2019 Aug;36(8):744-52.

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Cheryl A. King, PhD, clinical psychologist and professor in the department of psychiatry at Michigan Medicine, the academic health system at the University of Michigan, Ann Arbor, joined Nick Andrews at TEDMED2020.

Dr. King spoke with Nick (@Nick_Andrews_) at @TEDMed about a suicide risk screen for teens that is based on computerized algorithm.

Take-home points

Dr. King is a longtime researcher in teen suicide, and her current project is creating a personalized adaptive suicide risk screen for teens called CASSY (Computerized Adaptive Screen for Suicidal Youth).
In an adaptive algorithm, subsequent questions will change based on the previous answer. The aim is to create a profile of risk factors and warning signs to generate a risk level that will guide the type of mental health interventions required in the ED and beyond.
CASSY also is being developed as a universal screen for those who might come to the ED without a mental health history. Many teens who die by suicide do not have previous contact with mental health professionals.
More research is being done to create and validate treatment interventions for at-risk teens so the risk levels generated in the ED can be met with evidence-based interventions for preventing suicide.
With the scarce mental health resources in some areas, Dr. King and associates have created an intervention that trains youth-nominated adults from within families to intervene in times of crisis.

Summary

The CASSY is based on computerized algorithms from data collected by the Pediatric Emergency Care Applied Research Network (PECARN). Within this network, thousands of teens in mental health crisis, after suicide attempt or not, have completed a suicide risk survey aimed at modeling specific warning signs and risk factors for predicting suicide attempts in the next 3 months. In an adaptive algorithm, subsequent questions will change based on the previous answer.
The risk factors for teen suicide are well established, but teens who attempt are a heterogeneous group. The key to predicting an imminent risk of suicide depends on developing profiles of risk based on how the risk factors and warning signs group together. The result of the CASSY is a level of risk. Individual institutions can set their risk levels.
CASSY is being developed as a universal screen for those who might come to the ED without a mental health history. Many teens who die by suicide do not have previous contact with mental health professionals. The goal is for CASSY to be integrated into a medical system’s EHR in order to make it easier to use on a broad population.
The most common intervention in an ED for suicide risk is creating a safety plan that involves identifying warnings signs for decompensated mood, brainstorming coping skills, and delineating emergency contacts and a plan of action for suicidal emergency.
Dr. King and associates developed the Youth-Nominated Support Team intervention, which harnesses the strength of the adults in the family to bolster treatment as usual. The teens nominate “caring adults” who they want to support them after hospitalization, and the adults are provided psychoeducation and training to more effectively support the teens.
Dr. King is also working on a National Institute of Mental Health–supported study to identify the 24-hour warning signs for suicide attempts. Dr. King thinks there is more work to be done combining the screening tools with interventions in the ED and beyond.

References

King CA. J Am Acad Child Adolesc Psychiatry. 2019 Oct;58(10):S305.

King CA et al. J Clin Psychol Med Settings. 2017 Mar;24(1):8-20.

King CA et al. JAMA Psychiatry. 2019 Feb 6;76(5):492-8.

King CA et al. J Am Acad Child Adolesc Psychiatry. 2019 Dec 9. doi: 10.1016/j.jaac.2019.10.015.

ASQ toolkit for suicide screening: https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml

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Lorenzo Norris, MD, touches base with Nick Andrews to discuss COVID-19 and to welcome Jacqueline Posada, MD, as an occasional cohost of the MDedge Psychcast.

Dr. Posada, associate producer, interviews Lynne S. Gots, PhD, about treating anxiety, obsessive-compulsive disorder, and other disorders in the midst of the COVID-19 pandemic.

Dr. Gots is an assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington. She has a private psychotherapy practice and has no financial relationships to disclosure.

Take-home points

Anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities.
Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. Anxiety is an adaptive response to a threat, and COVID-19 and its repercussions makes this a threatening time.
In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety.
Consider the following suggestions for working with anxious patients and clinicians:
- Acknowledge that social media has the potential for shaming and worsening social anxiety.
- Limit exposure to news and social media as much as possible.
- Monitor patients for excessive reassurance-seeking behaviors, and enact ERP plans.
- Establish a regular but flexible routine with boundaries between work, home, and rest.
- Practice self-compassion by lowering expectations and even using formal self-compassion practices.

Summary

Cognitive-behavioral therapy is an evidence-based therapy for obsessive-compulsive disorder (OCD) and many forms of anxiety and depression. Acceptance and commitment therapy (ACT) is considered a third-wave modality of CBT. The acceptance component is based on mindfulness and acceptance of “what is.” The commitment component involves identifying core values and actions so that a person can use his/her values as a guide to behaviors. The goal is not to eliminate anxious or obsessional thoughts but to accept they are there and work alongside them.
Clinicians should be aware that anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. For example, a person’s OCD rituals may not be worsened, but an underlying tendency for perfectionism could be triggered as he/she tries to practice “the perfect quarantine.”
Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now.
In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety.
Clinicians can look for reassurance-seeking behaviors that have cropped up with increased anxiety. For example, for a person with contamination anxiety, it might be tempting to wash for longer than 20 seconds or to wipe things down compulsively. Advise patients to pick a routine, such as washing for 20 seconds and no more.
Individuals can choose a reputable source and follow its guidelines. The key is to avoid falling into the trap that more reassurance-seeking behaviors will alleviate anxiety. Using excessive reassurance-seeking behaviors can lead to increased anxiety through the conditional learning mechanism of negative reinforcement.

Other helpful suggestions

Social media contains a potential for shaming based on comparing oneself and behaviors to others, so individuals should limit exposure to it.
News intake should be limited to 1 hour a day, and only reputable sources should be used.
Video calls also can trigger social anxiety because individuals literally have to see themselves more often than usual. Ways to minimize this anxiety include minimizing your personal image or covering the image with a Post-it note.
For people who are at home all day, establish a routine with a regular wake and sleep time and scheduled breaks. Some type of boundary between home and work life should be created.
Self-compassion should be practiced. The first step is to lower expectations and live according to your values and what is realistically possible given the extensive changes in the past month.
Professionals need to seek support from other professionals going through the same thing, so connect with a colleague who can relate to your situation.
- Remember that, as mental health professionals, we are a repository for everyone else’s anxiety and suffering, so we need to be kind to ourselves.
Consider using a self-compassion practice.
- Recognize that you are suffering.
- Connect with the community: Everyone is suffering.
- Hold that suffering and offer yourself words of compassion and loving kindness.

References and resources

Dr. Gots’s website: https://cognitivebehavioralstrategies.com/

Blog post by Dr. Gots that summarizes her clinical advice: https://www.nami.org/Blogs/NAMI-Blog/March-2020/How-to-Protect-Your-Mental-Health-during-the-Coronavirus-Outbreak

Suggestions for when and how to decontaminate groceries: https://www.seriouseats.com/2020/03/food-safety-and-coronavirus-a-comprehensive-guide.html

Self-compassion practice suggestion: https://self-compassion.org/exercise-2-self-compassion-break/

Supportive touch practice for times of stress and vulnerability: https://self-compassion.org/exercise-4-supportive-touch/

Self-compassion evidence-based resources: https://self-compassion.org/the-research/

International OCD Foundation: https://iocdf.org/

Show notes by Dr. Posada, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest.

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Lorenzo Norris, MD, interviews Mary D. Moller, DNP, MSN, about taking advantage of the polyvagal theory of anxiety and social engagement during psychotherapy.

Dr. Moller is associate professor of nursing at Pacific Lutheran University in Tacoma, Wash., where she coordinates the psychiatric mental health nurse practitioner doctorate nursing practice program. She also is in practice at Northwest Integrated Health. Dr. Moller has no conflicts of interest.

Later, Renee Kohanski, MD, discusses the sacred relationship that exists between doctors and patients.

Take-home points

The polyvagal (PV) theory relates autonomic nervous system functions to human behavior and response to trauma.
The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which together regulate the autonomic state in response to the environment and influence behavior.
The unmyelinated dorsal vagus nerve controls the “freeze response,” while the myelinated ventral vagus nerve modulates social communication and can inhibit the arousal state.
This theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagus nerve.
It’s easier to apply the insights of polyvagal theory in person, but Dr. Moller suggests specific techniques during teletherapy. She prioritizes eye contact, which has to be done by looking at the camera; modulating your tone of voice to be more soothing; and having the patient use biofeedback techniques, such as taking their pulse during a session to make note of their physical response to anxiety.

Summary

The association between the sympathetic nervous system and “fight or flight” is well known. The polyvagal theory relates autonomic nervous system functions to behavior and response to trauma. The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which regulate the autonomic state in response to the environment and influence behavior.
The unmyelinated dorsal vagus nerve innervates from the diaphragm down, controlling the “freeze” response. When the dorsal vagus nerve is activated, physical signs can include bradycardia or tachycardia, shallow breathing, and a “pit in the stomach” feeling from slowing down the GI tract.
The myelinated ventral vagus nerve innervates from the diaphragm up, and modulates social communication and engagement, which can inhibit the arousal state. Social engagement is attunement to the subtle cues occurring during engagement with another person.
The PV theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagal nerve.
In the PV theory, the concept of “neuroception” is likened to an unconscious threat detector sensed by the vagus nerve before the threat is registered by the brain.
Coregulation is using the environment, most commonly the physical and emotional response of another person, for emotional regulation. This occurs in the therapeutic dyad when the therapist is attuned by and not enmeshed with the patient. Think of coregulation as akin to attachment theory; when the parent is attuned and present, the child feels safer and is able to relax.
Dissociation is the “freeze” mechanism of reacting to traumatic events in the moment, and again when the memories are triggered by stimulus in the environment. One way to treat dissociation is through engaging the ventral vagus nerve using social connection, such as gentle voice, gentle touch, and deep breathing or other grounding exercises. The PV theory connects the physical and emotional responses to trauma.
It is impossible to physically connect through telehealth, so Dr. Moller prioritizes eye contact by looking at the camera, though this means taking one’s eyes off the patient, as well as having the patient take their own pulse to reinforce the use of biofeedback, and “breathing together” over the video treatment.

References

Dana DA, Porges SW. The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation (New York: W.W. Norton & Co., 2018).

Porges SW. The polyvagal perspective. Biol Psychol. 2007;74(2):116-43.

Beauchaine TP et al. Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biol Psychol. 2007 Feb;74(2):174-84.

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Jay H. Shore, MD, MPH, returns to the Psychcast, this time to conduct a Masterclass lecture on using telepsychiatry in a regulatory environment that is quickly changing because of the physical distancing forced by the COVID-19 pandemic.

Dr. Shore is director of telemedicine at the Helen and Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also directs telemedicine programming at the medical center’s department of psychiatry.

He disclosed serving as chief medical officer of AccessCare Services and receiving royalties from American Psychiatric Association Publishing and Springer.

Take-home points

Practicing telepsychiatry has administrative, technological, and clinical considerations.

Administrative concerns include licensure, prescribing, billing, and establishing a procedure and protocol, especially about emergencies.
Technological considerations include choosing software, understanding HIPAA compliance during the current COVID-19 crisis (and afterward), and incorporating a virtual clinic workflow, such as scheduling and billing.
Clinical considerations include understanding how to manage a hybrid relationship with patients and tailoring your clinical style to teleconferencing, such as reading body language through video and directing the environment as the clinician.
Basic dos and don’ts: The clinical space for teleconferencing of both clinician and patient must be private and secure. Every person in each room must be introduced. The webcam should be placed on top of the computer screen that so eye contact is maintained, and the clinician’s head should take up two-thirds of the screen.

Administrative considerations

To practice telepsychiatry, typically psychiatrists must be licensed in the state in which the patient is located, with some exemptions within federal systems. During the COVID-19 pandemic, however, many states have waived this requirement. Inform your malpractice company that you are now participating in telepsychiatry to ensure that you are covered. During the COVID-19 crisis, the federal government has waived the Ryan Haight Act to allow the prescription of controlled substances without an initial in-person visit.
Tips for dealing with an emergency: The psychiatrist should establish the physical location of the patient at the start of every appointment and document how to get a hold of them if the connection is lost. It’s helpful to know how and when to contact local emergency services; 911 is often a local call based on the GPS of the cell phone. American Telemedicine Association and American Psychiatric Association guidelines suggest using a patient support person. That person would either be a family member or close friend who is onsite during the event with whom you have preconsent to contact the clinicians if an emergency occurs.

Technological considerations

Telepsychiatry services should have a procedures and protocol document to outline scheduling, billing, documentation, and how to address psychiatric emergencies. For telemedicine, the videoconferencing software must be HIPAA compliant. During the COVID-19 emergency declaration, the Department of Health & Human Services’ Office for Civil Rights will exercise “enforcement discretion” and, in most cases, waive penalties of HIPAA enforcement for clinicians who are serving their patients in good faith.
- Use only technologies such as FaceTime or Skype if you are unable to make adequate connection with HIPAA-compliant technology.
- Take your in-person operational workflow and try to replicate it virtually. Make sure that people’s responsibilities are clearly delineated.

Clinical considerations

“Hybrid relationships” are increasingly more common with in-person and virtual interactions from videoconferencing, patient portals, email, etc. In hybrid relationships, there are both physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. The virtual space often is convenient and provides a sense of physical and emotional space between clinician and patient, with advantages and disadvantages. The virtual space means rendering care to the patient in their home and gives insight into their environment. The virtual space can also decrease stigma because the patient does not have to seek care in a physical clinic. Sometimes, more small talk than usual about the environment is helpful to bridge that virtual gap. Use more active inquiry into emotions or body language if these are not clearly communicated over videoconference.
Dos and don’ts: Make sure that the lighting is good. Use the picture setting, so you can monitor your body language during the session.
- Make sure you are not too passive during the session. Be proactive. Animate yourself a little more than you would in person.
- Ask patients questions about their environment.
- Have a lower threshold for asking how patients are doing. More active inquiry can prove helpful.

References

American Psychiatric Association Telepsychiatry Toolkit: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit

American Telemedicine Association: https://www.americantelemed.org/

Joint guideline on telepsychiatry from APA and ATA: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-and-ata-release-new-telemental-health-guide

State licensure exemptions: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

HHS HIPAA information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

Ryan Haight Act information: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/ryan-haight-act

Yellowlees P and Shore JH. Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals. Arlington, Va.: American Psychiatric Association Publishing, 2018.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She has no disclosures.

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As the nation’s health care system braces for COVID-19 cases, physicians who’ve faced the pandemic first have critical lessons for everyone.

In this bonus episode, two Seattle-area critical care leaders explain how their medical centers are preparing for and responding to their region’s early outbreaks. And they share some creative approaches that are uniting Seattle’s critical care departments.

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MDedge Psychcast host Lorenzo Norris, MD, interviews Steven Wengel, MD, about the challenges of loneliness in geriatric populations in nursing homes, especially during the current COVID-19 pandemic.

Dr. Norris also discusses potential interventions with Dr. Wengel, who is a geriatric psychiatrist at the University of Nebraska Medical Center in Omaha.

And later, in the “Dr. RK” segment, Renee Kohanski, MD, talks about how, in the midst of the pandemic, we are slowing down while we’re speeding up … and are learning how to use – and not abuse – technology.

Take-home points

Loneliness has been defined as a form of social pain; it is more than sadness or a “state of mind.”
Loneliness and being alone are separate issues suggesting that loneliness is more of an emotional state and being alone is often a choice. Loneliness can be characterized as deficits in authentic interactions and connection because you can be surrounded by people and still feel lonely.
Loneliness has been studied as a predictor of health problems and is identified as a risk factor for early mortality and dementia and as a predictor of chronic illnesses such as depression.
When it comes to treating loneliness in the geriatric population, favor any type of intervention over none and avoid chalking up symptoms as “just loneliness.” Basic interventions include providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive type symptoms with an SSRI.

Summary

In a study of nursing-home patients, 9% report loneliness often or always and 25% report loneliness sometimes; older adults are more susceptible to loneliness secondary to frailty and limited transport options.
Loneliness is an independent risk factor for early mortality and a predictor for other chronic diseases including dementia, hypertension, depression, and overall poor health.
During the COVID-19 pandemic, most nursing homes are under lockdown, and all visitors are barred to minimize the introduction of COVID-19 to the facilities. This means residents are unable to see family and loved ones. This necessary intervention brings up the question of quality of life over quantity of life for older individuals. Isolation and social distancing have also taken away group activities like communal meals and games with socializing. Children of institutionalized patients might also feel a sense of loss and guilt as they are not allowed to see their loved ones. Particular to geriatrics, physical touch is essential to healing emotional pain, for example, a gentle touch or massage to relieve anxiety or physical redirection to ease agitation secondary to dementia.
Two primary means of addressing loneliness for the geriatric population include providing structure and finding opportunities for volunteerism such as helping other residents or completing simple tasks within the institution.
Loneliness and major depressive disorder are difficult to differentiate in the older population. Dr. Wengel recommends favoring intervention over none. This means using basic interventions like providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive symptoms with an SSRI.

References

Jansson AH et al. Loneliness in nursing homes and assisted living facilities: Prevalence, associated factors and prognosis. Jour Nursing Home Res. 2017;3:43-9.

Social isolation, loneliness in older people pose health risks. National Institute on Aging. https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks.

Cacioppo JT. Loneliness: Human Nature and the Need for Social Connection. New York: W.W. Norton and Company, 2008.

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Loneliness: Human Nature and the Need for Social Connection

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MDedge Psychcast host Lorenzo Norris, MD, interviews Sy Atezaz Saeed, MD, MS, about his annual analysis of the key studies that could change day-to-day psychiatric practice.

Dr. Norris’s conversation with Dr. Saeed is based on a two-part evidence-based review that identified the top 12 research findings for clinical practice from July 2018 to June 2019. Part 1, which Dr. Saeed wrote with Jennifer B. Stanley, MD, and Part 2 were published in Current Psychiatry.

Take-home points

Each year, Dr. Saeed identifies 10-20 high-quality journal articles with direct impact on clinical practice that, if used appropriately, can generate better outcomes for psychiatric patients. The goal of the list is to close the gap between cutting-edge science and clinical practice.
Secondary literature (for example, Cochrane Reviews, NEJM Journal Watch, and so on) is used to differentiate the clinically relevant “signal” from the noise of all the research produced.
Knowledge changes over time, so it’s important to be up to date but flexible in how the knowledge is applied.

Summary

The methodology used to generate the list is aimed at identifying 10-20 useful articles. Dr. Saeed took a three-pronged approach that reviewed research findings suggesting readiness for clinical utilization published between July 1, 2018, and June 30, 2019; asked several professional organizations and colleagues: “Among the papers published from July 1, 2018, to June 30, 2019, which ones in your opinion have (or are likely to have or should have) impacted/changed the clinical practice of psychiatry?”; and looked for appraisals in postpublication reviews such as NEJM Journal Watch, F1000 Prime, Evidence-Based Mental Health; commentaries in peer-reviewed journals; and other sources that suggest an article is of high quality and clinically useful.
This approach generated a solid list of articles to consider presenting at journal clubs or a topic to present at grand rounds.
- Studies on this list also might overlap with research covered in popular media, so the list is a tool that clinicians can use to answer questions patients raise.
The secondary literature is used to differentiate the clinically relevant “signal” from the noise of all the research produced. Those secondary sources include Cochrane Reviews, BMJ Best Practice, NEJM Journal Watch, Evidence-Based Mental Health, and commentaries in peer-reviewed journals to help distill the clinically useful articles for a busy clinician.
Four of the 12 articles that affected Dr. Saeed’s practice covered the risk of death associated with antipsychotic medication usage in children, the role of antipsychotic polypharmacy in schizophrenia to decrease inpatient hospitalizations, the outcomes associated with prescribing different adjunctive medications in combination with antipsychotics, and the use of prazosin for nightmares in PTSD.

References

Saeed SA et al. Top research findings of 2018-2019 for clinical practice. Part 1. Current Psychiatry. 2020 January;19(1):12-8.

Saeed SA. Top research findings of 2018-2019 for clinical practice. Part 2. Current Psychiatry. 2020 February;19(2):22-8.

Ray WA et al. Association of antipsychotic treatment with risk of unexpected death among children and youths. JAMA Psychiatry. 2019;76(2):162-71.

Tijhonen J et al. Association of antipsychotic polypharmacy vs. monotherapy with psychiatric rehospitalization among adults with schizophrenia. JAMA Psychiatry. 2019;76(5):499-507.

Stroup TS et al. Comparative effectiveness of adjunctive psychotropic medications in patients with schizophrenia. JAMA Psychiatry. 2019;76(5):508-15.

Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507-17.

Show notes by Jacqueline Posada, MD, associate producer of the MDedge Psychcast. Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

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Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, conducts a Masterclass on what psychiatrists and other mental health clinicians can do to mitigate the impact of COVID-19.

Dr. Ritchie is writing additional commentaries on this topic for MDedge Psychiatry.

And later, in the “Dr. RK” segment, Renee Kohanski, MD, says that, with simple tools or guidelines, humans have the ability to withstand adversity that is stronger than we will ever know.

Take-home points

Epidemics and pandemics are characterized by fear and anxiety.
Quarantine will be a challenge for patients with addictions and vulnerable populations such as individuals who are homeless.
Psychiatrists can aid with social distancing by providing patients refills for psychotropic medications without requiring an in-person visit and switching to telepsychiatry where possible. The Coronavirus Preparedness and Response Supplemental Appropriations Act waives Medicare telehealth reimbursement restrictions for mental health services during certain emergency periods.
Inpatient psychiatric units must take special precautions to prevent spread of COVID-19, such as improving procedures for sanitizing communal areas and items, limiting visitation, screening patients for symptoms, and arranging transfer when appropriate. COVID-19 infection can spread on units to patients and staff and may compromise clinicians’ ability to provide care safely.
Psychiatrists also play a role in helping address the shortage of personal protective equipment (PPE) by talking to patients about the appropriate use of PPE and sanitizer.

Summary

Emotional response to pandemics: Epidemics and pandemics are characterized by fear and anxiety as people worry about their risk of exposure, infection, and spreading the pathogen. Clinics can alleviate the anxiety by transitioning to telehealth when possible, discouraging handshakes, keeping a distance from patients, and rearranging waiting rooms and other spaces to provide more room between chairs and tables. Psychiatrists can encourage patients and fellow clinicians to engage in activities that normally reduce anxiety, such as exercising, setting aside time for relaxation at home, and taking regularly prescribed or over-the-counter medications.
Quarantine considerations: Quarantine and isolation will be difficult for most people, and especially so for patients with psychiatric disorders, including substance use disorders. Psychiatrists can prepare themselves and patients for quarantine by refilling medications for more than 30 days. The Centers for Disease Control and Prevention recommends clinicians refill nonurgent medications without an in-person visit. Patients who are addicted to alcohol or other substances may be tempted to leave the house to acquire those substances. It may be a physician’s responsibility to either suggest to patients that they have enough of their substance at home or give them something to treat withdrawal or cravings.
Considerations for inpatient psychiatric units: Psychiatric units are built for socialization and communal treatment; thus, psychiatric units will have to change policies, including limiting visitors; decreasing occupancy on the units; and ensuring that communal items such as phones, chairs, and books are properly sanitized.
Long-term psychological impact of a pandemic: The negative economic impact of the pandemic, such as unemployment in the tourism and service industries, may have consequences including rising rates of depression and anxiety, suicides, and increases in domestic violence and substance abuse. Psychiatrists can help address the shortage of PPE by talking to patients about the appropriate use of PPE and sanitizer. It is wise to have a stock of food, medications, and supplies for 14-21 days of quarantine, but in a public health emergency we can urge patients and ourselves to be mindful of the needs of others and avoid hoarding. We need to remind ourselves, our patients, and our colleagues to stay healthy by getting enough sleep, taking on the appropriate level of readiness, and remaining flexible as our daily lives are changed by the pandemic.

References

Centers for Disease Control and Prevention. Interim guidelines for healthcare facilities: Preparing for community transmission of COVID-19 in the United States.

H.R. 6074: Coronavirus Preparedness and Response Supplemental Appropriations Act. Passed Congress 2020 Mar 6.

Brooks SK et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet. 2020 Mar 14;395(10227):912-20.

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Lorenzo Norris, MD, interviews Nina J. Gutin, PhD, a psychologist with a private practice in Pasadena, Calif., about losing patients and loved ones to suicide.

Dr. Gutin wrote two evidence-based reviews on the topic late last year. The reviews were published in Current Psychiatry.

Take-home points

When mental health clinicians lose a patient to suicide, the sequelae can include stigma, potential legal consequences, impact on future clinical work, and restraints on processing the loss because of confidentiality concerns.
The American Association of Suicidology founded the Clinician Survivor Task Force (CSTF), which provides consultation, support, and education to mental health professionals to help them respond to the personal/professional loss from the suicide of a patient or loved one.
Mental health institutions can benefit from protocols on how to respond to a potential completed suicide, so clinicians and families are not left in a vacuum of uncertainty and blame.
After a patient suicide, clinicians need an anonymous or safe space to talk about the patient and the suicide without breaking confidentiality. This can be an online forum, such as the one sponsored by the CSTF, or an institution can identify a supportive colleague who has suffered a similar loss.
- The CSTF forum allows clinicians to remain anonymous.

Summary

Several domains require attention after the loss of a patient from suicide:

Confidentiality restrains the ability to talk about the details of the loss, which stymies grief and learning from the event. Restraints of confidentiality pertain to individual clinicians and clinical teams. On a team, it might feel as if the clinicians are unable to process the loss as a group and talk about important details.
Legally, clinicians worry about potential lawsuits, and “psychological autopsies” can lead to retraumatization. Clinicians might struggle with how – or whether – to talk to a patient’s family after suicide. Some lawyers advise compassion over caution. In collaboration with lawyers who advise what can be disclosed, a clinician can speak with a family, and this compassion toward families might decrease the risk of a lawsuit.
Clinicians should be prepared for a patient suicide to affect their clinical work. A clinician might become hypervigilant about suicide risk and overreact, or they might experience denial about the risk and avoid asking questions about suicide.
Ethically, suicide is an “occupational hazard” of working in the mental health field. Blaming clinicians for patient suicide hampers the depth of working with people with mental illness by causing some clinicians to avoid “high-risk” patients.
The stigma around death by suicide extends to the survivors of the loss. When clinicians express vulnerability about loss, it can be interpreted as guilt. Clinicians are expected to keep going no matter what, which is unrealistic. Grief over a patient’s death should be neither pathologized nor shamed.
Guilt and blame are the flip sides of each other; both express the complexity and ambiguity of these kinds of losses.
Institutions should have “postvention” protocols in place to respond to the likely event of a completed suicide. Guidelines can address what needs to be covered in a review of the case while also supporting clinicians, so they don’t feel like it’s a tribunal. Clinicians should be warned of the normal sequelae of a client suicide, and institutions can make accommodations based on the expected impact of suicide on a clinician’s work. Institutions can provide support by connecting clinicians who have also lost clients to suicide to dispel the belief that they are alone in their loss and to mitigate self-blame.
The CSTF provides support through in-person and online support groups, and postvention protocols for institutions. It also and maintains a bibliography of research on clinician survivorship.

References

Gutin NJ. “Losing a patient to suicide: What we know.” Current Psychiatry. 2019 Oct 18(10):14-6,19-22,30-2.

Gutin NJ. Losing a patient to suicide: Navigating the aftermath. Current Psychiatry. 2019 Nov 18(11):17-18,20,22-4.

American Association of Suicidiology. Clinicians as Survivors: After a Suicide Loss.

Owen JR et al. Suicide symposium: A multidisciplinary approach to risk assessment and the emotional aftermath of patient suicide. MedEdPORTAL. 2018 Nov 28;14:10776.

Myers MF and Fine C. Touched by suicide: Bridging the perspectives of survivors and clinicians. Suicide Life Threat Behav. 2007 Apr;37(2):119-26.

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Jonathan Meyer, MD, returns to the Psychcast, this time to conduct a Masterclass lecture on treating patients with lumateperone.

Dr. Meyer, of the University of California, San Diego, disclosed receiving either speaking honoraria or advising fees from several companies, including Intra-Cellular Therapies, which developed lumateperone (Caplyta).

Later, Renee Kohanski, MD, discusses tailored interventions psychiatrists can incorporate into their practices to address overweight and obesity resulting from medications tied to weight gain.

Take-home points

Lumateperone, an atypical antipsychotic, was approved by the Food and Drug Administration for the treatment of adults with schizophrenia on Dec. 20, 2019. It has only one approved effective dose of 42 mg given with food.
- Further studies might define doses higher or lower, but those data are not available yet.
- The only adverse effect found with lumateperone was somnolence or sedation. Lumateperone was 24%; placebo was 10%.
The medication has a low affinity and occupancy of the dopamine D2 receptors. This pharmacodynamic trait is reflected by the relatively low rates of extrapyramidal side effects in the clinical trial data.
- For now, the short-term studies of lumateperone suggest limited metabolic and endocrine effects, compared with other atypical antipsychotics.
The primary indication for using lumateperone may be its tolerability profile, because nonadherence contributes to the morbidity of schizophrenia.
Lumateperone is not a drug that should be used for treatment-resistant schizophrenia. The only drug that should be used for refractory patients with schizophrenia is clozapine (Clozaril).

Summary

Lumateperone has a unique pharmacologic profile. It has a low affinity for muscarinic, histaminergic, and alpha-adrenergic receptors. In the clinical trials, the primary side effect reported was somnolence and/or sedation.
The medication also has a lower affinity for dopamine D2 receptors and occupies less than 40% of these receptors even at peak-dose timing. Conventional treatment of psychosis suggests that antipsychotic properties of D2 antagonist medications occur when 60%-80% of D2 receptors are occupied. Yet, there may be other properties of atypical antipsychotics that can increase the efficacy with lower levels of D2 blockade.
Knowledge of alternative mechanisms comes from studying other antipsychotics. For example, pimavanserin (Nuplazid), an antipsychotic medication for treatment of psychosis in Parkinson’s disease, has no affinity for any dopamine receptors. Instead, it has a high affinity for serotonin 5-HT2A receptors as an inverse agonist and antagonist likely in cortical circuits with downstream glutamate signaling to dopamine circuits in the ventral tegmental area, which then decreases the amount of dopamine released in the mesolimbic pathway.
- Pimavanserin does not have any activity on the presynaptic D2 autoreceptors. Though counterintuitive, other atypical antipsychotics block the D2 presynaptic autoreceptor, which increases dopamine release. This mechanism is possibly why other antipsychotics require a 60%-80% D2 blockade to be effective in treating psychosis. In vitro studies suggest that lumateperone does not have presynaptic autoreceptor antagonism, which could be another reason why it doesn’t need as much D2 antagonism to be an effective antipsychotic agent.
Lumateperone also is a weak inhibitor of serotonin reuptake occupying 30% of the serotonin receptors. Given its diverse pharmacologic mechanisms, lumateperone may confer antidepressant properties, and clinical trials are in the process to evaluate the use of lumateperone in bipolar depression.
The drug is expected to be available at the end of March 2020.

References

Meltzer HY et al. Pimavanserin, a selective serotonin (5-HT)2A-inverse agonist, enhances the efficacy and safety of risperidone, 2 mg/day, but does not enhance efficacy of haloperidol, 2 mg/day: comparison with reference dose risperidone, 6 mg/day. Schizophr Res. 2012;141(2-3):144-52.

Correll CU et al. Efficacy and safety of lumateperone for treatment of schizophrenia: A randomized clinical trial. JAMA Psychiatry. 2020 Jan 8. doi: 10.1001/jamapsychiatry.2019.4379.

Corponi F et al. Novel antipsychotics specificity profile: A clinically oriented review of lurasidone, brexpiprazole, cariprazine, and lumateperone. Eur Neuropsychopharmacol. 2019;29(9):971-85.

U.S. National Library of Medicine. Lumateperone drug label

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Patricia Westmoreland, MD, returns to the Psychcast to conduct a Masterclass on treating bulimia.

Dr. Westmoreland, an attending psychiatrist at the Eating Recovery Center in Denver, previously discussed eating disorders. She is an adjunct assistant professor in the department of psychiatry at the University of Colorado at Denver, Aurora, and has a private forensic psychiatry practice in Denver.

Takeaway points

Anorexia nervosa and bulimia nervosa can have life-threatening medical complications.
All medical complications can resolve with consistent nutrition and full weight restoration.
Eating disorders must be treated and associated behaviors stopped to prevent complications from returning.
Anorexia-related medical complications usually are attributable to weight loss and malnutrition.
Bulimia-related medical complications can occur at any weight, and are related to the mode and frequency of purging. Complications include metabolic abnormalities, such as electrolyte and acid-base disturbances, volume depletion, and damage to the colon.
Patients with bulimia have a lower mortality rate than do those with anorexia. However, the mortality of patients with bulimia is two times higher than that of age-matched healthy controls because of acid-base disturbances and severe electrolyte abnormalities.
- The weight of the patients with bulimia does not matter. Acid-based disturbances and severe electrolyte abnormalities can kill patients at any time without warning and at any weight.

Summary

About 90% of purging behaviors consists of self-induced vomiting and/or laxative abuse.
Self-induced vomiting can cause local complications such as gastric reflux, which can lead to dysphagia and dyspepsia; hematemesis from Mallory-Weiss tears in the esophagus; nosebleeds and subconjunctival hemorrhages; and parotid gland enlargement, known as sialadenosis, which is a chronic, noninflammatory cause of swelling of the major salivary glands.
Systemic complications of self-induced vomiting include metabolic derangements, such as hypokalemia, metabolic alkalosis, and volume depletion, which can lead to pseudo-Bartter syndrome from chronic aldosterone secretion as the body attempts to maintain blood pressure; the syndrome is characterized by hyperaldosteronism, metabolic alkalosis, hypokalemia, and normal blood pressure.
Treatment of local complications: Gastric reflux can be treated with proton pump inhibitors, and the patient should be screened for Barrett’s esophagus with esophagogastroduodenoscopy. Dental complications such as erosion of the enamel should be addressed with fluoride-based mouthwashes and toothpastes, and gentle toothbrushing. Parotid gland enlargement is treated by sucking on sour candies, applying hot packs, and using anti-inflammatory medications.
Treatment of systemic complications: Hypokalemia, which is diagnosed on a basic metabolic panel, needs immediate repletion orally or intravenously. Depending on the severity of the hypokalemia, the patient may need cardiac monitoring in the hospital or ICU to prevent mortality from a lethal arrhythmia. In pseudo-Bartter syndrome, the elevated aldosterone does not normalize until a few weeks after purging stops, so individuals can develop edema and the other electrolyte abnormalities. Treatment is spironolactone, 25-200 mg/day.
Complications from laxative abuse occur primarily from stimulant laxatives, which stimulate the myenteric plexus, the nerves of the intestines, and increase intestinal secretions and motility. Cathartic colon syndrome occurs from continued use of stimulant laxatives, which damage the nerves of the colon by rendering it incapable of peristalsis without continued use of laxatives. Individuals who abuse laxatives more than three times per week for at least 1 year are at risk of cathartic colon syndrome and need to stop laxatives immediately.

References

Westmoreland P et al. Medical complications of anorexia nervosa and bulimia. Am J Med. 2016;129(1):30-7.

Mehler PS, Walsh K. Electrolyte and acid-base abnormalities associated with purging behaviors. Int J Eat Disord. 2016 Mar;49(3):311-8.

Gibson D et al. Medical complications of anorexia nervosa and bulimia nervosa. Psychiatr Clin North Am. 2019 Jun;42:263-74.

Sato Y, Fukado S. Gastrointestinal symptoms and disorders in patients with eating disorders. Clin J Gastroenterol. 2015 Oct;8(5):255-63.

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Charles L. Raison, MD, returns to the Psychcast to conduct a Masterclass on psychedelics for patients with major depressive disorder.

Dr. Raison, professor of psychiatry at the University of Wisconsin–Madison, previously conducted a Masterclass on the risks and benefits of antidepressants. He disclosed that he is director of translational research at the Usona Institute, also in Madison.

Later, Renee Kohanski, MD, raises questions about the felony child abuse case of pediatric emergency department doctor John Cox.

Takeaway points

Psychedelics are a range of compounds that share a common mechanism as agonists at the postsynaptic 5-HT2A serotonin receptor.
Psychedelic agents have a novel therapeutic quality. Studies suggest that a few or even one exposure to a psychedelic compound, which has a short-term biological effect, leads to long-lasting therapeutic effect, such as remission of mood disorder or change in personality characteristics. The clinical outcomes are mediated by the intensity of the psychedelic experience.
A psychedelic experience is characterized by profound, rapid alterations in what is seen, sensed, felt, and thought. It often leads to personal growth with experiences of transcendence. Subjects in trials often report a “mystical experience” they describe as a sense of unity with the universe and understanding of one’s deeper purpose. Psychedelic experiences also are characterized by a difficulty in describing them with words.
Because psychedelics are illegal substances, the traditional route of pharmaceutical companies’ funding the research for clinical trials is not available. Organizations such as Usona Institute and MAPS (Multidisciplinary Association for Psychedelic Studies) are leading the way.
The Food and Drug Administration has granted psilocybin a “breakthrough therapy designation” for the treatment of major depressive disorder.

Summary

Psilocybin, lysergic acid diethylamide (LSD), mescaline, ayahuasca (active ingredient: N,N-dimethyltryptamine [DMT]), and 3,4-methylendioxy-methamphetamine (MDMA) are all classified as psychedelics. Psychedelics have been used for thousands of years for spiritual ceremonies.
Psychedelics came to the attention of medicine and science after 1943 when Albert Hofmann, PhD, a chemist at a Sandoz Lab in Basel, Switzerland, synthesized LSD and accidentally ingested it, serendipitously identifying its mind-altering properties.
Until 1970, psychedelics were widely used in clinical research, and more than 1,000 academic papers about their use were published. For example, psychedelics were used as a model for schizophrenia and helped identify the role of serotonin in psychosis. They also were studied to treat addiction and as a treatment for existential anxiety in cancer. In 1971, psychedelics were declared illegal under the U.N. Convention on Psychotropic Substances.
Researchers returned to psychedelics in the 2000s, examining a variety of uses, including the capability to reliably induce psychedelic experience in healthy normal volunteers (no previous psychiatric diagnosis) and promote emotional well-being in healthy normal volunteers. The role of psychedelics as medicine are once again being studied in a variety of contexts, such as mood disorders, PTSD, addiction, and phase-of-life problems.
Most notable from the research is the capability of psychedelic compounds to induce long-lasting effects on personality, mood disorders, and PTSD after one or a few ingestions. What is remarkable is how the therapeutic effect remains long after the biological presence of the compound is gone from the body. The clinical outcomes are mediated by the intensity of the psychedelic experience.
The Usona Institute, a medical research organization, started as a nonprofit to advance the research into psychedelics needed for the FDA to approve psychedelics as a treatment. Because psychedelics are still illegal, the traditional route of pharmaceutical companies funding this type of research is not available.
The FDA has granted psilocybin a “breakthrough therapy designation” for the treatment of major depressive disorder. The breakthrough therapy designation “indicates that the drug may demonstrate substantial improvement on a clinically significant endpoint(s) over available therapies.”
The breakthrough therapy designation is for major depressive disorder, not for treatment-resistant depression, suggesting that the FDA recognizes the shortcomings of current treatments for depression.

References

Johnson MW, Griffiths RR. Potential therapeutic effects of psilocybin. Neurotherapeutics. 2017 Jul;14(3):734-40.

Griffiths RR et al. Psilocybin-occasioned mystical-type experience in combination with meditation and other spiritual practices produces enduring positive changes in psychological functioning in trait measures of prosocial attitudes and behaviors. J Psychopharmacol. 2018 Jan;32(1):49-69.

Johnson MW et al. Long-term follow-up of psilocybin-facilitated smoking cessation. Am J Drug Alcohol Abuse. 2017 Jan;43(1):55-60.

Griffiths RR et al. Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. J Psychopharmacol. 2016 Dec;30(12):1181-97.

Rozzo M. Book review: “‘How to Change Your Mind.” Columbia Magazine. 2018 Fall.

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William Lynes, MD, joins guest host Michael F. Myers, MD, to discuss his struggles with medical and psychiatric hardships, his suicidality, and the eventual suicide attempt that changed his life. Dr. Myers is professor of clinical psychiatry, State University of New York, Brooklyn.

Dr. Lynes, a retired urologist, author, and speaker/advocate on physician burnout and suicide, divides his professional life into two distinct eras: 1987-1998, during which he had a successful practice and happy life, and after 1998, when he spiraled downward medically and psychiatrically.

After meeting another physician with a similar experience who had published her story of burnout and mental health struggles in 2015, Dr. Lynes decided to speak out. Eventually, he published an essay about his experience in the Annals of Internal Medicine.

Take-home points

Being open with close colleagues or supervisors about mental health struggles and/or burnout can provide a much-needed lifeline to struggling physicians.
Addressing burnout and mental health diagnoses of physicians requires medical groups and institutions to provide access to psychiatric treatment from clinicians outside of the professional network in which the physician practices.
Practicing medicine can be a 24/7 profession, and being “on” all the time can contribute to burnout. Lifestyle choices such as exercise, hobbies, family, and spirituality are all helpful outlets to address the constancy of practicing medicine.
Giving in to the notion that you can treat yourself is not a good idea.
Decreasing the stigma tied to mental illness can be helped by people with lived experience, such as Dr. Lynes.

References

Lynes W. The last day. Ann Intern Med. 2016 May 3;164(9):631.

Myers MF and Freeland A. The mentally ill physician: Issues in assessment, treatment and advocacy. Can J Psychiatry. 2019 Dec 6;64(12):823-37.

Forbes MP et al. Optimizing the treatment of doctors with mental illness. Aust NZ Psychiatry. 2019 Feb;53(2):106-9.

Myers MF. “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.” 2017 Feb 14. (Self-published).

Bird JL. “Using Narrative Writing to Enhance Healing.” Medical Information Science Reference, 2019.

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Why Physicians Die by Suicide: Lessons Learned from Their Families and Others Who Cared

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George T. Grossberg, MD, conducts a Masterclass on treating mood disorders in geriatric patients from the CP/AACP Psychiatry Update 2019 meeting in Las Vegas. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Grossberg is the Samuel W. Fordyce professor and director of geriatric psychiatry at St. Louis University School of Medicine in St. Louis.

Later, Renee Kohanski, MD, discusses the first thing psychiatrists can do for patients.

Take-home points from Dr. Grossberg:

The prevalence of major depressive disorder among older adults who reside in the community is similar to that of the general population (6%). In nursing homes, the prevalence of significant clinical depression is close to 25%.
Depression in older adults in long-term care facilities is underrecognized and undertreated. Risk factors for depression include advanced age (80-90 years), loneliness and lack of social support, painful conditions, frailty, and medical comorbidities. Medications that are central nervous system depressants, such as opiates and benzodiazepines, also can contribute to depression. Alcohol can also be a depressant. Depression in the face of cognitive impairment is extremely common and can even speed cognitive decline.
Apathy, defined as lack of motivation, can look like depression. However, depression will have amotivation coupled with vegetative symptoms, such as disrupted sleep and loss of appetite, and mood changes, such as sadness and tearfulness. Low-dose stimulants are effective for apathy, but antidepressants are not; so, it’s important to differentiate the two.
Undiagnosed and untreated depression contributes to a significant degree of morbidity because it can slow recovery in rehabilitative settings and impair adherence to essential medications. Treating depression also can improve pain control by making it more tolerable as a somatic symptom.
Individuals older than 65 years account for more than 20% of all completed suicides in the United States. Psychological autopsy studies suggest that many of these individuals had undiagnosed depression.
Clinicians should not shy away from treating geriatric patients for depression with medication and interventions such as cognitive-behavioral therapy. With pharmacotherapy, start low, go slow, and titrate up to a therapeutic dose. Older adults may take longer, up to 8-12 weeks, to respond to SSRIs, so it’s imperative not to give up on medications too soon.
Electroconvulsive therapy is the most effective treatment for severe depression in geriatric patients. Some consider advanced age an indication for ECT; medical comorbidities are not a contraindication for ECT.
It is unclear how effective ketamine is in older patients, but it deserves consideration.
Prompt diagnosis and treatment of mood disorders is paramount in patients of advanced age and those living in long-term care facilities. Treating depression in the older patient also improves the quality of life for caregivers and professional staff.

References

Birer RB et al. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician. 2004 May 15;69(10):2375-82.

Sjoberg L et al. Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults. J Affect Disord. 2017 Oct 15;221:123-31.

Grossberg GT et al. Rapid depression assessment in geriatric patients. Clin Geriatr Med. 2017 Aug;33(3):383-91.

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In this, the 100th episode of Psychcast, Nick Andrews talks with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about the January front-page article in Clinical Psychiatry News that featured Matthew E. Seaman, MD, an emergency physician with depression who took his own life. The article describes the Dr. Seaman faced.

Later, Christine B.L. Adams, MD, a psychiatrist who practices in Louisville, Ky., discusses her book, “Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships” (Santa Barbara: Praeger, 2018), with Dr. Norris.

Take-home points from Dr. Adams

Children learn emotional patterns in families. These behaviors get reinforced. As children form dating relationships, for example, those patterns continue to be reinforced.
People may go on autopilot and have knee-jerk reactions in response to people, which allows them to react emotionally without thinking about what’s necessary for each person.
Long-term dynamic psychotherapy can help patients observe what they are doing in relationships and what others are doing.
Ultimately, patients can be taught to look at and uncover their automatic responses.
Once these patterns are uncovered and moved from the emotional realm to the intellectual realm, they can be interrupted.

Genesis and development of the book’s principles

Homer B. Martin, MD, a Louisville, Ky.–based adult psychiatrist who worked with Dr. Adams for 30 years, developed the original premise of the book. When he died, his wife asked Dr. Adams, who was his protégé, to finish it.
The book is based on the observations made by Dr. Martin during his 40 years of conducting psychotherapy with patients. It is designed to be accessible both to psychiatric trainees as well as to general readers.
- Dr. Adams started teaching the concepts in the book during a 6-week university class to determine whether the ideas were digestible and useful.
- Mainstream movies were used to help people learn to observe and identify roles that were emotionally conditioned and to determine how a character’s change in behavior would change the other person.
  - Movies that can be used to help people identify problematic patterns include “Ordinary People,” “Gran Torino,” “The Remains of the Day,” “The Door in the Floor,” and “When Harry Met Sally.”

References

Yazici E et al. Use of movies for group therapy of psychiatric inpatients: Theory and practice. Int J Group Psychother. 2014 Apr;64(2):254-70.

Ross J. You and me: Investigating the role of self-evaluative emotion in preschool prosociality. J Exp Child Psychol. 2017 Mar;155:67-83.

Werner AM et al. The clinical trait self-criticism and its relation to psychopathology: A systematic review – Update. J Affect Disord. 2019 Mar;246:530-47.

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In episode 99 of the Psychcast, Frank Yeomans, MD, PhD, clinical associate professor of psychiatry at the Weill Medical College of Cornell University, Ithaca, N.Y., spoke with Dr. Norris at the Group for the Advancement of Psychiatry (GAP) fall 2019 meeting about treating patients with personality disorders.

Characteristics of personality disorders

A personality disorder affects the quality of a person’s experience and his or her ability to deal with challenges in life, including comorbid psychiatric disorders. A personality disorder is not based on symptoms alone and determines how people engage with their environment; it is a part of the biological side of psychiatry.
The DSM traditionally relied on a traits-based definition of personality disorders. Yet, in the “emerging measures and models” section, the DSM-5 describes a dimensional/categorical model of personality disorders, which looks at personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. This harkens back to the concept of borderline personality organization as outlined by Otto F. Kernberg, MD.
The dimensional model suggests that individuals with personality disorders benefit from behavioral therapies, such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT), to treat problematic traits. Exploratory and insight-focused psychotherapies can help individuals understand their personality organization. Ideally, the treatments for personality disorders would be sequenced, starting with CBT or DBT and transitioning into exploratory therapy.
- Much like borderline personality disorder, at the core of narcissistic personality disorder is a fragmented sense of self, but in the latter disorder, a self-centered narrative exists that is coherent to the person but does not support reality. If mental health is defined as the ability to adapt to the different circumstances of life, people with narcissism cannot adapt and instead, develop a grandiose narrative to soothe the fragmented self.
  - Therapeutic interventions for narcissism focus on disrupting the narrative in a gentle way that allows patients to understand the model in which they currently experience the world and then reconstitute an adaptive narrative.
- An effective treatment approach is psychodynamic therapy, with a focus on a treatment contract and specific, explicitly agreed-upon goals. Try to focus more on the interaction with the patient than on the narrative content of the session. The therapy must focused on how the patient acts in therapy, and their adaptations and reactions, because these are the actions that negatively affect their relationships and daily lives.
- The biological part of a person is processed at the psychological level, so psychiatrists must be interested in psychological aspects of treatment.

References

Sharp C et al. The structure of personality pathology: Both general ('G') and specific ('S') factors? Abnorm Psychol. 2015 May;124(2):387-98.

Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry. 2009 May 1;166(5):530-9.

Caligor E et al. Narcissistic personality disorder: Diagnostic and clinical challenges. Am J Psychiatry. 2015 May;172(5):415-22.

Morey LC et al. Personality disorders in DSM-5: Emerging research on the alternative model. Curr Psychiatry Rep. 2015 Apr;17(4):558.

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Alberto J. Espay, MD, MSc, conducts a Masterclass lecture on treating patients with Parkinson’s-related psychosis from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Espay is professor of neurology at the University of Cincinnati. He also serves as director of the James J. and Joan A. Gardner Family Center Research Chair for Parkinson’s Disease and Movement Disorders.

And later, in the “Dr. RK” segment, Renee Kohanski, MD, asks you to think about some of the complex issues tied to getting treatment for people who are both homeless and have serious mental illness.

Treatment of Parkinson’s-related psychosis

Psychosis related to Parkinson’s disease (PD) is a common reason for hospitalization, institutionalization, and decline of patients with PD. The diagnosis of PD is required before the development of psychosis to diagnose patients with Parkinson's-related psychosis. Parkinsonism that appears after development of psychosis is Lewy body dementia.
Many factors influence the development of psychosis in PD. Extrinsic factors include medical illnesses or metabolic derangement causing delirium with psychosis; nonessential dopaminergic medications such as ropinirole and selegiline; anticholinergic medications such as benztropine, amantadine, and bladder antispasmodics; and insomnia. The last resort for treatment of psychosis is levodopa because patients will experience motoric decline and loss of functioning.
There are several mechanisms for psychosis to occur via the dopaminergic, serotonergic, and glutamatergic pathways; thus, three neurotransmitters – serotonin, dopamine, and glutamate – can be manipulated to treat psychosis. Quetiapine, clozapine, and pimavanserin are the three antipsychotics safe for use in Parkinson’s disease.
Clozapine is infrequently used, because of the risk of neutropenia and required blood work monitoring, but evidence shows that the benefits usually outweigh the risks of motor decline.
Quetiapine is commonly used, because it has a favorable effect on sleep and psychosis, but it negatively affects the movement disorder of Parkinson's disease.
Pimavanserin (Nuplazid), the only medication FDA approved for hallucinations and delusions associated with psychosis in Parkinson’s disease, is highly selective for the 5-HT2A receptor as both an inverse agonist and antagonist.
Primary adverse effects are peripheral edema and confusion, but overall the adverse effects profile is similar to that of placebo. In the pimavanserin clinical trials, a subset of patients worsened and experienced more visual hallucinations. In addition, pimavanserin can prolong the QT interval, so patients taking other QT-prolonging medications or who have cardiac comorbidities should be monitored with an EKG.
Post hoc data analysis from as pivotal phase 3 study suggests that patients with cognitive impairment and dementia may receive more benefit from pimavanserin.

References

Cruz MP. Pimavanserin (Nuplazid): A treatment for hallucinations and delusions associated with Parkinson’s disease. P T. 2017 Jun;42(6):368-71.

Cummings J et al. Pimavanserin: Potential treatment for dementia-related psychosis. J Prev Alzheimers Dis. 2018;5(4):253-8.

Huot P. 5HT2A receptors and Parkinson’s disease psychosis: A pharmacological discussion. Neurodegenerative Disease Management. 2018 Nov 19. doi: 10.2217/nmt-2018-0039.

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Michael A. Norko, MD, professor of psychiatry at Yale University in New Haven, Conn., spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about incorporating patients’ spiritual and religious histories into psychiatric evaluations.

Dr. Norko, lead author of a paper exploring whether religion is protective against suicide, sat down with Dr. Norris at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP.

Evidence, questions to consider about religion and spirituality

Various spiritual and religious factors are linked to decreased rates of suicide behaviors and attempts, including weekly attendance to worship services, personal beliefs about the preciousness of life, and commitment to a faith practice. Which specific parts of religious and spirituality are protective? Are the protective factors the social connection or the spiritual connection alone?
Those who attend worship services weekly are at lower risk of suicide. It’s unclear whether weekly attendance is a proxy for the social connectedness or for the level of internalization of the religious beliefs.
Commitment to a faith is measured by a consistent and strong belief in the faith tradition. Just because someone says they belong to a faith tradition does not automatically mean a person is at lower risk of suicide.
Strong alignment with the faith also is protective. Alignment is different from commitment, because if patients are doubting or their personal beliefs conflict with long-held religious traditions, this can increase patients’ suicide risk.

Questions to ask about spirituality and religion in clinical practice

A spiritual and religious history is essential to a psychiatric evaluation, because asking about religion lets the patient know that this is a welcome topic. Examples of questions a clinician can ask include: “Is there any faith tradition that you belong to? How important is your faith or beliefs? Is there anything about your religious beliefs you think are important to your mental health treatment?”

Difficult areas to navigate with religion and spirituality

Lack of expertise or personal experience with religion can be a barrier. It is important to remember that patients usually welcome curiosity about their religious beliefs and emotional lives. Clinicians need not be experts in religion, but they can be alert to the salient values and notice whether the person is struggling with certain beliefs. Clinicians also can encourage patients to talk to their clergy.
When someone asks a clinician, “What is your faith practice?” this can be approached as an informed consent question. The clinician can ask how talking about their own beliefs or faith practices will deepen and help the therapeutic work of the patient.
If a person is feeling let down by a certain failing of their religious community, therapy is a good place to explore what strengths and succor they had received from their religion. Therapy also can be used to guide patients toward additional places, or even substitutes, to meet their needs.
Understanding patients’ faith background and beliefs can help clinicians reframe certain crises, especially if the psychiatrist and therapist have talked discussed those crises with patients over time. It’s more useful to understand patients’ faith before the crisis, because grasping for a spiritual or religious answer at the last moment can feel inauthentic.

References

Norko et al. Can religion protect against suicide? J Nerv Ment Dis. 2017. Jan;205(1):9-14.

Kruizinga R et al. Toward a fully-fledged integration of spiritual care and medical care. J Pain Symptom Manage. 2018 Mar;55(3):1035-40.

Thomas LP et al. Meaning-centered psychotherapy: A form of psychotherapy for patients with cancer. Curr Psychiatry Rep. 2014 Oct;16(10):488.

Lawrence RE et al. Religion and suicide risk: A systematic review. Arch Suicide Res. 2016;20(1):1-21.

D’Souza R, George K. Spirituality, religion and psychiatry: its application to clinical practice. Australas Psychiatry. 2006 Dec;14(4):408-12.

FICA Spiritual History Tool: https://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool, which is based on Puchalski C and Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000 Spring;3(1):129-37.

George Washington University Institute for Spirituality and Health (GWISH): https://smhs.gwu.edu/gwish/

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Lorenzo Norris, MD, and Roger McIntyre, MD, talk about obesity, inflammation, and mental illness. The conversation, which originally dropped a few months ago, took place at the Focus on Neuropsychiatry 2019 meeting. The meeting was sponsored by Current Psychiatry and Global Academy for Medical Education.

The original podcast included robust Show Notes by Jacqueline Posada, MD. Also, you can watch the conversation between Dr. Norris and Dr. McIntyre on video or on YouTube.

Later, Renee Kohanski, MD, talks about different ways to think about resolutions and behavioral change.

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In this episode of the MDedge Psychcast, we revisit an interview that Lorenzo Norris, MD, MDedge Psychiatry editor in chief, conducted earlier this year by phone with two psychiatrists working in New Mexico.

Dr. Norris spoke with Caroline Bonham, MD, and Avi Kriechman, MD, about enhancing resilience in rural communities. Dr. Bonham is vice chair in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is assistant professor in that department, and a pediatrician who works on youth suicide prevention and school mental health.

Understanding risks of suicide in rural communities

Nationally, suicide rates have been going up across the United States, including in rural communities.
Paucity of mental health clinicians supporting youth and their families has implications for youth suicide.
Impact of structural poverty and the opioid epidemic also have implications for these rising rates.

Identifying resources within small, rural communities

Communities have resources that are not tapped into enough by clinicians, such as churches, teachers, and community health workers. Recent studies show that most communities have members who know people at risk and want to help.
It is important for clinicians to think outside of the box so that they help facilitate the use of natural resources/strengths that exist within small communities, such as food pantries that operate out of mental health centers, spiritual organizations, and aftercare programs in schools.

Building resilience among individuals

The literature shows that engaging people in a collaborative, transparent process of care is effective.
If community members who do not have problems, such as suicidality, physical ailments, or a severe mental illness, are taught to reach out, destigmatize, and facilitate treatment, the mental health outcomes of patients are better.
Concrete, feasible intervention would be to work with gun store owners about the risk factors for suicide, how to encourage people to seek help.
Some police departments provide education about the safe storage of firearms.

References

Curtin SC and Heron M. Death rates due to suicide and homicide among persons aged 10-24: United States, 2000-2017. NCHS Data Brief. 2019 Oct;(352):1-8.

Altschul DB et al. State legislative approach to enumerating behavioral health workforce shortages: Lessons learned in New Mexico. Am J Prev Med. 2018 Jun;54(6 suppl 3):S220-9.

Bonham C et al. Training psychiatrists for rural practice: A 20-year follow-up. Acad Psychiatry. 2014 Oct;38(5):623-6.

Kriechman A et al. Expanding the vision: The strength-based, community-oriented child and adolescent psychiatrist working in schools. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):149-62.

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Ruta Nonacs, MD, PhD, conducts a Masterclass lecture on treating women with postpartum depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Nonacs is a staff psychiatrist with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital in Boston.

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Features of postpartum depression

Postpartum depression (PPD) affects 10%-15% of women after delivery. For many women, their depression starts in the third trimester and worsens after delivery.
Unique symptoms of PPD include difficulties bonding with the baby, feeling like an inadequate mother, and experiencing severe sleep disturbance with anxiety and edginess. In a common scenario, the mother will not be able to sleep at night, though her baby is sleeping well. Anxiety is a common comorbidity, especially obsessive thoughts about the baby’s safety.

Treatment of PPD

Treatment in this population is complicated by many demands placed on a mother as the primary caregiver of an infant. The medication chosen must target depression and anxiety, improve sleep, yet not be too sedating.
The concentration of antidepressants in breast milk is low, but many women will defer treatment for their depression until they’ve stopped breastfeeding.
Treatment of mild PPD includes recruiting more support to help the mother with care of the infant and psychotherapy to identify stressors and coping skills. In moderate to severe PPD, antidepressants are needed. Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are the preferred treatments, and studies support the use of sertraline, fluoxetine, paroxetine, and venlafaxine at their standard dosages. SSRIs and SNRIs are compatible with breastfeeding, because the medications are detected in the breast milk at very low levels.
Brexanolone (Zulresso) is the only Food and Drug Administration–approved medication for postpartum depression. It is a neurosteroid and derivative of allopregnanolone, which is a positive allosteric modulator of the gamma-aminobutyric acid receptor. Brexanolone has low oral bioavailability and is administered only as a 60-hour infusion in a certified medical setting with continuous monitoring. The trials for brexanolone included women with moderate to severe PPD, and Hamilton Depression Rating Scale scores (HAM-D) scores ranging from 20 to 25. After the 60-hour infusion, 45% of the subjects with severe PPD in the brexanolone group achieved remission by the end of treatment, compared with 23% in the placebo group. Women retained the antidepressant effect at the 30-day follow-up. The results in the moderate PPD group were not as impressive; these women had a decrease in their depression HAM-D scores, but the antidepressant effect did not continue to the 30-day follow-up.
The FDA approval came with a Risk Evaluation Mitigation Strategy in place.

Currently, approximately 100 sites are ready to administer brexanolone; however, some obstacles remain:

Obstacles to using brexanolone

The medication costs more than $30,000 per infusion, and it is uncertain how much insurance will cover.
Since brexanolone is administered in hospital settings, women must be separated from their children for several days.
Breastfeeding must be stopped while women are on the medication because of the lack of data about excretion in breast milk.
Brexanolone is labeled as a Schedule IV medication because it has a similar mechanism of action to midazolam and diazepam. Likelihood of diversion is low, but some women with substance abuse histories might be concerned about this treatment.

References

Leader LD et al. Brexanolone for postpartum depression: Clinical evidence and practical considerations. Pharmacotherapy. 2019 Nov;39(11):1105-12.

Meltzer-Brody S et al. Brexanolone injection in postpartum depression: Two multicenter, double-blind, randomized, placebo-controlled, phase 3 trials. Lancet. 2018 Sep 22;392(10152):1058-70.

Nonacs R. A Deeper Shade of Blue: A Woman’s Guide to Recognizing and Treating Depression in Her Childbearing Years. New York, NY: Simon & Schuster; 2006.

Massachusetts General Hospital Center for Women’s Mental Health. womensmentalhealth.org

National Institutes of Health. Drugs and Lactation Database (LactMed).

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Roberto Lewis-Fernández, MD, returns to the MDedge Psychcast, this time to discuss ways to approach pharmacotherapy for Latino patients with depression. Previously, on episode 36 of the Psychcast, Dr. Lewis-Fernández discussed the role of cultural assessments in providing person-centered mental health care.

Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University and director of the New York state Center of Excellence for Cultural Competence and the Hispanic Treatment Program at the New York Psychiatric Institute, spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP.

And later, in the “Dr. RK” segment, Renee Kohanski, MD, asks whether some euphemisms that are becoming more common in society keep us from finding real solutions to problems.

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How Latino patients typically think of illness and medications

Commonly, patients of Latino descent seek mental health treatment after trying other interventions, such as talking with family, clergy, and primary care clinicians. Latino patients, similar to other patient populations, sometimes present with ambivalence about medications and concerns that the medications might be “fairly strong” or addictive. The need to take medications is seen as an admission of sorts that the presenting problem of depression or anxiety is serious.
Specifically, Latino patients are concerned about medications and risk of physical and psychological addiction and being reliant on a crutch. For example, a Latino patient might worry that by taking an antidepressant medication, they will lose their innate ability to improve on their own. This belief plays out when Latino patients stop medication prematurely, just as it begins to be effective, in order to “poner de mi parte,” which translates to “do my share.” The Latino culture puts weight on self-reliance.
Latino patients often look for flexibility in medications and express concern about their effect on the body. For example, some patients might want to take medication only on days in which they feel sick. Others might ask for days off from the medication to ensure that the body does not weaken from being dependent on medications.
Natural remedies often are favored by Latino patients. In some Latino communities, there might be natural pharmacies and “botanicas,” which provide herbal and vitamin remedies. Natural medicines are viewed as “gentle” and more in line with what the body needs.
Psychotherapy for the treatment of mild depression often is favored by patients who want to use therapy before medications. Latino patients usually prefer more "advice"-driven psychotherapy that focuses on problem solving.

Possible structural barriers to treating Latino patients

Common structural barriers to accessing care include limited time to make appointments because of work and family obligations as well as a fragmented health care system with ever changing clinicians.
Stigma and concerns about “harm to the body” can prove to be barriers.

How clinicians might work with Latino patients

Be open to being flexible to patients’ requests, such as the desire to perhaps skip a day each week or even stop medications. Exerting clinical authority based on biological understanding of the medication and diagnosis can backfire and can result in patients stopping the medication altogether.
Understand different conceptions in the Latino community about how and when emotions should be expressed. The “ataque de nervios” (“attack of nerves”) presented in the DSM-5 as a culture-bound syndrome is indicative of the Latino attitude that emotions are meant to be expressed but also controlled. So “un ataque de nervios” represents a situation that is so overwhelming that emotions take over, such as an attack and cannot be controlled.
Know that warmth is more important than expertise in the eyes of some Latino patients.

References

Vargas SM et al. Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy. Transcult Psychiatry. 2015 Apr;52(2):244-73.

Lewis-Fernández R et al. Impact of motivational pharmacotherapy on treatment retention among depressed Latinos. Psychiatry. 2013 Fall; 76(3):210-2.

Moitra E et al. Examination of ataque de nervios and ataque de nervios like events in a diverse sample of adults with anxiety disorders. Depress Anxiety. 2018 Dec;35(12):1190-7.

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Martha Sajatovic, MD, conducts a Masterclass lecture on older-age bipolar disorder from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Sajatovic is professor of psychiatry and of neurology at Case Western Reserve University in Cleveland. She also directs the Neurological and Behavioral Outcomes Research Center at University Hospitals Cleveland Medical Center.

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Conceptualizing OABD

Older–age bipolar disorder (OABD), defined as a person aged 60 years or older with bipolar disorder, makes up one-quarter of bipolar patients. It is a heterogeneous population that includes early- and late-onset disease. Late onset is diagnosed when a person has a manic or hypomanic episode at or after the age of 50 years.
Bipolar depression in later life has long been seen as a “special population,” and the treatment has been extrapolated from larger clinical trials of younger patients.
Late–onset bipolar disorder usually has attenuated manic episodes and depressive episodes are prolonged and severe. In OABD, the patients are more likely to have multiple morbidities, which makes medication management more complex.
People with bipolar disorder lose 1-2 decades of life, compared with the general population.
No medications are specifically approved by the Food and Drug Administration for bipolar disorder or bipolar depression in older adults. However, the treatment follows general geriatric psychiatry principles: Start low and go slow.

International guidelines on treating bipolar disorder

Starting low means using half or even less of the recommended dose that a clinician would use in mixed-aged populations. Titrate slowly to allow the person time to acclimate to side effects that usually resolve. Bipolar disorder is a chronic disease, so medication adherence is paramount. Adherence can be jeopardized when a person experiences excessive side effects from the beginning of treatment.
First-line treatment for bipolar depression in OABD include lurasidone (Latuda) or quetiapine (Seroquel) with low dosing and slow titration. This recommendation is supported by data from a post hoc analysis of the clinical trial data of lurasidone for bipolar depression.
Lithium is also recommended and underused. The level should be lower for OABD; an appropriate target for older adults with bipolar disorder is 0.4-0.8 mEq/L, especially in people who are older and frailer.
Lamotrigine (Lamictal) also is helpful and fairly well tolerated.
Clinicians need to be attentive to a patient’s medical comorbidities and psychosocial support to enhance adherence and improve outcomes. This approach would entail working closely with primary care clinicians and using an integrative approach as the medical comorbidities will influence the success of bipolar treatment.

References

Sajatovic M and Chen P. Geriatric bipolar disorder. Psychiatr Clin North Am. 2011 Jun 3;34(2):319-33.

Eyler LT et al. Understanding aging in bipolar disorder by integrating archival clinical research datasets. Am J Geriatric Psychiatry. 2019 Oct;27(10):1122-34.

Shulman Kl et al. Delphi survey about using lithium in OABD. Bipolar Disord. 2019 Mar;21(2):117-23.

Forester BP. Safety and effectiveness of long-term treatment with lurasidone in older adults with bipolar depression: Post hoc analysis of a 6-month, open-label study. Am J Geriatr Psychiatry. 2018 Feb;26(2):150-9.

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This week, we are replaying five interviews that MDedge Psychiatry editor in chief Lorenzo Norris, MD, conducted at the 2019 American Psychiatric Association annual meeting.

Dr. Norris spoke with Igor Galynker, MD, (Mount Sinai Beth Israel, N.Y.) about identifying suicide crisis syndrome; Jonathan M. Meyer, MD, (University of California, San Diego) about prescribing clozapine for treatment refractory schizophrenia; Robert M. McCarron, DO, (University of California, Irvine) about psychiatry and primary care; Cam Ritchie, MD, MPH, about preparing patients for disruptions in psychiatric medications; and Richard Balon, MD, (Wayne State University, Detroit) about overcoming resistance to prescribing benzodiazepines for patients with serious mental illnesses.

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Jack Drescher, MD, returns to the MDedge Psychcast, this time to discuss ethical issues raised by the treatment of gender-variant prepubescent children with MDedge Psychiatry editor in chief Lorenzo Norris, MD. The two spoke at the 2019 Group for Advancement in Psychiatry (GAP) meeting in White Plains, N.Y.

Dr. Drescher is a Distinguished Life Fellow of the American Psychiatric Association, past president of GAP, and a past president of the APA’s New York County Psychiatric Society. He has a private practice in New York.

And later, in the “Dr. RK” segment, Renee Kohanski, MD, says artificial intelligence is much more powerful than we imagined.

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Three approaches used to address gender-variant children

Despite the acceptance of gender dysphoria as a diagnosis with standardized treatments, the treatment of gender-variant prepubescent children remains a controversial area. There are several treatment approaches regarding how and when a child should have a social transition to their desired gender.

The oldest treatment approach is based on research that shows that most children will grow out of their gender dysphoria when the therapies applied help the children get used to living in the body of their assigned gender. Essentially, this approach discourages public or private social transition.
The Dutch Protocol is based on research that shows the difficulty in predicting which children will continue to have gender dysphoria and which will not. Some children will have persistent gender dysphoria and become transgender; some may become homosexual; and others may identify with their own biological sex. The Dutch approach encourages children to have cross-gender interests and to privately identify with their desired gender, but there is not a public social transition.
- Families and clinicians use watchful waiting to see whether the gender dysphoria persists. It’s based on the idea that one cannot predict the future and so parents accept the child wherever they are.
The final approach focuses on social transition without a medical or surgical treatment. Therefore, if the child’s gender dysphoria desists, they can “detransition,” since there was no medical intervention.
- The gender-affirmative approach, mostly found in the United States, presupposes that it is possible to identify which children will persist in their transgender presentations and encourages a public, social transition to living as their identified gender. In case the child “makes a mistake,” they can transition back to their biological sex.
- A social transition occurs when a child, with the help of clinicians, explains to the family that they believe the gender dysphoria is going to last and that the child should be allowed to present publicly as their desired gender. This includes communicating with the school, family, and friends to help the child to be treated respectfully in the gender they desire.

Treatments for gender-variant children

Puberty suppression is a medical treatment used by physicians in all three approaches. These medications block sex hormone action and are used to delay puberty and prevent the development of undesired secondary sex characteristics of the biologic sex. Adolescents frequently experience anxiety, depression, even suicidal ideation during this period because they feel pressured to choose their gender and avoid developing the secondary sexual characteristics of their biological sex.
Social changes are outpacing the science. More frequently, children show up at gender clinics already socially transitioned by their parents; these children outnumber the subjects in the persist and desist literature. Regardless of the approach used, parents and clinicians should try to act on the exigent circumstances to relieve the distress of the child.
Patients who are transitioning should be referred to a specialist, because this is a sensitive topic and treatment requires expertise.

References

Shumer DE et al. Advances in the care of transgender children and adolescents. Adv Pediatr. 2016 Aug;63(1):79-102.

Reed GM et al. Disorders related to sexuality and gender identity in the ICD-11: Revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21.

Zraick K. Texas father says 7-year-old isn’t transgender, igniting a political outcry. New York Times. 2019 Oct 28.

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Michelle Magid, MD, conducts a Masterclass lecture on botulinum toxin for depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Magid is associate professor University of Texas in Austin, and associate professor of Texas A&M University in College Station. She disclosed serving as a speaker for Ipsen, maker of Dysport (abobotulinumtoxinA, or ABO), and as a consultant for Allergan, maker of Botox (onabotulinumtoxinA).

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This week in psychiatry:

Conduct disorder in girls gets overdue research attention
by Bruce Jancin

The physiological and emotion-procession abnormalities that underpin conduct disorder in teen girls are essentially the same as in teen boys. however, the clinical presentation of conduct disorder in the two groups is often different.

What we know about botulinum toxin

Botulinum toxin is the product of Clostridium botulinum. The neurotoxin inhibits the release of acetylcholine, resulting in flaccid muscle relaxation. Its clinical use started in 1989 to treat strabismus (crossed eyes) and blepharospasm, a dystonic reaction in the eyes. Currently, botulinum is a Food and Drug Administration–approved treatment of chronic migraine in adults.
For use in depression, 30-40 units of botulinum toxin is injected into the glabellar region of the face (the forehead). A purported mechanism of action of botulism for depression includes the “facial feedback hypothesis,” in which the activation of muscles of facial expression, consciously or unconsciously, influences emotions.
Botulinum toxin for depression is an off-label treatment with four case series, five randomized, controlled studies, and a phase 2 trial by supported by Allergan.

New findings on use of botulinum toxin for depression

Magid and colleagues completed a pooled analysis of three randomized, controlled trials totaling 134 patients. Fifty-nine people were included in the botulinum toxin intervention group with a Beck Depression Inventory (BDI) score of 29, and 75 individuals in the placebo group with BDI of 26. In each group, 64% of patients were continued on other medications for depression, and the groups had similar histories of long-standing depression.
In the botulinum toxin group, 52% had a response to the intervention, with an at least 50% reduction in their baseline depression scores, compared with a limited response in the placebo group.
In the pooled analysis, Dr. Magid’s group analyzed whether the cosmetic effect of botulinum toxin could be a confounding factor. The investigators ruled out that effect by using a subanalysis to evaluate whether the decrease in wrinkles correlated with decrease in depression, and it did not.
Allergan moved forward with a phase 2 proof-of-concept trial; the results were mixed. The endpoint was response rate in Montgomery-Åsberg Depression Rating Scale (MADRS) at week 6. With a 30-unit Botox dose, there was a statistically significant decrease in MADRS at week 9, but not at week 6. There was no statistically significant divergence in data between the placebo and intervention group with the 50-unit dose. Given the response rate at week 9, Allergan is proceeding with a phase 3 trial.
The cost is about $400 per treatment, and the treatment is given three to four times a year, which makes the cost comparable to that of other psychopharmacologic treatments. Adverse events are mild and include headache and local site irritation. In the current studies, botulinum treatment has been used as both monotherapy and augmentation; however, there are not enough data to know whether one is more effective than the other.
In conclusion, burgeoning psychopharmacology research on treatments such as botulinum toxin for depression and novel medications, such as esketamine and brexanolone, broaden our understanding of the etiology of depression. This research is generating novel modes of treatment that will help more patients with refractory illness.

References

Magid M et al. Treating depression with botulinum toxin: A pooled analysis of randomized controlled trials. Psychopharmacology. 2015 Sep;48(6):205-10.

Magid M et al. Treatment of major depressive disorder using botulinum toxin: A 24-week randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2014 Aug;75(8):837-44.

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Andrew Penn, MS, NP, conducts a Masterclass lecture on psychedelic-assisted psychotherapy from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Mr. Penn, a psychiatric nurse practitioner, is associate clinical professor of community health systems in the School of Nursing at the University of California, San Francisco.

Later, Dr. Renee Kohanski is back – this time to discuss the need to call out the truth when we see it.

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Reemergence of MDMA for PTSD and psilocybin for MDD

Psychedelic-assisted psychotherapy is currently being investigated with 3,4-methylenedioxy-methamphetamine (MDMA) for treatment-resistant post-traumatic stress disorder (PTSD) and psilocybin for the treatment of major depressive disorder (MDD). The use of these compounds would be highly regulated. These are not medications that would be dispensed for a patient to take home.
Both would be given in the clinical setting of one or more psychotherapy sessions with two therapists who would continue to work with the patient over time.
MDMA was first patented by Merck in 1912, synthesized again in the 1970s, and used by psychotherapists to assist treatment. However, its recreational use spread, leading to its classification as a Schedule I controlled substance, thus prohibiting research or use in a medical setting.
Lobbying through the Multidisciplinary Association for Psychedelic Studies, also known as MAPS, managed to bring MDMA into phase 3 clinical trials, and in 2017 the Food and Drug Administration granted breakthrough therapy designation for its use with psychotherapy for PTSD.
MDMA is a potent releaser of serotonin, oxytocin, and prolactin, which in combination, allow the patient to feel less fear, trust the psychotherapist more, and overcome the defenses blocking them from talking about traumatic experiences. MDMA permits patients to stay in the optimal arousal zone to discuss the traumatic event. After the psychedelic-assisted session, patients continue to process memories and sequelae of the event and integrate changes into their lives to overcome trauma.
If MDMA is approved by the FDA, it would be available only under a REMS, or Risk Evaluation and Mitigation Strategy, or drug safety program.
Psilocybin is a partial agonist on 5-HT2A serotonin receptors. The brain of a severely depressed person is extremely rigid with limitations on the usual predictive capacity of the human brain. Psilocybin facilitates plasticity to “reset” and see a situation as it truly is, rather than through the rigid cognitive distortions of depression.
Although MDMA and psilocybin are controlled substances, we can think of these medications like anesthetics, which are drugs that can be prescribed in clinical settings under supervision only.
These are old compounds used in a novel manner that can reduce suffering for patients who have not responded to the current modes of therapy for PTSD and MDD.

References

Mithoefer MC et al. MDMA-assisted psychotherapy for treatment of PTSD: Study design and rationale for phase 3 trials based on pooled analysis of six phase 3 randomized trials. Psychopharm (Berl). 2019 Sep;236(9):2735-45.

Carhart-Harris RL et al. Psilocybin with psychological support for treatment-resistant depression: An open-label feasibility study. Lancet. 2016 Jul 1:3(7):619-21.

Pollan M. The Trip Treatment. New Yorker. 2015 Feb 9.

Cooper A. Psilocybin sessions: Psychedelics could help people with addiction and anxiety. 60 Minutes. 2019 Oct 13.

Sessa B. “The Psychedelic Renaissance: Reassessing the Role of Psychedelic Drugs in 21st Century Psychiatry and Society.” London: Muswell Hill Press, 2012.

Usona Institute: News on Psychedelics

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Mark S. Gold, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to discuss the intersection between the rise in suicide and the opioid crisis in the United States.

Dr. Gold is adjunct professor of psychiatry at Washington University in St. Louis. He also serves on the editorial advisory board of MDedge Psychiatry. Previously, Dr. Gold served as distinguished professor and chairman of the psychiatry department at the University of Florida, Gainesville.

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Timestamps:

This week in Psychiatry (01:11)
Interview with Dr. Gold (03:40)

This week in Psychiatry

Demeaning patient behavior takes an emotional toll on physicians
by Steve Cimino

Suicide and the opioid crisis

In 2017, more than 70,000 people died from overdose, and 47,600 of those deaths involved prescription or illicit opioids. Most coroners list the deaths as “accidental” unless there is a suicide note or the deceased spoke about an intent to die.
- Chronic opioid self-administration changes the brain. The person becomes less high and more depressed over time.
The prevalence of depression is at least 50% in those with opioid use disorder. Some experts estimate that up to 30% of opioid overdoses are intentional and count as suicide. A person with opioid use disorder has 13 times the risk of attempting and completing suicide, compared with the general population.
Until recently, psychiatric evaluations and suicide assessments were not routine in the chain of events from opioid use to overdose to transition to medication-assisted treatment (MAT).
People whose overdoses are reversed by naloxone are prime candidates to ask whether an overdose was accidental. In an emergency department in Flint, Mich., 30% of overdose patients rescued with naloxone described their overdose as a suicide attempt.
Although some people revived with naloxone are angry, it is important to consider irritability and anhedonia that come from giving an opioid antagonist during a high.

Future of treatments in the opioid crisis

Much is still unknown. For example, there are no MAT options for either stimulant or cannabis use disorders, which are implicated in the morbidity and mortality of the overdose crisis. More research is needed to determine how long patients should be on MAT and when their brains “reset” after addiction.
Also, in the pipeline is advanced imaging showing how drug use changes a person’s neurocircuitry and genetics. The OPRM1 gene, for example, is a polymorphism whose presence predicts whether a person is more likely to become addicted after their first use of opiates and determines treatment resistance to recovery.
In the next year, efforts aimed at preventing overdoses and investigating the risk and rates of suicide are likely to continue.
If every patient with a high-dose opioid prescription were offered naloxone, nearly 9 million more naloxone prescriptions could have been dispensed in 2018. So, we might see state-level policies that seek to increase naloxone prescriptions to patients based on morphine equivalents.
Looking beyond overdoses and relapse prevention, the National Institute on Drug Abuse (NIDA) has identified novel targets focused on regenerating the reward system in order to return the brains of people with addictions to premorbid function after years of abuse.

References

Volkow N and Gordon J. Suicide deaths are a major component of the opioid crisis. NIDA. 2019 Sep 19.

Oquendo MA and Volkow ND. Suicide: A silent contributor to opioid-overdose deaths. New Engl J Med. 2018;378:1567-9.

5-point strategy to combat the opioid crisis. U.S. Department of Health & Human Services.

Still not enough naloxone where it’s most needed. Centers for Disease Control and Prevention. 2019 Aug 6.

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Dinah Miller, MD, returns to the MDedge Psychcast, this time to do a Masterclass lecture on involuntary commitment.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care.” She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. In addition, Dr. Miller is a columnist for Clinical Psychiatry News and serves on the editorial advisory boards of CPN and MDedge Psychiatry.

Timestamps:

This week in Psychiatry (00:37)
Masterclass lecture (02:00)
Dr. RK (40:50)

This week in Psychiatry:

Duloxetine 'sprinkle' launches for patients with difficulty swallowing
by Christopher Palmer

Drizalma Sprinkle (duloxetine delayed-release capsule) has launched for the treatment of various neuropsychiatric and pain disorders in patients with difficulty swallowing.

Overview of the involuntary commitment debate

Four main controversies surround involuntary treatment

First, standards for involuntary commitment vary by state; most states require that a person be diagnosed with a mental illness and is imminently dangerous to self or others. Some states extend their parameters to include those who are “gravely disabled” or need of psychiatric treatment.
Second, as involuntary beds decrease, there is no place for involuntary treatment.
Third, involuntary treatment includes outpatient civil commitment (OCC), and policy groups differ in their opinions of involuntary inpatient and outpatient treatments. Laws defining the need and amount of mandated outpatient services vary, based on geographical area. Also, outpatient commitment is difficult to enforce.
The final controversy addresses a patient’s right to refuse treatment with medication.

Groups hold wide-ranging positions along policy spectrum

The Treatment Advocacy Center is a strong proponent of involuntary hospitalization. The group advocates for more state hospital beds in the United States, monitors the number of state hospital beds, proposes an involuntary standard of based on need for treatment, and argues that anosognosia justifies involuntary hospitalization.
The National Alliance on Mental Illness (NAMI) is a grassroots organization founded by parents of individuals with serious mental illness (SMI) and initially represented a view in favor of involuntary hospitalization based on protecting those with SMI. However, as NAMI has grown to represent a broad swath of people with mental illness, the organization has struggled with whether it represents the interests of people with SMI only or a broader group of people with any mental illness.
The American Psychiatric Association holds the middle ground, identifying dangerousness as the standard of involuntary care. In 2015, the APA released a carefully worded stance in support of outpatient commitment on a limited basis.
Organizations strongly against involuntary treatment include the Bazelon Center for Mental Health Law, whose mission is to protect and advance the rights of adults and children with mental illness. The Bazelon Center opposes anything that restricts the rights of people with mental illness.
The recovery movement, which developed as a backlash against the perceived paternalism of psychiatry, prioritizes the mental health consumer’s autonomy with an emphasis on peer support and being proactive in health care choices.
On the antipsychiatry spectrum are the groups MindFreedom International and the Citizens Commission on Human Rights. Both of those groups oppose involuntary treatment.

Violence and mental illness

In the community, psychiatric illness is thought to be responsible for 4% of total violence and 7%-10% of murders.
The MacArthur Foundation investigated rates of violence in people with mental illness 10 weeks after an inpatient hospitalization. It found that, compared with community samples, people with mental illness following hospitalization have higher rates of violence. The rate of violence was 8% for people with schizophrenia, 15% for bipolar disorder, 18% for depression, and 23% for personality disorder. Twenty weeks after discharge, patients with more treatment contacts were less likely to be violent.
Mental illness does not belong in conversations about violence prevention because violence is more strongly correlated with substance use, anger, and early exposure to violence. Thus, mass murder cannot be prevented with forced care or institutionalization.
The case is less clear for involuntary treatment for suicide prevention. For example, we know that two-thirds of gun deaths are suicides; however, we do not have statistics to elucidate whether involuntary hospitalization would prevent suicides.

Final thoughts

Involuntary hospitalization should be the treatment choice of last resort. A psychiatrist should pursue careful assessment with as many sources as possible and strongly suggest alternatives, such as voluntary hospitalization.
Involuntary hospitalization could be less traumatizing by implementing steps such as reducing forced treatments, minimizing seclusion and restraints, asking patients for feedback at the end of their stays, and acknowledging that involuntary treatment is difficult.
Involuntary care would be less necessary if voluntary care were easier to access earlier in an illness to avoid crisis and hospitalization.

References

Miller D and Hanson A. “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

Torrey EF et al. The MacArthur Violence Risk Study revisited: Two views ten years after its initial publication. Psychiatr Serv. 2008 Feb 1;59(2):147-52.

Testa M and West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010 Oct;7(10):30-40.

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Kent A. Kiehl, PhD, joins host Lorenzo Norris, MD on the MDedge Psychcast to discuss the use of MRI scans to provide information about the brains of people who exhibit antisocial behaviors. The goals are to use the information to treat patients and prevent violent crimes.

Timestamps:

This week in Psychiatry (00:33)
Meet the guest (03:35)
Interview (04:25)
Credits (54:10)

Dr. Kiehl is professor of psychology, neuroscience, and law at the University of New Mexico, Albuquerque. He also codirects a nonprofit mental health research institute called the Mind Research Network, also in Albuquerque. He also helps run a for-profit consulting firm that helps attorneys do better science, called MINDSET.

This week in Psychiatry:

Suicide attempts up in black U.S. teens
by Randy Dotinga

Overall rates of suicide dipped from 1991 to 2017, according to research published in Pediatrics. However, the rate of suicide attempts grew slightly in black adolescents during that time.

SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI: 10.1542/peds.2019-1187.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Brain imaging can support diagnoses

Dr. Kiehl works with cutting-edge technology using noninvasive structural and functional brain imaging; machine learning, such as artificial intelligence; and algorithms to evaluate forensic patients and understand psychopathology, predict outcomes, and measure the impact of interventions. Dr. Kiehl and his team travel to prisons across the country with two mobile MRI units imaging incarcerated individuals and forensic patients.
More and more, brain imaging is considered in capital cases, because MRI provides valuable information for defense attorneys and prosecutors. For example, a man was charged with murder and his MRI supported a diagnosis of frontotemporal dementia with a behavioral variant, so he was able to plead not criminally responsible based on his illness – and was sent to a state mental hospital rather than to death row. The case of John W. Hinckley Jr., who shot former President Ronald Reagan and his press secretary, James Brady in 1981, was an initial case in which neuroscience and imaging influenced the verdict. The shooter’s brain imaging showed enlarged ventricles and cortical atrophy, which supported a diagnosis of schizophrenia – particularly when compared with the imaging of age-matched controls.
Structural and functional MRI is an adjunct to neuropsychological tests. Neuroscientists are elucidating patterns through artificial intelligence and algorithms that can be useful to civil and criminal cases.
For example, age is considered a strong predictor of antisocial behaviors. To enhance accuracy, Dr. Kiehl’s team has developed a neuroprediction model in which MRI quantifies brain age, which correlates closely with cognitive testing scores. So, brain age might be more useful for predicting behavior than chronological age. This study used more than 1,000 imaging studies of inmates. The data were analyzed using an algorithm called independent component analysis, which evaluates distinct neural circuits to identify components that predict age. In the next step of analysis, the algorithm identifies patterns associated with reoffending. Younger brain age in the anterior temporal lobe and orbitofrontal cortex – brain areas associated with decision making – accurately estimates the risk of reoffending better than just chronological age.
Based on an understanding of brain plasticity, dogma suggesting that people who commit violent crimes cannot be changed should be challenged. A group at the University of Wisconsin, Madison, was asked to create an evidence-based, multimodal treatment program for the hardest-to-treat violent juvenile offenders. The program, which includes interventions such as multisystemic family therapy and positive reinforcement contingency treatment, resulted in a decrease in reoffending and violent crimes in participants who received 10 months of treatment. Dr. Kiehl’s group followed up with those juvenile boys using MRI to evaluate what had changed in their brains, how much treatment is required, and how or whether those brain changes can be reinforced. Reduction in incarceration costs is a return on investment for the states that fund those types of programs.

Take-home points

If scientists can identify useful interventions and identify brain changes though imaging, perhaps science can affect outcomes such as societal violence and incarceration rates.
Implementation is the primary short-term obstacle. This type of research needs more funding and institutional change to identify programs that work.
The brain has an incredible amount of plasticity, which translates into opportunities for change.

References

The Mind Research Network

Kiehl KA. The Psychopath Whisperer: The Science of Those Without Conscience. Random House, 2014.

Kiehl KA et al. Age of gray matters: Neuroprediction of recidivism. Neuroimage Clin. 2018;19:813-23.

Steele VR et al. Machine learning of structural magnetic resonance imaging predicts psychopathic traits in adolescent offenders. Neuroimage. 2017 Jan 15;145(Pt B);265-73.

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The Psychopath Whisperer: The Science of Those Without Conscience

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Susan Hatters Friedman, MD, returns to the MDedge Psychcast to join host Lorenzo Norris, MD, to discuss postpartum psychosis.

Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman and colleagues recently wrote an article published in Current Psychiatry examining this topic, Postpartum psychosis: Protecting mother and infant.

Timestamps:

This week in psychiatry (01:09)
Interview (05:07)
Dr. RK (22:07)

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Overview of postpartum psychosis

Postpartum psychosis is a medical emergency with a fulminant development occurring within 1-4 weeks after delivery.
Onset is usually 3-10 days postpartum, and women experience a spectrum of symptoms from psychosis to dysphoric mania and confusion. Many women who experience postpartum psychosis do not have a past psychiatric history, although they might go on to develop bipolar disorder.
Symptoms change quickly, with risks of devastating consequences. A woman with postpartum psychosis might minimize or even conceal her symptoms to avoid being separated from her child or out of fear that her child will be taken away. Collateral information is extremely important.
A woman is at the greatest risk of developing a mental illness in the period around childbirth. The rate of postpartum depression is 1 in 9, and the baseline rate of postpartum psychosis is 1/500. Women with bipolar disorder (which may be undiagnosed until the postpartum psychosis) or a previous episode of postpartum psychosis are at highest risk of postpartum psychosis.

Prevention and intervention

Clinicians must be proactive with their psychoeducation about pregnancy, contraception, and the natural course of mental disorders during pregnancy and postpartum. If a patient with bipolar disorder is of childbearing age, the clinician should consider having her on medications that are relatively safe during pregnancy. In 2011, 45% of pregnancies in the United States were unintended; thus, preconception counseling is necessary.
Medications for bipolar disorder can help prevent postpartum psychosis. Other preventive measures include using sleep strategies after childbirth, such as arranging support to assist at night and weighing the risks of breastfeeding. Breastfeeding can lead to sleep deprivation, which in turn, increases the risk of decompensation.
If a woman wants to breastfeed, the psychiatrist should be in touch with the pediatrician and plan for breastfeeding by having the mother on medications that are safe for breastfeeding.
Involuntary hospitalization might be required if the postpartum psychosis puts the mother or child at imminent risk of harm. Family and nonpsychiatrists on the health care team might be resistant to psychiatric hospitalization because it would mean separating the mother from the child.
Psychiatrists can broach resistance by explaining the details of a thorough risk assessment and emphasizing that, while bonding is important, the hospitalization is meant to prevent the worst outcomes of suicide or infanticide.

Review of key points

Postpartum psychosis can present with mood symptoms or delirium, so those signs should make a clinician vigilant for postpartum psychosis.
The symptoms of postpartum psychosis change rapidly with escalating danger, such as infanticide and suicide, so collateral from family and speedy treatment are essential.
Focused early collaboration and education with team member such as ob.gyns. and pediatricians help make future interventions go more smoothly.

References

Friedman SH et al. Postpartum psychosis: Protecting mother and infant. Curr Psychiatr. 2019 Apr 1;18(4):13-21.

Sit D et al. A review of postpartum psychosis. J Womens Health (Larchmt). 2006 May;15(4):352-68.

Harlow BL et al. Incidence of hospitalization for postpartum psychosis and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry. 2007;64(1):42-8.

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Susan Hatters Friedman, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about family murder.

In addition, Dr. Hatters Friedman is editor of Family Murder: Pathologies of Love and Hate, which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Overview of family murder

Family murder is defined as situations in which any member of a family kills another family member. It encompasses a wide scope of violence that includes intimate partner homicide; infanticide, including purposeful feticide; neonaticide (murder in first day of life); siblicide; and parricide (a child killing a parent).
The book, Family Murder: Pathologies of Love and Hate, discusses the epidemiology and public health implications of family murder, various motivations, and pertinent psychiatric assessments, including risk assessments and sanity evaluations. It was written to prompt better screening and risk assessments, with the goal of prevention.

Motivating factors leading to murder

Phillip J. Resnick, MD, who also works in forensic psychiatry at Case Western, identified five main motives of parent-child violence.

Fatal maltreatment is the result of fatal neglect or abuse by a parent. This type of family murder is common and is most likely to be prevented, especially with intervention by Child Protective Services.
Altruistic murder occurs in three categories in which a parent wants to spare a child from perceived suffering:
Psychotic parents with delusions about their children being harmed.
Murder-suicide, such as when a severely depressed and suicidal parent kills their child to avoid leaving them without a parent after their suicide.
Parents who kill a child with serious, chronic physical illness as a means of “saving” the child from a “worse” fate.
Acutely psychotic murder occurs in the context of serious mental illness such as schizophrenia, bipolar disorder, or postpartum psychosis. Preventing this type of murder means monitoring the content of delusions and hallucinations related to family members. The Andrea Yates murders are a prime example of this type of murder.
Unwanted child motive is most common in neonaticide cases. The child is considered a hindrance to something the parent wants, such as a relationship. To screen for this risk, physicians can ask whether the pregnancy was planned and observe the interaction between child and parent, especially during the first hours to days of life.
Partner revenge is rare but is most likely to occur in context of a custody battle, with one partner seeing murder as a means of revenge. Psychiatrists can observe interactions between partners and inquire about threats from partners.

Screening and preventing violence

Psychiatrists can screen for violence by asking: “How are disagreements handled in your family?” This broad, neutral question elucidates family dynamics about partner violence, anger, and negative parental practices. It can generate information aimed at preventing fatal outcomes.
Strong human emotions, such as anger, jealousy, and pride, combined with risk factors such as a history of violence and access to weapons, drive family murder.
Psychoeducation about childhood development can decrease the risk of violence, especially in the fatal maltreatment category.

Addressing countertransference issues

Family murder stimulates strong countertransference in response to the perpetrator. Working as a team can diffuse these emotions and allows a venue for processing.
Building rapport with patients and recognizing their humanity by using phrases such as “When he died,” rather than “When you killed him.”

References

Family Murder: Pathologies of Love and Hate. Group for the Advancement of Psychiatry, 2018.

Hatters Friedman S. Filicide-suicide: Common factors in parents who kill their children and themselves. J Am Acad Psychiatry Law. 2005 Jan. 33(4):496-504.

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Henry Nasrallah, MD, was the first-ever guest on the MDedge Psychcast. In a three-part series, he joined Lorenzo Norris, MD, host of the Psychcast and editor in chief of MDedge Psychiatry, to talk about schizophrenia. In this throwback episode, the three-part conversation has been edited together into one episode.

Part I: Etiology, presentation, and recent advances
Part II: Manifestations; treating early
Part III: Treatment of first-episode schizophrenia

In part I, Dr. Nasrallah and Dr. Norris talk about the etiology, presentation, and the recent advances in how schizophrenia is conceptualized.

In part II, the two discuss the need for clinicians to treat the schizophrenia as early in the disease process as possible.

In part III, the conversation continues, as they talk about treatment of a patient's first episode of schizophrenia.

Henry Narallah, MD, is Sydney W. Souers Endowed Chair and professor and chairman of psychiatry and behavioral sciences at Saint Louis University. He also is editor in chief of Current Psychiatry.

You can read some of Dr. Nasrallah's work in Current Psychiatry here.

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Karl Doghramji, MD, is professor of psychiatry with secondary appointments in neurology and medicine at Thomas Jefferson University in Philadelphia. He also directs the Sleep Disorders Center at Thomas Jefferson.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Classification and consequences

Insomnia is defined by the DSM-5 as dissatisfaction with sleep quantity or quality, difficulty falling asleep or staying asleep, or both. The symptoms need to occur at least three times per week for more than 3 months and cause dysfunction or distress in the patient.
20%-30% of the population reports insomnia; within inpatient psychiatry populations, the rates rise to up to 80%.
Insomnia is thought to be caused by central nervous system hyperarousal or hyperactivity of unclear etiology, and there is evidence of genetic vulnerability.
Insomnia is associated with significant impairments, such as diminished ability to enjoy life and sleep during inappropriate times (i.e., while driving or in occupational settings). In addition, insomnia confers increased risk for chronic illnesses such as major depressive disorder, substance use disorder, as well as diabetes, hypertension, and dementia.

Treating insomnia

It is best to first treat the comorbidities of insomnia, such as mood disorders and anxiety, and then target insomnia with both behavioral modifications and medications. When prescribing medications, choose a pharmacologic agent that targets the period of sleep difficulty.
Evaluation of insomnia must examine the dimensions of sleep, including falling asleep (sleep initiation), compared with staying asleep (sleep maintenance).

Behavioral techniques

Stimulus control therapy: If a person is unable to fall asleep within 20-30 minutes, either at initiation or in the middle of sleep cycle, he/she should get out of bed and do something outside of the room and return to bed only when feeling sleepy.
Relaxation therapies, such as progressive muscle relaxation, can improve sleep if performed once a week for 12 weeks.
Sleep hygiene improvements, such as addressing late caffeine consumption, room brightness, and daytime napping can mitigate insomnia.

Pharmacologic interventions

Over-the-counter options include valerian root and histamine1 antagonists, such as diphenhydramine and melatonin. Melatonin is modestly effective at low doses, though the effects have not panned out in meta-analyses. At low doses, melatonin may increase total sleep time or improve sleep initiation by a few minutes. Watch out for adverse effects with long-term use of melatonin, such as disruption of other receptors, decreased fertility, and altered efficacy of chemotherapeutic agents.

Prescription drugs approved by the Food and Drug Administration

Benzodiazepines approved for insomnia include flurazepam (Dalmane), temazepam (Restoril), estazolam (Prosom), and triazolam (Halcion). However, those medications have long half-lives and tend to contribute to excessive daytime sedation.
“Z-drugs” are the selective benzodiazepine receptor agonists. Zaleplon (Sonata) and zolpidem are useful for sleep initiation but might not help with sleep maintenance through the entire night. Eszopiclone (Lunesta) and zolpidem extended release (Ambien CR) can help with sleep initiation and sleep maintenance through the entire sleep period.
Z-drugs, especially if mixed with alcohol, can contribute to parasomnias such as sleep walking and sleep driving. The FDA counsels that if patients develop parasomnias, they should not be rechallenged with those drugs.
Nonscheduled medications include ramelteon (Rozerem), a melatonin receptor agonist that is effective for sleep initiation, and low-dose doxepin (Sinequan), which is effective for middle to late portions of the night.

References

Pavlova MK and Latreille V. Sleep disorders. Am J Med. 2019 Mar 132(3):292-9.

Clark J. Slumber Camp. Conquer insomnia. For clinicians. Slumber Camp is an award-winning, 28-day, online course that teaches the principles of cognitive-behavioral therapy for insomnia.

Cui R and Fiske A. Predictors of treatment attendance and adherence to treatment recommended among individuals receiving cognitive behavioral therapy for insomnia. Cogn Behav Ther. 2019 Mar 14:1-7.

Christensen MA et al. Direct measurements of smartphone screen-time: Relationships with demographics and sleep. PLoS One. 2016 Nov 9;11(11):e0165331.

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Judith R. Milner, MD, MEd, SpecEd, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about steps psychiatrists can take to address the mental health needs of people traumatized by a natural disaster, such as Hurricane Dorian survivors.

In This Week in Psychiatry, Katherine Epstein, MD, and Helen M. Farrell, MD, write about miracle cures in psychiatry. You can read the article online by clicking here or you can access the downloadable PDF by clicking here.

Time Stamps:

This Week in Psychiatry (02:37)
Interview with Dr. Milner (06:33)
Dr. RK with Dr. Renee Kohanski (39:31)

Dr. Milner is a general and child and adolescent psychiatrist in private practice in Everett, Wash. She has traveled across the globe with various groups in an effort to alleviate some of the suffering caused by war and natural disaster.

Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses the extent to which people choose what is important and meaningful. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

STAGES OF NATURAL DISASTERS

Devastation stage

During the devastation stage, the primary objectives are giving basic first aid and attending to the sick, searching for those who are missing, and getting people safely into shelters.
Psychological first aid (PFA) is the primary form of mental health treatment. PFA addresses basic needs by helping people find shelter, food, water; assisting with communication; reuniting families; and conducting case management to address acute needs.

Normalization stage

The normalization stage continues for several months after the disaster and includes the honeymoon phase, in which people are grateful to have survived and the community unites to rebuild; and then the disillusionment phase, during which frustrations and hopelessness arise as communities and individuals realize the limits of disaster assistance.
Psychiatric disorders are likely to develop during the normalization stage. Acute stress disorder (ASD) typically occurs 3-30 days after the event with cardinal symptoms such as hyperarousal, hypervigilance, and negative cognitions that affect relationships. Medical professionals should monitor for development of chronic disorders such as PTSD, major depressive disorder, and anxiety disorders. Prolonged stressors, such as living in a damaged home, increase the risk of depression and anxiety.
Those with preexisting vulnerabilities – such as past traumatic experiences from physical, sexual, or emotional abuse; previous natural disasters; or other chronic stressors of poverty and medical illness – are at greatest risk of developing a trauma-related disorder after a natural disaster.
The normalization stage is a critical period to use the “training the trainer” model. Because many locations do not have a surplus of mental health clinicians, psychiatrist volunteers can train local individuals to provide services. For example, mental health professionals can train the trainers to recognize symptoms of common psychiatric conditions and to provide basic treatment.
Manualized therapies are useful but require in-depth training. Other simple modalities, such as deep breathing, visualization, and relaxation techniques, can be useful.

Acceptance stage

During the acceptance stage, rates of persistent PTSD range from 25% to 40%.
Ongoing therapy is helpful, especially group therapy, which is an effective use of resources. Facilitation of group therapy can be taught while training the trainers.
If a mental health professional volunteers and participates in the training the trainers’ model, there must be follow-up, which should include providing intellectual support and refresher courses, evaluating how training is being used, and checking up on patients/clients who have received services.

Predisaster advice: Do not go it alone. Affiliate with a group that has a plan, so that your presence on the scene does not add to the chaos.

Postdisaster advice:

Be aware of compassion fatigue and take time away from volunteerism. Recognize signs of secondary traumatic stress.
Counsel volunteers upon their return from the disaster site.

References

Substance Abuse and Mental Health Services Administration. Phases of disaster. Last updated 2018 Oct 1.

Pfefferbaum B et al. Practice parameter on disaster preparedness. J Am Acad Child Adolesc Psychiatry. 2013 Nov;52(11):1224-38.

World Health Organization. Psychological first aid: Guide for field workers. 2011.

National Child and Traumatic Stress Network. Psychological first aid online.

International Institute for Psychosocial Trauma. Clinical assessment of survivors of trauma.

U.S. Department of Veterans Affairs. PTSD: National Center on PTSD.

Compassion Fatigue Awareness Project.

Disaster Psychiatry Outreach.

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J. John Mann, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about the need for medicine to shift its approaches to preventing suicide. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education.

Dr. Mann is professor of translational neuroscience at Columbia University in New York.

For a complete video of this interview, see this vodcast.

Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how a religious wedding she attended made her think about the distinction between cults and cultures. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Why are suicide rates on the rise?

In the United States, between 2001-2017, the suicide rate increased by 33%, making suicide the second-leading cause of death for people aged 15-34 years.
Why the suicide rate has increased is unclear. Factors influencing rising suicide rates include the 2008 recession and the opioid crisis; however, these events cannot fully explain the trend because they occurred in the middle of the rising rates.
As suicide rates increase, the medical community missed opportunities for prevention at both primary care and psychiatry visits. A Centers for Disease Control and Prevention study that examined suicide rates and psychiatric illness found approximately half of suicide decedents did not have a known mental health condition.

Connections to untreated psychiatric illness

Only 22% of people with psychiatric illness who die by suicide had their mental illness treated.
The age of onset for major depressive disorder has been occurring earlier and indicates a greater pool of individuals is at risk of suicide. For example, during 2005-2014, major depressive episodes in adolescents increased by nearly one-third.
Individuals who attempt and die by suicide have a predisposition to respond to their mental illness with suicidal behaviors. This trait poses a challenge in the face of rising rates of mental illness in the United States.

Role of treatment by primary care physicians

45% of individuals who die from suicide see their primary care clinician within a month of their death. If nonpsychiatrist doctors or primary care physicians are trained to recognize depression and suicide, the rates of death and disability from depression can be decreased.
Most people who die by suicide are seeking help by going to a health care professional. How should the clinician respond? If a person presents with somatic complaints with no clear causes (for example, normal lab values), this is a time for the primary care physicians to ask about depression and suicide.

What steps can be taken to prevent suicide?

Medicine needs an updated approach in education about depression and suicide that is similar to the changes that have taken place during the opioid crisis. Now all clinicians must complete continuing medical education about pain management and opioid prescribing, which has led to a decrease in deaths from prescription pain medications. All clinicians must be able to recognize and treat depression, because it is becoming a leading cause of death and disability.
Clinicians need to do a better job of making connections between somatic complaints and mood disorders.

References

U.S. Department of Health and Human Services, National Institutes of Health. Mental health information: Suicide. Updated August 2019.

Stene-Larsen K and A Reneflot. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019 Feb;47(1):9-17.

Reed J. Primary care: A crucial setting for suicide prevention. SAMHSA-HRSA Center for Integrated Solutions.

U.S. Department of Health and Human Services. Adolescent mental health basics. Rising rates of MDD in adolescents.

Bruce ML et al. Reducing suicidal ideation and depressive symptoms in depressed older patients. JAMA. 2004 Mar 3;291(9):1081-91.

DA Brent and N Melhem. Familial transmission of suicidal behavior. Psychiatr Clin North Am. 2008 Jun;31(2):157-77.

Mohatt NV et al. A menu of options: Resources for preventing veteran suicide in rural communities. Psychol Serv. 2018 Aug;15(3):262-9.

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In this masterclass, Philip D. Harvey, PhD, professor of psychiatry and behavioral sciences at the University of Miami, discusses the relationships between aging, neurocognition, and functional outcomes.

And in a new segment from MDedge, called This Week in Psychiatry, we’d like to share a Current Psychiatry evidence-based review on using antidepressants for pediatric patients (PDF) by Jennifer B. Dwyer, MD, PhD, and Michael H. Bloch, MD, MS.

Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Introduction to normal aging

Changes in cognitive abilities are part of normal aging.
Crystalized intelligence, the storage of information learned throughout life, does not change over time in normal, healthy aging.
Fluid intelligence, the ability to learn new information, solve problems, concentrate, and rapidly process information, starts changing at age 65 or so.
Episodic memory performance, the ability to learn new verbal information, declines 30% between ages 65 to 80, followed by another equivalent decline from ages 80 to 90.
Alzheimer’s disease and amnestic mild cognitive impairment are characterized by signature memory loss called rapid forgetting, which occurs in cases in which a person is unable to remember information right after being told.
Older people who are self-aware and sensitive to their age-related cognitive changes have a better prognosis.

Technology and aging

Individuals in their 80s to 90s might have retired before the advent of technological advances such as ATMs, cell phones, the Internet, smartphones, and other touch screen devices.
For these individuals, vital aspects of daily living, such as accessing finances online, requires using Internet navigation skills, and those skills were not acquired at a younger age.
A direct connection exists between cognitive abilities and learning how to use technology for the first time.
Healthy older people will be challenged by new technology the first time because of their lack of exposure. Yet, their ability to learn how to use technology is comparable to that of younger people.

Embracing technology to prevent normative cognitive decline

The ACTIVE study, sponsored by the National Institute on Aging, enrolled 2,800 older healthy adults, with a mean age of 75, to evaluate the effectiveness of cognitive interventions in maintaining cognitive health and functional independence in older adults.
Participants were randomized to either computerized speed training, memory training, problem solving training, or psychosocial intervention.
The computerized speed training produced the most significant benefit in cognitive functioning. Participants randomized to computerized speed training sustained their functioning of instrumental daily activities of living and had a 50% lower rate of at-fault motor vehicle collisions, compared with controls, over a 6-year follow-up period.
The ACTIVE study results suggest that age-related changes might be reversible with 14 1-hour sessions of brain training. Normative age-related cognitive decline can be attenuated through the use of affordable, accessible technology.

In summary, not all age-related cognitive complaints are pathological

Clinicians must ask specifically about memory loss and rapid forgetting of information to differentiate normative age-related changes from Alzheimer’s dementia.
Patients should be empowered to use technology to intervene for their cognition.
Both brain and physical fitness are paramount to preventing dementia.
Physical fitness is essential to prevention, because chronic illnesses such as type 2 diabetes are primary risk factors for dementia, and being overweight in middle age is a major predictor for developing type 2 diabetes.
Physical exercise, brain exercise, and embracing technology are essential to preventing social isolation and subsequent dementia.

References

Antidepressants for pediatric patients
by Jennifer B. Dwyer, MD, PhD; Michael H Bloch, MD, MD

An evidence-based review from Current Psychiatry: 2019 September:18(9):26-30,32-36,41-42,42A-42F

Click here for the webpage
Click here for the downloadable PDF

Tennstedt SL and FW Unverzagt. The ACTIVE study: Study overview and major findings. J Aging Health. 2013 Dec;25(8 0):3S-20S. doi: 10.1177/0898264313118133.

Rebok GW et al. Ten-year effects of the ACTIVE cognitive training trial on cognition and everyday functioning of older adults. J Am Geriatr Soc. 2014 Jan;62(1):16-24.

Harvey PD and MT Strassnig. Cognition and disability in schizophrenia: Cognition-related skills deficits and decision-making challenges add to morbidity. World Psychiatry. 2019 Jun;18(2):165-7.

Brem AK and SL Sensi. Towards combinational approaches for preserving cognitive function in aging. Trends Neurosci. 2018 Dec;41(2):885-97.

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Roger McIntyre, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about obesity, inflammation, and treatment implications for mental health conditions. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education.

Dr. McIntyre is a professor of psychiatry and pharmacology at the University of Toronto, and head of the mood disorders psychopharmacology unit at the University Health Network, also in Toronto.

For a complete video of this interview, please visit the vodcast.

Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how to think through whether sharing personal information with patients helps move their therapy forward. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Reconceptualizing mental illness by looking at inflammation

Mental illness should be viewed as a disease involving many organs – including the brain – and psychiatry should expand its understanding of the etiology of mental illness.
Increasingly, research suggests that a subgroup of people with mental disorders, including those with a variety of diagnoses, have symptoms related to alterations in their immune system and inflammation.
Inflammation plays a role in disparate psychiatric diagnoses, including childhood disorders such as obsessive-compulsive disorder, ADHD, and autism, and adult disorders such as schizophrenia, depression, and Alzheimer’s disease.
Currently, psychiatry uses the monoamine paradigm to explain psychiatric diagnosis, and most medications were developed using that paradigm.
A subgroup of people is not sufficiently helped by current medications, so looking at inflammation as a driver of mental illness provides another biological avenue to pursue drug development.

Role of obesity and chronic health conditions in worsening inflammation

Obesity, particularly abdominal obesity, is overrepresented in people with mental illness and is not fully explained by either social determinants of health or medication side effects.
Obesity and mental illness have a bidirectional relationship; each affects the body as multiorgan system diseases.
Mental illness can be conceptualized as a kind of “metastasis to the brain.” Adipose tissue releases a surfeit of neurochemicals hazardous to brain function and that disrupt neurocircuitry.
For example, compared with an individual with major depressive disorder (MDD) only, an individual with MDD and obesity is more likely to have symptoms driven by inflammation, such as anhedonia, cognitive impairment, limited motivation, and a dysregulated reward system.
Obesity should also be a target symptom worthy of a focused treatment plan.
Heart disease is the leading cause of death in schizophrenia, and coronary artery disease is an inflammatory illness. Research is identifying connections between psychiatric illness such as schizophrenia and potentially inflammatory driven symptoms, often called “sickness behaviors,” such as low motivation, anhedonia, and cognitive impairment.

Clinical implications of obesity and inflammation

Alterations in inflammation and metabolism are not just a consequence of obesity. For example, patients will bipolar disorder who report sexual or physical trauma are more likely to be in a proinflammatory neurochemical state and benefit from anti-inflammatory interventions.
Are patients with early trauma who do not respond fully to “traditional” monoamine medications part of the subpopulation who respond to anti-inflammatory interventions because trauma is driving inflammation?
The genetics of mental illness already are complicated and will be influenced by the environment and a “proinflammatory milieu.”

Which tests show inflammation?

Current inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein, are not specific enough to direct treatment of inflammation in mental illness.
Elements of a patient’s history, including history of trauma, disrupted sleep and circadian disturbances, cigarette smoking, poverty, housing dislocation, and exposure to racism, can indicate inflammation.
We can conceptualize as anti-inflammatory several current treatments, such as mindfulness-based therapy, electroconvulsive therapy, and selective serotonin reuptake inhibitors.
Alternative treatments to treat inflammation exist; however, specific anti-inflammatory treatments, such as NSAIDs, cyclooxgenase-2 inhibitors, and minocycline, are not yet recommended for patients with mental illness.

Targeting inflammation as prevention of psychiatric illness

Clinicians can target drivers of inflammation as a means of treatment and prevention of mental illness. They can also target the basics, such as sleep, diet, exercise, and socializing, as preventive measures that also target inflammation.
The incidence of depression can be decreased by targeting lifestyle changes and metabolic illness with treatments such as exercise and statins.
Interventions focused on inflammation are being investigated as a means of prevention for people at risk of mental illness. For example, a study in China in which Dr. McIntyre was involved explored whether exercise can decrease the development of bipolar disorder in children who have a genetic predisposition to the illness. Caloric restriction can reduce inflammation and improve cognition.

Inflammation and the absence of ‘meaningful connections’

In social baseline theory, human beings allocate energy in proportion to their social connectivity.
People with fewer social connections are more likely to be in a proinflammatory state and more likely to consume high-carbohydrate food.
Loneliness can be conceptualized as an epidemic associated with serious health outcomes, such as suicide, addiction, and other chronic mental and physical health problems. We are living in a society of anxious despair.
Psychiatry needs to broaden its understanding of mental illness by investigating a variety of underlying causes, from inflammation to the monoamine theory.

References

Rosenblat JD et al. Inflamed moods: A review of the interactions between inflammation and mood disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2014 Aug 4;53:23-34.

Harvey SB et al. Exercise and prevention of depression: Results of the HUNT cohort study. Am J Psychiatry. 2018 Jan 1;175(1):28-36.

Redlich C et al. Statin use and risk of depression: A Swedish national cohort study. BMJ Psychiatry. 2014 Dec 4;14:348. doi: 10.1186/s12888-014.0348-y.

Leclerc E et al. The effect of caloric restriction on working memory in healthy non-obese adults. CNS Spectr. 2019 Apr 10:1-7. doi: 10.1017/S1092852918001566.

Schwabel D. “Vivek Murthy: How to solve the work loneliness epidemic.” Forbes.com. Oct 7, 2017.

Ho RCM et al. Factors associated with risk of developing coronary artery disease in medical patients with major depressive disorder. Int J Environ Res Public Health. 2018 Oct;15 (10): 2073. doi: 10.33901/ijerph1510102073.

Dantzer R. Cytokine, sickness behavior, and depression. Immunol Allergy Clin North Am. 2009 May;29(2): 247-64.

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Jack Rozel, MD, returns to the MDedge Psychcast to discuss gun violence and a new report from the National Council for Behavioral Health. In episodes 29 and 33, Dr. Rozel talked with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about this topic in the wake of the shooting last year at the Tree of Life synagogue in Pittsburgh.

Dr. Rozel is medical director of resolve Crisis Services at the Western Psychiatric Institute and Clinic of the University of Pittsburgh. He also is president-elect of the American Association for Emergency Psychiatry and a member of the National Council. Dr. Rozel can be found on Twitter @ViolenceWonks.

Later, Renee Kohanski, MD, discusses betrayal in the context of Erik Erikson’s conceptualization of trust vs. mistrust. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Gun violence in the United States

Mass violence with guns is a distinctly American problem occurring with greater frequency and severity in the United States, compared with other countries.
The United States has a broad swath of firearm violence: Deaths by suicide account for 60% of gun deaths, and the remaining 40% are deaths by homicide.
1%-2% of homicides are completed in mass shootings, which are defined as an event in which a gunman indiscriminately shoots four or more people.
Firearm homicides have been trending downward, while mass shootings have increased.
Mass shootings might be influenced by media coverage; media exposure about mass shootings can incite possible perpetrators.
Mass shootings are shown to cluster in ways similar to suicide contagion.

Responses to mass shootings/violence

The National Council for Behavioral Health addresses mass violence by releasing a new report:
The report, called “Mass Violence in America: Causes, Impacts and Solutions,” was written by a group of 30 multidisciplinary experts, including Dr. Rozel.
It was released in response to stigma and incorrect messages linking psychiatric diagnoses to mass violence.
The report reviews models aimed at preventing violence and understanding threat assessment.

Predicting violence and diffusing threats

Pathway to violence is a model for predicting mass violence generated by data and analysis of violent acts by the Los Angeles Police Department, U.S. Capitol Police, U.S. Marshals Service, and the U.S. Secret Service.
- Grievances: Violence often starts with a grievance. Clinicians might be familiar with patients who are “grievance collectors” and do not get along with any person, whether at work, family, or society at large.
- The pivot: A transition from simply having a grievance to violent ideation and wanting vengeance through violence. Psychiatrists certainly will see people who express violent fantasies. Perpetrators of violence shift from fantasy into research about planning and preparing to attack.
Clinicians want to identify the point at which people feel aggrieved and should become most concerned when these people begin to get certain fixations.
- Preparation: The person will start to acquire weapons and tactical clothing; probe into vulnerabilities of their targets, conduct “test attacks”; and eventually carry out the final attacks.
- Identification: The grievance stage is the most effective place to intervene, once the identification has been made, and potentially diffuse a violent outcome.

The United States holds a unique position when it comes to gun ownership, violence

The United States is one of the three countries in the world that allow citizen access to firearms in their constitutions.
With 393 million civilian-held firearms, the United States has more civilian-owned firearms than the next 39 countries combined.
- India, which has 70 million civilian-held firearms, ranks No. 2.
Regardless of what happens with gun control following each mass shooting, the guns already are out there in civilian hands.
Behavioral health clinicians must talk with patients about firearms safety.
A person living in the United States is 10 times more likely to die of firearm-related suicide and 25 times more likely to die of firearm-related homicide, compared with people living in other economically developed countries.

Components of proposed legislation that could reduce gun violence:

Increasing mental health access: Violent acts can be attenuated through access to mental health with anger-management classes and interventions at emotional regulation.
Implementing universal background checks for gun purchases. Currently, this policy varies from state to state.
Requiring a background check to obtain a concealed carry permit.
Testing competency/shooting ability with guns before giving a permit.
Increasing access to gun violence restraining orders, also called gun violence prevention orders. The restraining orders are aimed at temporarily stopping people who pose a threat to themselves or others by buying or possessing a firearm. The number needed to treat to prevent suicide with this type of restraining order is 11-20.

Education and research that could address the problem

Research about the pathway to violence model and threat assessment can be used to create training for the array of professions that touch on violence – such as police, gun stores, teachers, and health care professionals. Training can focus on de-escalation and recognition of individuals at risk of perpetuating violence against themselves and others.
Training for health care professionals should not be limited to just a psychiatry rotation, but also in emergency medicine and primary care, since gun violence affects patients within every field.
Research into firearm violence prevention is incredibly underfunded, primarily because of the restrictions embedded in the Dickey Amendment.
- Named for the late Rep. Jay Dickey of Arkansas, the provision specifies that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” This amendment remains a huge obstacle to any group seeking to research gun violence.

References

Lankford A. Do the media unintentionally make mass killers into celebrities? An assessment of free advertising and earned media value. Celebr Stud. 2018;9(3):340-54.

Knoll IV JL and GD Annas. Mass shootings and mental illness. In: Gold LH and RI Simon (eds). Gun Violence and Mental Illness. Arlington, Va.: American Psychiatric Association Publishing, 2016.

Silver J et al. Foreshadowing targeted violence: Assessing leakage of intent by public mass murderers. Aggress Violent Behav. 2018;38:94-100.

Metzl JM and KT MacLeish. Mental illness, mass shootings, and the politics of American firearms. Am J Public Health. 2015;105(2):240-9.

Swanson JW et al. Gun violence, mental illness, and laws that prohibit gun possession: Evidence from two Florida counties. Health Aff (Millwood). 2016 Jun 1;35(6):1067-75.

Van Dorn R et al. Mental disorder and violence: is there a relationship beyond substance use? Soc Psychiatry Psychiatr Epidemiol. 2012;47(3):487-503.

Rahman T et al. Anders Breivik: extreme beliefs mistaken for psychosis. J Am Acad Psychiatry Law. 2016;44(1):28-35.

National Council for Behavioral Health. Mass violence in America: Causes, impacts, and solutions. 2019 Aug.

Mass shooters and murderers: Motives and paths. National Collaborating Centre for Mental Health. Violence and aggression: Short-term management in mental health, health and community settings.2019 Apr 1.

Betz ME and GJ Wintemute. Physician counseling on firearm safety: A new kind of cultural competence. JAMA. 2015;314(5):449-50.

District of Columbia v. Heller (2008).

Rostron A. The Dickey amendment on federal funding for research on gun violence: A legal dissection. Am J Public Health. 2018 Jul;108(7):865-7.

“More research could help prevent gun violence in America.” Rand Review. 2018 Jul 10.

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Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, interviews the psychiatry residents who produce the PsychEd podcast, which as they put it, is “created by medical learners, for medical learners.”

Dr. Norris speaks with some of the members of PsychEd podcast team: Sarah Hanafi, MD, a first-year resident in psychiatry at McGill University, Montreal; Alex Raben, MD, a fourth-year resident in psychiatry at the University of Toronto; Lucy Chen, MD, a fourth-year psychiatry resident at the University of Toronto; and Bruce Fage, MD, a fifth-year psychiatry resident at the University of Toronto.

And later, in the “Dr. RK” segment, Renee Kohanski, MD, discusses the role of the placebo in the modern setting. Dr. Kohanski is a member of the MDedge Psychiatry Editorial Advisory Board and is a psychiatrist in private practice in Mystic, Conn.

Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Why podcasting?

The PsychEd podcast originated when the team identified a gap in podcast-mediated learning for psychiatry trainees.
In psychiatry, there have been podcasts that reviewed recent publications, but none that examined foundational topics. Other specialties, such as emergency medicine, have several podcasts covering basic topics aimed at trainees.
Podcasts are identified as an asynchronous educational material. They are a medium that can be used in “downtime,” especially because many trainees commute or have other time during which they can consume information.
At the American Psychiatric Association’s 2019 Annual Meeting, the PsychEd team presented on the integration of podcasting into medical education.
Materials should focus on digital natives vs. digital immigrants.
In 2015, one research group polled emergency medicine residents and found a differential in the use of podcasts; 90% of users were residents and 45% were program directors.

Podcasts are a supplement to other types of learning

Podcasts can distill information as well as engage with information and experts in an alternative fashion.
Podcasts are efficient in their use of time and broaden listeners’ exposure to information and experts.
Podcasts offer one modality of learning and are not meant to replace other sources.
Resources should focus on what information is needed and be tailored to where students, residents, and all learners spend their time.

PsychEd beginnings

After the team identified the need for a psychiatry education–focused podcast, they started meeting to create an environment for collaboration.
Learning how to podcast – using the equipment, editing the recording, and uploading to relevant platforms – was the hardest part.
All PsychEd podcasting is done “live.” The team takes their recording equipment to the experts they interview. Presently, their guests are located in Toronto. The team has expanded to Montreal with a new team member, Sarah Hanafi, a first-year psychiatry resident at McGill University.

Formatting

The podcast started with a case-based format, using a composite case presented to an expert, followed by a junior learner asking questions. Now the team does more prep work to create a structured script that includes educational objectives.
Using a script allows for the interview to flow in a more organized structure, which makes for easier editing. Meeting and preparing the script with experts demands time and preparation in order to create the milieu for a generative interview.
Most often, the “pearls” come from the unscripted questions that elicit reflections.
Experts have been willing and excited to participate in the podcast and to disseminate their knowledge in a format that will reach trainees.

PsychEd topics

So far, PsychEd has covered basic topics of psychiatry, including major depressive disorder, schizophrenia, bipolar disorder, and anxiety, and it is now expanding to more complex topics.
An initial idea was to incorporate the patient perspective to add nuance to the foundational-level topics. Listeners were indifferent to this idea since they already encounter the patient experience on a regular basis and incorporating the patient voice did not necessarily target the educational content.
This scenario illustrates in difficulty of choosing topics: Subject matter that will draw in listeners but also are creative and add meaning.
There is space for societal topics in psychiatry such Big Data, climate change, technology, and loneliness.
PsychEd has been awarded a grant through the University of Toronto to expand subject matter focused on clinical skills to target priorities identified by the Royal Board of Canada through its “Competency by Design” initiative.

Other challenges in podcasting

Choosing topics is a balance of identifying cutting-edge topics vs. issues universal to all psychiatrists. Should popular topics be revisited?
Deciding how to identify topics that can enhance learning but are also professionally enriching to the psychiatrist as an individual.

What personal growth has come from podcasting?

Learning leadership skills: Leading a small team to create a quality podcast and then expanding to research about the impact.
Providing a creative outlet both in content and thinking about the scope of scholarship within psychiatry.
Enhancing time management and learning how to juggle interests outside of clinical work.
Understanding how to access rich local resources, ranging from experts to other trainees who want to podcast and contribute.
Broadening one’s vision and perspective by talking with thought leaders: As psychiatrists, our work resonates with similar themes, and it’s inspiring to talk to others about universal themes.

References

The PsychEd podcast: https://www.psychedpodcast.org/

Mallin M et al. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014 Apr;89(4):598-601.

Matava CT et al. eLearning among Canadian anesthesia residents: A survey of podcast use and content needs. BMC Med Educ. 2013 Apr 23;13:59.

Riddle J et al. A survey of emergency medicine residents’ use of educational podcasts. West J Emerg Med. 2017 Feb; 18(2): 229-234.

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Welcome to this bonus episode of the MDedge Psychcast. In this episode, as a tribute to the late Carl C. Bell, MD, we would like to replay highlights from the interview that Lorenzo Norris, MD, did with him last year at the annual IPS (Institute on Psychiatric Services) Mental Health Services conference in Chicago.

Dr. Norris, host of the MDedge Psychcast, is assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Bell, who died Aug. 1, was a psychiatrist at Jackson Park Hospital in Chicago and an emeritus professor of psychiatry at the University of Illinois at Chicago. He spoke with Dr. Norris in episodes 26 and 27 about identifying and preventing fetal alcohol spectrum disorders.

Conceptualizing intellectual disabilities in children

In the late 1960s, African American children had twice the rates of mild intellectual disabilities as did white children.
Some clinicians thought that the intellectual disabilities they were seeing among African American children were the result of social-cultural mental retardation, but that conclusion did not make sense to Dr. Bell.
Julius B. Richmond, MD, former surgeon general, cocreated Head Start as a way to address some of the educational disadvantages faced by low-income children.
African American psychologists began to suggest that standardized tests were biased against certain racial and low-income groups.
Bell thought some African American and low-income children might have knowledge that their counterparts in other communities might not have.

Fetal alcohol exposure emerges as an explanation

A few years ago, Dr. Bell was talking with a woman patient with three children in the Illinois Department of Children and Family Services. The children had poor tempers, social/emotional skills. And when he looked at their mother, he saw fetal alcohol facies.
After talking with the patient longer, he learned that she had not gotten far in school. She also had problems with simple subtraction. At that point, he thought that the patient might have had fetal alcohol exposure.
He then began looking at family medicine patients at Jackson Park Hospital in Chicago. The question at that time was: “Were you drinking while you were pregnant?” That question did not explain why patients had children who could not do basic subtraction and had ADHD, for example.
Bell realized that the right question was: When did you realize you were pregnant? In many cases, they would say that they had learned they were pregnant at 4-6 weeks.

Choline deficiency and fetal alcohol exposure

The Institute of Medicine recommended that pregnant women consume 450 mg/day of choline each day.
Robert Freedman, MD, and his colleagues found that higher amounts of choline as a prenatal supplement are tied to more self-regulation among infants who had common maternal infections during gestation.
Bell began giving choline to patients. In one example, a patient’s ability to relate to others improved dramatically after taking choline over an 18-month period.
The American Medical Association passed a resolution supporting the addition of adequate amounts of choline to prenatal vitamins.

References

Freedle RO. Correcting the SAT’s ethnic and social-class bias: A method for reestimating SAT scores. Harvard Educ Rev. 2003. 73(1):1-42.

Bell CC and J Aujla. Prenatal vitamins deficient in recommended choline intake for pregnant women. J Fam Med Dis Prevent. 2016. 4(2):1-3.

Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders: A randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2015 Nov;102(5):1113-25.

Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders(FASD) has high feasibility & tolerability. Nutr Res. 2013. Nov;33(11):897-904.

Zeisel SH and KA da Costa. Choline: An essential nutrient for public health. Nutr. Res. 2009. Nov;67(11):615-23.

Freedman R et al. Higher gestational choline levels in maternal infection are protective for infant brain development. J Pediatr. 2019 May. 208:198-206.

Velazquez R et al. Maternal choline supplementation ameliorates Alzheimer’s disease pathology by reducing brain homocysteine levels across multiple generations. Mol Psychiatry. 2019 Jan 8. doi: 10.1038/s41380-018-0322-z.

Wilhoit F et al. Fetal alcohol spectrum disorders: Characteristics, complications, and treatment. Community Ment Health J. 2017 Aug;53(6):711-8.

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Last week, Igor Galynker, MD, PhD, spoke with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about how to identify suicide crisis syndrome. This week, he explores the kinds of “gut feelings” that clinicians can access to help them identify when a patient might have the syndrome.

Dr. Galynker has been a guest on the Psychcast twice before, once to discuss the impact of suicide on physicians and a second time to talk about his research on the arguments for adding a suicide-specific diagnosis to the DSM-5. He is associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel in New York. In addition, Dr. Galynker is founder and director of the Richard and Cynthia Zirinsky Center for Bipolar Disorder, and professor of psychiatry at the Icahn School of Medicine, both at Mount Sinai.

Later, Renee Kohanski, MD, discusses the ability of psychiatrists to help patients realize that they can choose what matters in their lives. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

The “gut feelings” -- emotional reactions to the patient in suicide risk assessment -- also will elicit behaviors from a clinician.

Behavioral signs of the four emotions are pertinent for clinicians who are burned out or may have limited emotional awareness. Examples include:

Anxious overinvolvement manifested as going above and beyond for a patient; doing things that are out of character, such as answering phone calls/texts on the weekend; reluctance to set boundaries.
Dislike and distancing: The patient in suicide crisis syndrome will be the last one the clinician sees on the inpatient unit or the one he/she postpones or forgets to see; the clinician experiences dread tied to the prospect of seeing a patient all day, shortens sessions, or does not answer phone calls.

How to combine emotional response and the suicide crisis syndrome.

New research from Dr. Galynker and colleagues suggests that the predictive validity for suicide risk doubles if the patient meets criteria for suicide crisis syndrome and the clinician has an emotional response as described above.
The emotional response is elicited not just from the suicide crisis syndrome but also from the suicidal narrative.
The narrative of a suicidal person describes an intolerable present with no future. This type of aberrant narrative triggers an emotional response in the clinician.
One could argue the electronic medical record makes it difficult to understand the patient’s narrative, which can impede the clinician’s ability to have an emotional response to the patient’s suffering.

Why has psychiatry not focused on suicide over other mental health diagnoses?

As a transdiagnostic phenomenon, one could argue that suicide must be a primary focus of assessment and treatment by psychiatrists.
Suicide elicits a variety of cultural responses, ranging from shame, disgust, and a sense of weakness to empathy for the pain and suffering of a suicidal person.
It is difficult to connect with someone who is suffering from a desire to die, but this might be what the patient wants.
Clinical excellence is the ability to connect with a variety of patients in different settings, and it’s about demonstrating how one cares.

References

Olfson M et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-26.

Galynker I et al. Prediction of suicidal behavior in high-risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb;34(2):147-58.

Cohen LJ et al. The suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav. 2018 Oct;48(5):613-23.

Suicide rising across U.S. Centers for Disease Control and Prevention. Vital Signs. 2018 Jun.

Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: Advantages outweigh limitations. World Psychiatry. 2014 Jun;13(2):128-30.

Fawcett J. “Diagnosis, traits, states and comorbidity in suicide” in The Neurobiological Basis of Suicide. Boca Raton, Fla.: Taylor & Francis, 2012.

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Igor Galynker, MD, PhD, talks with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about suicide crisis syndrome.

Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Later, in the “Dr. RK” segment, Renee Kohanski, MD, tells the story of a patient who found a way to rediscover his value system against great odds. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Suicide crisis syndrome: A suicide-specific mental state

Until recently, there was no differentiation between the mental state associated with lifelong suicide risk versus the mental state associated with imminent suicide risk.
Jan Fawcett, MD, distinguished these mental states for the first time by differentiating acute risk of imminent death and lifelong risks and traits of suicidal behavior.
Lifetime suicide risk factors include mental illness, history of suicide attempts, depression, and substance abuse.
Imminent suicidal behavior risk factors include panic, acute anhedonia, agitation, and insomnia.

Dr. Galynker and colleagues have identified a condition they call suicide crisis syndrome, which they define as a mental state that predicts imminent suicidal behavior in days to weeks. The predictive validity has been replicated across several cultures and populations.

Suicide crisis syndrome: To be identified as having suicide crisis syndrome, the patient must meet both criterion A and two criteria of B.

Criterion A: Frantic hopelessness or state of entrapment defined as being stuck in a life situation that is painful and intolerable, and a feeling that all routes of escape are blocked. The risk of suicide within 1 month is 13% for people who meet criteria for suicide crisis syndrome.
Criterion B:
- Affective dyscontrol, including emotional pain or mental pain; severe panic with agitation, and dissociation; rapid mood swings that can include happiness; and acute anhedonia.
- Cognitive dyscontrol, which can include ruminative flooding associated with headache or head pressure; cognitive rigidity; and inability to suppress the ruminative thoughts. (For example, you might assess by asking: “Do you control the thoughts or do the thoughts control you?”)
- Overarousal with insomnia and agitation.
- Social withdrawal and isolation, and evading communication.

Why are suicide-specific diagnoses necessary?

75% of people who die by suicide do not report suicidal ideation to a clinician, psychiatrist, or primary care physician.
Notably, suicide crisis syndrome does not include suicidal ideation in the criteria, because not all people within imminent risk feel suicidal until the moment strikes. Some patients will hide their suicidal ideation from their clinician to prevent having their plan foiled.
Suicide crisis syndrome creates a fuller picture of patient risk. Assessment of the criteria help a clinician consider more risk factors for imminent risk than simply a patient’s self-report about suicidal ideation.

Approach suicidality with a different framework

Suicide-specific diagnoses represent a profound shift in approach, because suicide is a transdiagnostic phenomenon for depression, bipolar disorder, and schizophrenia.
A person can be at imminent risk for suicide without meeting criteria for other DSM diagnoses.
Other suicide-specific diagnoses: Maria A. Oquendo, MD, PhD, and colleagues have put forward “suicidal behavior disorder,” which is a diagnosis that captures the propensity of suicidal behavior and urges to kill oneself.
Suicidal behavior disorder and suicide crisis syndrome provide clinical targets for treatment of suicide.
Without a diagnosis, clinicians cannot test treatment or teach the assessments.

Use emotional reactions to the patient in suicide risk assessment

Clinicians can identify “gut feelings” that help hone their assessments.
Galynker and colleagues have identified four emotions that can help clinicians identify suicide risk:
- Distress.
- Dislike with distancing.
- Anxious overinvolvement, with a paradoxical combination of hope and distress.
- Collusion/abandonment/rejection, which includes a type of hopelessness and calm.
Clinicians can be trained to identify these emotions, which they may have been taught to suppress.
Recognition of these emotions can be cultivated through “emotional awareness rounds.”

Dr. Fawcett is a professor of psychiatry at the University of New Mexico, Albuquerque. Dr. Oquendo is the Ruth Meltzer Professor of Psychiatry at the University of Pennsylvania, Philadelphia.

References

Olfson M et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-26.

Galynker I et al. Prediction of suicidal behavior in high-risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb;34(2):147-58.

Cohen LJ et al. The suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav. 2018 Oct;48(5):613-23.

Suicide rising across U.S. Centers for Disease Control and Prevention. Vital Signs. 2018 Jun.

Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: advantages outweigh limitations. World Psychiatry. 2014 Jun;13(2):128-30.

Fawcett J. “Diagnosis, traits, states and comorbidity in suicide” in The Neurobiological Basis of Suicide. Boca Raton, Fla.: Taylor & Francis, 2012.

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Elspeth Cameron Ritchie, MD, MPH, talks with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about averting disruptions in psychiatric medications after short- and long-term disasters.

Dr. Ritchie is a psychiatrist who works in Washington.

Show Notes by Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Later, in the “Dr. RK” segment, Renee Kohanski, MD, discusses the potential impact of pharmacogenomics on the practice of psychiatry. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Dr. Ritchie and disaster psychiatry

She entered disaster psychiatry through her many years as a military psychiatrist.
She had to think about how to plan and treat psychiatric emergencies during deployments to an austere environment, such as Somalia and Iraq.
She was on active duty during Sept. 11, 2001, and helped coordinate the disaster response during that period and then completed a fellowship in disaster psychiatry at the Uniformed Services University in Bethesda, Md.
Ritchie says that the field has changed immensely, from the way in which it once handled debriefings to the current use of psychological first aid. Yet, she thinks that psychiatric medications are a neglected area of planning.

Minor, major disasters can cause disruptions in psychiatric medications

Access/continuity of psychiatric medications is overlooked in planning.
Disruption in psychotropic medications will affect many populations, including people with serious mental illness (SMI), first responders, and patients dependent on controlled substances such as methadone, buprenorphine and naloxone, and benzodiazepines.
- Especially for those with SMI in a disaster that creates increased stress, the absence of medications can have longer negative consequences, such as changes in behavior as hospitalizations or that may lead to contact with the legal system.
Plans need to be made in advance with patients to prevent disruption in medications.
Small disasters could include a weather event, such as a snow or rainstorm. These can create barriers to medication at the basic level, such as a lack of electricity affecting computer systems, a pharmacist cannot make it to work, etc.
Larger disasters, such as hurricanes, can have effects that last months to years, such as loss of psychiatrists or lack of other infrastructure related to mental health.

Population-specific planning during disasters

Patients with SMI: Some might be homeless and affected by weather conditions; there often may be a robust citywide response aimed at creating a safety net for these individuals.
First responders: It is essential to have medications available for sleep, such as trazodone or zolpidem, to mitigate the effects of long, stressful workdays that make it hard to “turn off” and get rest.
Working professionals: Many people balance busy lives on a routine basis, so it’s important to help these patients maintain their medications and functioning. Psychiatrists should make sure that these patients have adequate supplies of medications, such as SSRIs.

How can psychiatrists help to prepare?

They can ensure that patients can have an adequate supply of medications in several locations in case of disaster or emergency.
They can provide a 90-day supply of medication in the event of a large disaster with lasting effects.
They can determine that patients have a printed up-to-date list of all their medications in case they need to change pharmacies or have medications refilled by another clinician, such as a primary care physician.
- Patients and doctors rely on the electronic health records for medication lists, which may fail during a disaster.
They can identify at-risk patients, such as those on controlled substances (opiates and benzodiazepines), and refill any medications that, if missed, can result in withdrawal syndromes.

Disaster planning has come a long way over the last 30 years

Disaster planning often takes into consideration food supply and medications. However, psychiatric medications often are forgotten as being essential to patients.
- For example, the Centers for Disease Control and Prevention does not stockpile psychotropic medications, other than valium, for emergencies.
Psychiatrists can advocate within their cities or states to ensure that disaster plans include a contingency for psychiatric care, such as stockpiles of psychotropic medications.
Psychiatrists can help in disaster planning by consulting on formularies for disasters and suggesting versatile psychotropic medications that can be used in multiple settings or for different patient types.
- Examples of versatile medications include mirtazapine for sleep and depression, bupropion for depression and ADHD, medications for sleep, antipsychotics, and such key SSRIs as fluoxetine.
Psychiatrists also must plan for themselves and consider their own self-care as well as emergency planning for their offices and their families.

References

Ritchie EC et al. When a disaster disrupts access to psychiatric medications. Current Psychiatry. 2019 May;18(5):22-6.

Kenardy J. The current status of psychological debriefing: It may do more harm than good. BMJ. 2000 Oct 28;321(7268):1032-3.

Rodriguez JJ and R Kohn. Use of mental health services among disaster survivors. Curr Opin Psychiatry. 2008 Jul;21(4):370-8.

Redd SC and TR Frieden. CDC’s evolving approach to emergency response. Health Secur. 2017 Jan/Feb;15(1):41-52.

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Ep. 70

Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

In this episode, Richard Balon, MD, returns to the MDedge Psychcast to discuss benzodiazepines. This time, Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, interviewed Dr. Balon about prescribing benzodiazepines for patients with serious medical illnesses. They also examine some of the controversies around benzodiazepines and common mistakes that some clinicians make when prescribing these drugs.

Dr. Balon is professor of psychiatry at Wayne State University in Detroit.

And later, in the “Dr. RK” segment, Renee Kohanski, MD, explores the need for psychiatrists to challenge the distorted thinking patterns of patients, particularly in light of the growing influence of social media. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Benzodiazepines can be used for patients with serious mental illness across several areas of medical illness, including those with cardiovascular, gastrointestinal, and sleep disorders, as well as for those with generalized anxiety disorder (GAD) and panic disorder.

Cardiovascular illness

Patients with cardiovascular illness might have just encountered a near-death experience and present with somatic symptoms of their cardiovascular illness and anxiety.
- This overlap of symptoms makes cardiovascular illness a reasonable comorbidity in which to use benzodiazepines for anxiety.
A naturalistic study of patients with heart failure showed patients on benzodiazepines had a small decrease in mortality. The reason is unknown, but it could be from a decrease in anxiety and stress, both of which affect the heart.
Older studies show that some benzodiazepines can be used in addition to antihypertensives.

Gastrointestinal illness

Benzodiazepines also are useful for such gastrointestinal (GI) illnesses as peptic ulcer disease, inflammatory bowel disease, irritable bowel syndrome, etc.
The symptoms of GI illness, such as constipation, diarrhea, and nausea, can complicate the use of SSRIs or tricyclic antidepressants for anxiety.
Older studies suggest that adding benzodiazepines to the regimen of these patients, especially those without substance use disorder, can improve outcomes.

Sleep disorders

Five benzodiazepines have been approved for sleep disorders: triazolam, flurazepam, temazepam, estazolam, and quazepam.
These medications are used infrequently despite having a long half-life, which is useful for sleep initiation and maintenance.
Quazepam is designed specifically for insomnia and has activity at a different part of the alpha subunit on the GABA receptor.
Clonazepam also is useful, especially for patients with comorbid anxiety and sleep issues, because it contributes to sedation, and as a result of its long half-life, it continues to relieve anxiety throughout the day.

Generalized anxiety disorder (GAD) and panic disorder

Many clinicians are leery about using alprazolam for several reasons.
The medication’s short half-life contributes to patients using the drug several times a day.
Immediate relief of anxiety has a reinforcing effect, which in turn, increases the risk of abuse.
There are no well-designed trials comparing benzodiazepines with SSRIs. Many of the recommendations about how to use benzodiazepines come from clinical experience.
Some patients with GAD without substance use benefit from benzodiazepines such as clonazepam.
It is possible for some patients to stay on long-term treatment with benzodiazepines and not need higher doses because of tolerance.

Clarity is needed about the true impact of benzodiazepines on patients

Benzodiazepines are an integral part of the psychopharmacology armamentarium yet are underused.
Their use is increasingly discouraged, and trainees are not getting enough experience with prescribing benzodiazepines.
Benzodiazepines are rarely abused on their own.

Common mistakes in using benzodiazepines

Patients who might need or benefit from treatment with benzodiazepines are not adequately assessed.
Dose escalation with benzodiazepines often is avoided. When patients ask for an increase in the dose, this is not necessarily sign of abuse. A dose increase might be a sign that the patient is still anxious.
Trainees are not getting proper guidance in prescribing benzodiazepines; they need to be familiar with prescribing all classes of psychotropics.

References

Slee A et al. Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. Lancet 2019 Feb 23;393(10173):768-77.

Guina J, Merrill B. Benzodiazepines I: Upping the care on downers: The evidence of risks, benefits, and alternatives. J Clin Med. 2018 Jan 30. doi: 10.3390/jcm7020017.

Salzman C. The APA task force report on benzodiazepine dependence, toxicity, and abuse. Am J Psychiatry. 1991 Feb;148(2):151-2.

Fava GA et al. Benzodiazepines in anxiety disorders. JAMA Psychiatry. 2015;72(7):733-4.

Tully PJ et al. The anxious heart in whose mind? A systematic review and meta-regression of factors associated with anxiety disorder diagnosis, treatment, and morbidity risk in coronary heart disease. J Psychosom Res. 2014 Dec;77(6):439-48.

Colussi GL et al. Benzodiazepines: An old class of new antihypertensive drugs? Am J Hypertension. 2018 Apr;31(4):402-4.

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Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

In this episode, Lorenzo Norris, MD, host of the MDedge Psychcast, interviews Jonathan M. Meyer, MD, about prescribing clozapine and understanding barriers of use.

Dr. Meyer is clinical professor of psychiatry, University of California, San Diego, and a psychopharmacology consultant with the California Department of State Hospitals.

Overview of clozapine

Clozapine is an effective medication for treatment-resistant schizophrenia and lethality/suicide.
Clozapine is underused by clinicians for many reasons.
Clinicians have less comfort with prescribing clozapine.
- Too few trainees are exposed during residency to prescribing clozapine.
Using clozapine during training provides the knowledge and comfort necessary to prescribe it once out in practice.
- Fear of prescribing clozapine outweighs the benefits to patients who need it.
- Other barriers include monitoring burdens in confluence with systems issues.

Indications for use

Treatment-resistant schizophrenia is defined as an inadequate response to two antipsychotic trials, and treatment-resistant schizophrenia occurs in about 30% of patients with schizophrenia.
- People with treatment-resistant schizophrenia have a 5% chance of responding to other antipsychotic medications, while the response rate to clozapine is about 40%.
In light of those statistics, getting patients with schizophrenia on clozapine should be a priority.
Everyone benefits when a patient with treatment-resistant schizophrenia is started on clozapine.
Clozapine treatment leads to decreased symptoms and suffering, improved quality of life, decreased suicidality and aggression, and lower hospitalization rates, which in turn, lead to decreased health care costs.

Barriers to using clozapine

Education is key to empowering physicians to start prescribing clozapine and overcoming the initial resistance to prescribing.
SMI Adviser is a website sponsored by the American Psychiatric Association (APA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) that provides access to education, data, and consultations for clinicians who treat serious mental illness.
SAMHSA also has sponsored “centers of excellence” in New York state and the Netherlands that provide consultation and on-demand answers to questions about prescribing.
The Clozapine Handbook, written by Dr. Meyer and Stephen M. Stahl, MD, PhD, is another centralized resource for prescribers.
- Dr. Meyer and Dr. Stahl wrote the handbook to educate and encourage clinicians to prescribe clozapine and improve patient outcomes.

Adverse events and monitoring

Myocarditis: Rate of myocarditis ranges from 0.5% to 3% (most rates from Australia), an adverse event that happens primarily within the first 6 weeks of clozapine therapy.
- Symptoms suggesting myocarditis include fever and elevated troponin level more than twice the upper limit of normal. Clinicians can order a C-reactive protein test, which can help rule in myocarditis if troponins are elevated but not at twice the upper limit range.
- In the first 6 weeks of therapy, clinicians are encouraged to order a troponin test during the patients' weekly labs.
Isolated fever does not mean myocarditis, because fever is a common side effect during titration, and clinicians can complete the fever work-up.
Cigarette smoke can induce cytochrome P450 (CYP) enzyme, including CYP1A2.
It is not necessary to have patients stop smoking when they start clozapine.
- Clinicians can adjust the clozapine dose based on response and clozapine level.
Induction of CYP1A2 enzyme happens only when people smoke or burn the actual leaf of tobacco or marijuana.
- Vaping or e-cigarettes will not induce CYP1A2 and change clozapine levels.
Threshold of response is 350 ng/mL, however levels that lead to response differ with each individual and will be influenced by smoking habits.
Other common side effects include orthostasis, sedation, and sialorrhea.

New technologies are available to reduce barriers of prescribing clozapine and to improve patient adherence to hematologic monitoring.

Athelas is a company that manufactures a Food and Drug Administration–cleared point-of-care device to measure neutrophil count by way of a finger stick.
- Results are dispensed real time.
- Athelas also will take care of medication dispensing.
A point-of-care device is in development for plasma clozapine levels with fingerstick, which will allow clinicians to make titration decisions in real time instead of 1 week after levels.
- The device already is available in Europe.

Creating a system that allows for adherence

Using case managers to improve clozapine adherence is cost effective when the amount saved from avoiding hospitalization is taken into account.
Clozapine can lead to a functional recovery in terms of how a patient interacts with family, friends, and society at large.
Clozapine has the ability to improve productivity leading to employment, which is another way the benefits of creating a system to improve clozapine adherence outweigh financial costs.

References

Kane JM et al. Clinical guidance on the identification and management of treatment-resistant schizophrenia. J Clin Psychiatry. 2019 Mar 5;80(2): doi: 10.4088/JCP.18com12123.

Suskind D et al. Clozapine response rates among people with treatment-resistant schizophrenia: Data from a systematic review and meta-analysis. Can J Psychiatry. 2017 Nov;62(11):772-7. doi: 10.1177/0706743717718167.

Kelly DL et al. Addressing barriers to clozapine underutilization: A national effort. Psychiatr Serv. 2018 Feb 1;69(2):224-7.

Bui HN et al. Evaluation of the performance of a point-of-care method for total and differential white blood cell count in clozapine users. Int J Lab Hematol. 2016 Dec;38(6):703-9.

Other resources

SMI Adviser: Clozapine Center of Excellence, sponsored by the APA and SAMHSA.

The Clozapine Handbook (Cambridge University Press, 2019).

Clozapine and smoking cessation (NSW Health, Australia).

Point of care neutrophil measurement.

https://athelas.com/fda/.

https://curesz.org/.

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In this episode, we revisit three of our best episodes on preventing suicide. In episode 46, Lorenzo Norris, MD, host of the MDedge Psychcast, interviewed Igor Galynker, MD, about how to assess suicide crisis syndrome. Dr. Norris is editor in chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Galynker is associate chairman for research in the department of psychiatry at Mount Sinai, New York.

In episode 42, Dr. Norris interviewed Caroline Bonham, MD, and Avi Kreichman, MD, about addressing suicidality in rural communities and strategies for enhancing resilience. Dr. Bonham and Dr. Kreichman work together at the University of New Mexico, Albuquerque. She serves as vice chair of the department of psychiatry and behavioral sciences at the university, and he is an assistant professor there.

In episode 54, Sidney Zisook, MD, who directs the residency training program at the University of California, San Diego, conducted a Masterclass on the many causes of physician suicide and how this might be prevented.

And stay tuned for our Dr. RK segment, where Renee Kohanski, MD, who talks about making mistakes while caring for patients and granting ourselves full and complete forgiveness. Dr. Kohanski has a private practice in Mystic, Conn.

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Headline: Update on the American Psychiatric Association – Part 2

Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Lorenzo Norris, MD, interview with Saul Levin, MD, MPA, CEO and medical director of the American Psychiatric Association (APA). Dr. Levin also is clinical professor at George Washington University.

Improving access to care and impact of psychiatrists is imperative.

Finding a doctor: More physicians need to be trained. Increasing the number of physicians can be accomplished through initiatives funded by the government and by private medical centers.
- Innovation in training at both undergraduate and graduate levels is needed to increase the number of physicians across all specialties.
- Debt repayment: The APA is encouraging the federal government to diversify its loan repayment options, such as by making it possible for psychiatrists to practice in more diverse but underserved places in exchange for loan repayment.
Getting to a doctor: Telepsychiatry and collaborative care are means of increasing access.
- Collaborative/integrative care: The psychiatrist acts as an adviser to a whole team and then offers direct patient care in more complex cases.
- Telepsychiatry improves access by decreasing stigma and reducing commute time to and from patient visits.
  - Both psychiatrists and patients save time and gain convenience.
Using evidence-based treatments (EBT) is important in psychiatry.
- One goal is to advance the use of EBT to enhance the impact of psychiatric treatment, especially by using quality measures (for example, the nine-item Patient Health Questionnaire) to validate the impact of treatment.
- The Centers for Medicare & Medicaid Services has given grants to medical associations such as the APA to create quality measures to quantify/validate the impact of treatments in an effort to foster more EBT in psychiatry.

Conclusion: Advocating on behalf of people with psychiatric disorders requires a broad approach.

The APA lobbies for fairness, parity, and quality treatment.
The group works to advance EBTs and new treatments.
Recruitment of diverse individuals to psychiatry is important.
“Moonshot” level research is integral to the advancement of psychiatry and the mental health of the patients.
The APA strives to balance a mission of government advocacy and individual psychiatrist education.

References

APA Innovation Lab

Mental health parity advocacy

Advocacy and APAPAC

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Update on the American Psychiatric Association – Part 1

Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Lorenzo Norris, MD, interview with Saul Levin, MD, MPA, CEO and medical director of the American Psychiatric Association (APA). Dr. Levin also is clinical professor at George Washington University.

In 2019, the American Psychiatric Association celebrated its 175th anniversary.

The APA was the first medical association formed in the United States.
The 2019 APA annual meeting in San Francisco attracted 13,000 psychiatrists and mental health professionals, and hosted 650 sessions covering all topics in psychiatry, including subjects related to private, community, and academic psychiatry.
Highlights of the 2019 meeting included:
- A Gala at San Francisco City Hall, which allowed generations of psychiatrists to celebrate the progress of the APA.
- Sessions at the meeting, which focused on the latest basic, clinical, service, and psychopharmacology research.
- Additional sessions focused on minority and underrepresented populations, both within APA membership and patient populations.
Major networking opportunities at the APA were available, allowing peers and experts in the field to create lifelong professional relationships.
- A burgeoning networking opportunity is the Psychiatry Innovation Lab, which is “an incubator at the American Psychiatric Association that aims to catalyze the formation of innovative ventures to transform mental health care.”

The APA’s role in advocacy: The organization is not just a guild that seeks to support psychiatrists.

Part of the APA’s mission is to advocate for patients with mental health illness with a focus on improving treatment and outcomes.
For members, the APA sponsors a National Advocacy Day on Capitol Hill and state advocacy days, in which the APA helps fund people to come talk to their elected representatives.

Major areas of advocacy by the APA as a medical association are numerous.

Mental health parity: Advocating for equal pay to psychiatrists for treating mental health diagnoses as well as the provision of equal coverage of psychiatric diagnoses by insurance companies.
Augmentation of the workforce: Supporting measures aimed at making sure that there are enough psychiatrists to treat patients with mental illness in the United States.

Examples of advocacy initiatives by the APA are numerous. The group is active in the following areas:

Advocates for legislation that advances telepsychiatry by supporting laws aimed at reducing barriers to the technology.
Promotes integrative mental health care models.
Explains the concept of prior authorization on Capitol Hill and helps to craft sensible guidelines.
Promotes evidence-based treatments for substance use disorders, especially opioid use disorders.
Lobbies for appropriations for agencies such as the Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health, and the National Institute on Alcohol Abuse and Alcoholism.
Helps construct smart loan repayment plans aimed at allowing psychiatrists to practice in low-resource areas.

The APA recommends several research initiatives.

“Moonshots” should be a goal in in psychiatry, much like those taken with illnesses such as HIV and breast cancer.
Stigma must be reduced, and money must be appropriated to mental illness research in the same way it is for other medical illnesses.

References

APA Innovation Lab

Mental health parity advocacy

Advocacy and APAPAC

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Show Notes

Lorenzo Norris, MD, interview with Robert McCarron, DO, at the American Psychiatric Association meeting (#APAAM19)

Dr. McCarron is vice chair of education and integrated care at University of California, Irvine, department of psychiatry. He is also trained as an internist.

Shortage of psychiatrists, other mental health providers

About 70% of all psychiatrists are over the age of 50 years and looking toward retirement.
This also pertains to other mental health providers, such as psychologists.

Implications of shortage

People with severe mental illnesses (SMIs) are not getting the care they need. On average, they die 10-15 years younger than people who do not have SMIs. Patients with SMIs have a higher risk of death from illnesses such as heart disease, hypertension, and osteoarthritis because they are not getting preventive/primary care.
Patients with chronic pain issues are not getting care.
In California, physician assistants provide care to many patients, but they get only 2 weeks of instruction in psychiatry.
About 80% of all antidepressants are prescribed by nonpsychiatrists. About 60% of all mental health care is delivered in the United States by clinicians who do not specialize in mental health. This care is delivered in primary care settings. About 40%-45% of patients seen in primary care offices are treated for behavioral health issues, such as depression, anxiety, or substance use disorders.
Suicides are up more than 20% over the last decade. On average, 25 veterans die by suicide each day.

Training primary care colleagues in psychiatry

Primary care physicians have a core baseline in biomedical sciences. Giving them a booster in behavioral health is a way to address the shortage.
The Train New Trainers Primary Care Psychiatry Fellowship was launched at University of California, Davis, and the University of California, Irvine. It has 125 fellows throughout the country, and the hope is to double that number.
- The program lasts 1 year, including two intensive weekends.
- It teaches fellows how to conduct motivational interviewing; short, targeted, and brief psychotherapies that are effective and evidence based.
- The Fellowship includes Web-based presentations two to three times per month.
- It also includes small group mentorship meetings in which fellows discuss patients and learn how to navigate complex cases.
A combined residency program might be another way to address the need for more training in psychiatry.

References

Price S. Front line: Using primary care to prevent suicide. Tex Med. 2018 Nov 1;114(11):16-21.

Santiani A et al. Projected workforce of psychiatrists in the United States: A population analysis. Psychiatr Serv. 2018 Jun;69(6):710-3.

Huff C. Shrinking the psychiatrist shortage. Manag Care. 2018 Jan;27(1):20-2.

Wilkins KM et al. Integration of primary care and psychiatry: a new paradigm for medical student clerkships. J Gen Intern Med. 2018 Jan;33(1):120-4.

McGough PM et al. Integrating behavioral health into primary care. Popul Health Manag. 2016;19(2):81-7.

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Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Guest

George T. Grossberg, MD: Samuel W. Fordyce Professor; director, geriatric psychiatry at Saint Louis University.

Dr. Grossberg spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.

New developments in Alzheimer’s research

The Systolic Blood Pressure Intervention Trial, also known as the SPRINT MIND Study, showed that tightly controlled systolic blood pressure (SBP) of 120 mm Hg, compared with an SBP of 140 mm Hg, resulted in a 20% reduced risk of developing mild cognitive impairment.
- The SPRINT study was terminated early at the median follow-up of 3.26 years as its results showed that tightly controlled SBP significantly reduces the risk of stroke and heart disease.
- The Alzheimer’s Association has agreed to fund an additional 2 years of the SPRINT MIND Study to evaluate whether tightly controlled BP is effective in reducing the risk of Alzheimer’s disease.
In the brain, the glymphatic system was discovered in 2012 and is similar to the lymphatic system in its role as a drainage system for removing toxins.
- Glial cells mediate toxin removal, and the glymphatic system removes toxins that eventually can cause cell death in the brain.
- Because the glymphatic system is involved in removing the beta-amyloid plaques that contribute to cell death in AD, the glymphatic system is another area of investigation in the pathogenesis of AD.
Novel treatment of moderate to advanced AD involves using plasma infusion.
- Infusion of plasma products from healthy, nonimmunocompromised 18-year-old individuals into older patients with AD is a potential treatment for AD.
- Precedent for this intervention comes from animal studies investigating parabiosis, a procedure in which two animals are connected so that they share each other’s blood stream.
  - When such a circulatory exchange occurs between a younger mouse and an older mouse with AD, the older AD model mouse regains cognitive abilities and is able to complete mazes that it was unable to complete before.
How can this model be adapted to humans? One possibility might involve infusing plasma from young healthy individuals into older adults with advanced AD.
- A safety proof-of-concept study, published recently, found that plasma products can be safely infused. The next step is an efficacy study.
A relationship has been found between AD and periodontal disease.
- The primary bacteria related to periodontal disease, Porphyromonas gingivalis, is found in close proximity in the brain to the plaques and tangles of AD.
- One theory posits that the presence of this bacteria is related to inflammation that may contribute to the causality of AD.
- Could AD be treated with the antibiotics used to treat periodontal disease? The answers remain unclear.
Aducanumab, a monoclonal antibody targeting the beta-amyloid plaques of AD, initially showed favorable changes in imaging studies of the brains of people with AD.
- In March 2019, the study was halted because of futility.
- An independent data-monitoring committee determined that the early results seen on imaging did not result in clinically meaningful changes, compared with placebo.
- Some AD researchers consider this drug failure the “final nail in the coffin” of the amyloid hypothesis, and the pathogenesis of AD is most likely related to tau neurofibrillary tangles and other mediators, such as the immune system and inflammation.

References

SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 26 Nov 2015;373:2103-16.

Jessen NA et al. The glymphatic system: A beginner’s guide. Neurochem Res. 2015 Dec;40(12):2583-99.

Dominy SS et al. Porphyromonas gingivalis in Alzheimer’s disease brains: Evidence for disease causation and treatment with small-molecule inhibitors. Science Advances. 23 Jan 2019;5(1): doi: 10.1126//sciadv.aau3333.

Conese M et al. The fountain of youth: A tale of parabiosis, stem cells, and rejuvenation.

Open Med (Wars). 2017;12:376-83.

Phase 3 study of aducanumab in early Alzheimer’s disease. ClinicalTrials.gov Identifier: NCT02477800.

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Part I of II (episode 62)

If you have lost a patient to suicide, or if you simply want to be part of the conversation, we strongly encourage you to email us at podcasts@mdedge.com your email will be read and discussed in a future episode. You can also tweet at us at @MDedgePsych.

If you're someone struggling with suicide in need of care, the national suicide hotline is 800-237-8255.

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Part I of II (episode 62)

If you have lost a patient to suicide, or if you simply want to be part of the conversation, we strongly encourage you to email us at podcasts@mdedge.com. Your email will be read and discussed in a future episode. You can also tweet at us at @MDedgePsych.

If you're someone struggling with suicide in need of care, the national suicide hotline is 800-237-8255.

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In this masterclass, Charles L. Raison, MD, returns to the MDedge Psychcast to discuss the risks and benefits of antidepressants. He previously appeared on the Psychcast in episodes 15 and 16.

Dr. Raison is Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families and professor, School of Human Ecology, and professor, department of psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison.

Later, Renee Kohanski, MD, discusses the need for psychiatrists to take care of and nourish their communities.

Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Treatment with antidepressants

The STAR-D trial, a large effectiveness trial (n = 4,000), looked at the effect of SSRIs and other medications for the treatment of depression.
As an effectiveness trial, STAR-D looked at “real” patients with comorbidities (as opposed to efficacy trials, which use “perfect patients” with no comorbidities to minimize confounding effects).
- Only 30% of patients went into complete remission with first step of treatment with an SSRI (citalopram) at the highest tolerated dose.
- Almost 50% experienced a response (a 50% reduction in symptoms of depression on standardized scale).

Cynicism and hope for antidepressants

To obtain Food and Drug Administration approval, a medication requires two positive studies (showing that the drug beats placebo), and on average, an SSRI requires five to seven studies to get the two positive studies.
- A meta-analysis of negative SSRI studies that were “filed away” found only a 1.8-point difference on Hamilton Depression Rating Scale score between SSRI vs placebo.
- The difference between SSRI and placebo in treatment disappeared among patients who were less depressed.
Geddes et al., presented a more balanced view in a published meta-analysis of 522 trials that included more than 100,000 patients.
- Antidepressants had a modest benefit, compared with placebo.
- In head-to-head studies, some antidepressants were better than others, such as amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine.

Predictors of response

Poor response to antidepressants: Presence of comorbid anxiety disorder, failure of first or subsequent antidepressant trials.
- Within STAR-D, among those who failed three treatment steps, only 13% responded to the next treatment.
Good response to antidepressants: An acute response to an antidepressant predicts long-term response.
- A 20% or greater improvement within 2 weeks of treatment resulted in a higher chance of remission, compared with those who don’t initially respond, who then had a less than 5% chance of remission.

Are antidepressants good for everyone?

The difference between active antidepressants and placebo is small.
A latent growth curve analysis of placebo vs. antidepressants for depression showed that there are two separate trajectories with antidepressants: 70% will respond and are vastly improved, while 30% actually do worse.
A National Institute of Mental Health study from 1980s randomized patients to two types of psychotherapy vs. tricyclic antidepressants (TCAs) vs. waitlist control group. Treatment took place for 16 weeks, and patients were followed for 18 months.
- People who went into remission on TCAs were more likely to relapse than those who went into remission on psychotherapy.
Epidemiological Catchment Area (ECA) trial: Prospective data of 92 people from the total 3,500 in the study.
- Of the 92 with a first major depressive episode, 50% had a second major depressive episode.
- Of those who were treated into complete remission, even after 5 years, more than 50% had a relapse of their depression.

Conclusion: Relapse of depression is common when patients come off antidepressants

To stay well, a patient with depression should continue to receive an antidepressant.
Clinicians must ask: Do the antidepressants increase the risk of relapse of depression?
Depression is a disabling disease, so treatment is necessary. But clinicians should question for whom and when antidepressants should be used.

References

Turner EH et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358:352-60.

Cipriani A et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet. 2018 Apr 7:391(10128):1357-66.

Penninx BW et al. Two-year course of depressive and anxiety disorders: Results from the Netherlands study of depression and anxiety (NESDA). J Affect Disord. 2011 Sep;133(1-2):76-85.

Perlman K et al. A systematic meta-review of predictors of antidepressant treatment outcome in major depressive disorder. J Affect Disord. 2019 Jan 15;243:503-15.

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In part II of this Psychcast Masterclass, Patricia Westmoreland, MD, returns to discuss severe, enduring eating disorders, including management and ethical questions.

In Dr. RK this week, Renee Kohanksi explores the impact of censorship and self-censorship.

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Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Guest

Patricia Westmoreland, MD, a forensic psychiatrist at the University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; adjunct assistant professor of psychiatry at the University of Colorado Denver.

Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.

Harm reduction, palliative care, and futility

Harm reduction model: A focus on returning to reasonable level of functioning without focus on full weight restoration, especially if full weight restoration has not proven sustainable with previous treatment.
- Harm reduction is managed an as outpatient with regular check-ups. Team collaborates for attainable, mutual treatment goals.
- Patients are allowed to stay at a lower body mass index (BMI) and are able to partially function and do things they enjoy, such as living with family and working part time.
- Patients maintain an agreed-upon weight and regularly check labs.
Inpatient hospitalization is pursued only to restore weight back to previously agreed-upon goal:
- BMI is a marker of risk; BMI greater than 15 kg/m2 is lower risk, and BMI less than 13 kg/m2 is higher risk (lower BMI is tied to higher immunocompromised risk, more fractures, and other illnesses, as well as a greater risk of suicide, etc.)
Palliative care is offered when patients have failed harm reduction and cannot sustain an acceptable body weight (not weight restored):
- Palliative care is NOT hospice, and therefore, there are no specific expectations.
- Treatment goal is comfort care, i.e., analgesics for fractures and decubitus ulcers, anxiolytics for refractory anxiety.

Ethics and futility:

When to say “enough is enough”? In anorexia nervosa (AN), frequently, many treatments have been implemented, and there may be no cure.

Some think that anorexia should never be an end-stage diagnosis.

Cynthia Geppert, MD, MPH, a health care ethicist and a professor of psychiatry and internal medicine at the University of New Mexico, Albuquerque, who wrote in the American Journal of Bioethics: “Futility and chronic anorexia nervosa: A concept whose time has not yet come,” argues against futility:

AN does not meet definition of a terminal illness:
- The patient’s depleted weight renders a patient as having a life-threatening illness.
- Can a patient be terminal and is care futile if there is hope for long-term recovery?
Legally: Cognitive distortions make up the core of AN as an illness. Do patients with AN have the capacity to decide that further treatment is futile?
- Cognitive impairments often normalize with treatment. Are physicians obligated to treat first in order to restore a patient’s decision-making capacity before allowing them to choose palliative care?
- People with AN may lack capacity because they cannot appreciate the consequences of their decision, which is one of the four components of capacity.

In support of futility, Cushla McKinney, PhD, of the biochemistry department at University of Otago (New Zealand), argues against the complete rejection of the concept of futility, saying it risks forcing a small and chronic group of patients into an intolerable situation.

Arguments for futility: Not EVERY individual with AN lacks capacity.
- Some argue for futility, and allowing patients to make choices in line with what they value in life.
- Prognosis, even with treatment, is poor, especially for older individuals with years of failed treatments and medical comorbidities.
- Are we doing harm by forcing an invasive treatment that patients don't want – especially after much treatment?

Illustrative case of AG, a 29-year-old female with chronic AN, who had a guardian for medical decision making:

The guardian had decided in favor of tube feedings many times; AG had suffered complications such as heart failure.
AG wanted to enter palliative care, arguing that she did not want to die, but if death were the result of AN, then “so be it.”
The judge ruled she could refuse treatment. He did not comment on capacity, but ruled she could make this decision to die on her terms.

Emerging concerns:

Is anorexia nervosa an end-stage illness or not? How will physician aid-in-dying overlap with AN? Do eating disorder patients have the capacity to request aid-in-dying, and what is the physician obligation?

References

Eddy J. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. Clin Psychiatry. 2017 Feb;78(2):184-9.

Sjostrand M et al. Ethical deliberations about involuntary treatment: Interviews with Swedish psychiatrists. BMC Med Ethics. 2015;16:37.

Geppert C. Futility in chronic anorexia nervosa: A concept whose time has not yet come. Am J Bioethics. 2015. 15(17):34-43.

Cushla M. Is resistance (n)ever futile? A response to “Futility in chronic anorexia nervosa: A concept whose time has not yet come,” by Cynthia Geppert. Am J Bioethics. 2015 Jul 6. 15(7):53-4.

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In Episode 59 Patricia Westmoreland, MD, gives a masterclass lecture on managing severe and enduring eating disorder (SEERS).

Renee Kohanksi, MD, poses the question, "What do we want?"

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Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Guest

Patricia Westmoreland, MD: forensic psychiatrist at University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; and adjunct assistant professor at University of Colorado Denver in department of psychiatry.

Introduction, definition, role of involuntary treatment, and novel treatment options

Introduction:

Prognosis: Anorexia nervosa (AN) has the highest mortality of any psychiatric disorder.
- Risk factors for death: Older age at first presentation, lower weight at presentation, greater duration of illness, comorbid alcohol or diuretic abuse, comorbid mood disorder, history of psychiatric hospitalization and suicide attempts, and self-harm.
  - Less than 50% recover completely, about 30% improve somewhat but require frequent hospitalizations or treatments, and 20% develop a SEED.
- Eddy et al. longitudinal study of eating disorders (EDs): AN patients can recover over the long term. Overall, 31% were better at 9 years; 63% better at 22 years of follow-up.

Treatment:

Treat ASAP, especially if patient is seen at a young/pediatric age before symptoms are fully developed and weight loss is profound.
- Weight gain as the central treatment: Many patients are reluctant to get treatment that focuses only on food intake and weight gain.
- Predictors of improvement: Weight gain that is parallel to improvement in physical and psychological well-being, diagnosis at a younger age, and shorter duration of illness.
Medications: Fluoxetine is the only Food and Drug Administration-approved treatment for EDs, including bulimia, at doses of 60 mg and above.
- Patients with EDs have poor response to selective serotonin reuptake inhibitors because of starvation and limited production of serotonin and serotonin receptor abnormalities.

Severe and enduring eating disorders (SEED) definition:

6-12 years of an ED can qualify as chronic.
Lower likelihood of recovery with symptoms substantially interfering with quality of life.

Role for involuntary treatment in EDs: Few treatment centers do involuntary treatment of ED.

Involuntary treatment can involve guardianship for medical decisions.
- Guardianship is useful for medical treatment and admission to a medical ward, for example, when a patient requires forcible tube feeding for life-threatening starvation.
Commitment or certification is required for involuntary treatment in a psychiatric hospital.
- Commitment is sought by a psychiatrist and is a tool in cases when the patient is dangerous to self or others and is gravely disabled.
  - It is useful to commit a patient who is refusing care and has not been sick for long. Often, commitment/certification is used as a last resort, and the patient is too sick to truly recover.
- Pros and cons of involuntary treatment:
  - Pro: No difference in weight restoration in voluntary vs. involuntary treatment, and patients are often grateful after involuntary treatment.
  - Cons: Involuntary tube feeding has unclear long-term outcomes.
    - Some studies show poor outcomes for people who are treated involuntarily, though this is likely because of their comorbidities.

Novel treatment options:

Ketamine has been used in EDs. Concerns remain about the drug’s addictive potential and inability to clearly change eating disorder pathology.
Oxytocin: There are reduced cerebrospinal fluid levels of oxytocin in AN, and oxytocin restores during recovery.
- Experimentally in rats, oxytocin may reduce the fear and social phobias related to eating.
Electroconvulsive therapy does not reduce ED symptoms such as restricted eating and fear of fatness, but it can improve depression.
- People with ED are often medically ill, so the patient must be physically able to undergo treatment.
- Because of medical comorbidities, AN patients are more likely to have complications like delirium.
Transcranial magnetic stimulation: Dorsolateral prefrontal cortex involved in self-regulatory control, inhibitory control, and cognitive flexibility.
- Some studies show promising results of using this intervention with ED and mild side effects like syncope and headache.
Deep brain stimulation (DBS): Treatment targets the nucleus accumbens and the subcallosal cingulate gyrus, which theoretically alter balance between reward and cognitive inhibitory and control systems that are related to pathological eating behaviors.
- DBS has strongest theoretical rationale in terms of neurocircuitry targets.

References

Eddy J. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. Clin Psychiatry. 2017 Feb;78(2):184-9.

Sjostrand M et al. Ethical deliberations about involuntary treatment: Interviews with Swedish psychiatrists. BMC Med Ethics. 2015;16:37.

Geppert C. Futility in chronic anorexia nervosa: A concept whose time has not yet come. Am J Bioethics. 2015. 15(17):34-43.

Cushla M. Is resistance (n)ever futile? A response to “Futility in chronic anorexia nervosa: A concept whose time has not yet come,” by Cynthia Geppert. Am J Bioethics. 2015 Jul 6. 15(7):53-4.

In part 2, Dr. Westmoreland will discuss harm reduction, palliative care, and futility.

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Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Masterclass guest

Richard Balon, MD: professor of psychiatry and training director at Wayne State University, Detroit.

In March, Dr. Balon spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.

Physician burnout and effective interventions

The scales (for example, the Maslach Burnout Inventory) do not necessarily represent the full extent of burnout:
- If physicians work 12 hours but find fulfillment in work, they will be tired but not necessarily burned out. However, if physicians work 12 hours a day feeling frustrated by the systemic problems, then burnout can ensue.
Common contributors to provider burnout:
- Excessive workload: Pressures of working with an electronic medical record, extensive time spent on documentation; lack of work satisfaction and job control; lack of respect for the work; student loan burden.
- “Moral injury”: The emotional burden, which occurs when physicians cannot deliver ideal care/treatment to patients, especially when limited by resources (such as insurance or poverty), or other systemic health care issues.
- Work environment and organizational culture: These factors also contribute to physician burnout.

Burnout is a problem for health care organizations as a whole

Two main ways to address burnout: Physician-directed interventions (focused on individuals) and organization-directed interventions.
Organization-directed burnout prevention strategies include:
- Reducing workload; reducing time spent on documentation, such as decreasing time spent in front of EMRs; cultivating effective teamwork; fostering a sense of job control.
Organizations prefer individual-focused interventions over systemic changes.
- Examples include mindfulness teaching, yoga, cognitive-behavioral therapy techniques, education about burnout, and education.
- Individual-focused interventions are great, but they are not realistic for changing the culture that contributes to burnout.

Interventions for burnout

In a systematic review and meta-analysis in JAMA Internal Medicine, Maria Panagioti, PhD, and colleagues found that:

Burnout interventions focused on individual physicians have small, significant effect on physician burnout.
Organizational-directed approaches result in greater treatment effects, especially when interventions focus on promoting healthy individual-organization relationships.
- The impact of individual interventions can be improved when supported by organizational interventions.
- Interventions targeted at more experienced physicians within primary care settings show greater treatment effect than interventions targeted at less experienced physicians within secondary treatment settings.
Approaches identified by staff, as outlined in a New England Journal of Medicine article, can lead to meaningful change.
- A Hawaiian health care system queried individuals (physicians, mid-levels, and nursing staff) to identify parts of EMR documentation that are poorly designed and unnecessary, and lead to unintended burdens contributing to burnout.
- This type of survey improves efficiency of a system and shows that the health care organization cares about preventing clinician burnout.

References

Panagioti M et al. “Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis.” JAMA Intern Med. 2017 Feb 1;777(2):195-205.

Ashton M. “Getting rid of stupid stuff.” N Engl J Med. 2018 Nov. 8;379(10):1789-91.

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Host Lorenzo Norris, MD, returns this week for a dual-specialty episode on the opioid crisis and how it can be mitigated. He welcomes psychiatrist Martin Klapheke, MD, and family practice physician Magdelena Pasarica, MD, PhD, to talk about education, strategies, and collaboration between psychiatry and family practice medicine.

In Dr. RK this week, Renee Kohanski, MD, talks about whether something is indeed better than nothing.

You can contact the Psychcast by emailing us at podcasts@mdedge.com or you can follow us on Twitter at @MDedgePsych.

Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Guests

Dr. Martin M. Klapheke: psychiatry residency program director; assistant dean, medical education; and professor of psychiatry at University of Central Florida, Orlando

Dr. Magdalena Pasarica: associate professor of medicine; medical director, KNIGHTS (Keeping Neighbors in Good Health Through Service) student-run free clinic; family medicine chair, Family Medicine Interest Group adviser at University of Central Florida, Orlando

How to address the opioid crisis during training

The opioid crisis looms large over the medical field:
- 130 deaths from opioid overdoses per day.
- 11 million people misuse opiate prescriptions and 2.1 million people have an opioid use disorder.
In 2018, the Department of Health & Human Services released a 5-point strategy in response to the opioid crisis:
Access: Providing better prevention, treatment, and recovery services.
Data: Offering timelier, more specific public health data and reporting.
Pain management: Mitigating risk while prescribing with healthy, evidence-based methods of pain management.
Overdoses: Targeting overdose-reversing drugs better.
Research: Doing better research on pain and addiction.

Educating the next generation of medical professionals to address the opioid crisis

From the family medicine and resident education point of view:
- Mitigate the risk when prescribing opiates.
- Identify opioid use disorder (OUD).
- Use the interdisciplinary approach to know when to refer to psychiatry and pain medicine.
- Primary care providers are on the front lines of the crisis, as 11% of patients report chronic pain.
- PCP will have to treat pain and:
From the psychiatric and medical education point of view:
- Before opioid crisis, there was little instruction in how to treat acute or chronic pain.
- Medical education now teaches about pain management: Information about non-narcotic analgesics, nonmedication pain treatments, and addiction and its treatment.
- Medical students: Focus on working with family members of those with OUD and especially on using naloxone to reverse opioid overdose.

Interprofessional approach is most effective with communication with shared priorities

We can collaborate effectively by understanding our shared priorities and offering all providers the opportunity to working toward these priorities in their own ways.

From Dr. Klapheke: The opioid crisis crosses all specialties of medicine, and doctors will reach the limit of their expertise.

Work interprofessionally by communicating and knowing what resources are available.
Communicate what each party is doing for the epidemic and for the patient.
This means knowing about resources in the hospital, clinics, city, county, law enforcement, etc.

From Dr. Pasarica: Again, we must acknowledge the limits of our expertise and work interdisciplinarily in a team-based approach.

Each team member needs to be responsible for the follow-up, even if the patient is referred to another person such as a counselor or a psychiatrist.
Each team member must share information and what has been done for the patient.

How is addressing the opioid epidemic being integrated into medical student and resident education?

From Dr. Klapheke: At University of Central Florida, the medical school uses vertical and horizontal integration of information into the curriculum.

During the preclinical years: Write OUD and pain management into standardized patient work.
- Focus on the pharmacology of opiates and understanding neuroscience of addiction.
During clinical rotations: Discuss OUD and the opioid epidemic during every specialty rotation and in lectures:
- Use simulations: For example, during the third year, treat a patient experiencing opioid overdose.
Medical schools should take advantage of already created online resources to teach about substance use disorder and opioid use disorder.
Educating medical students and residents to incorporate family members in treatment:
- Give family members information on chronic pain, addiction, and refer them to support groups.

From Dr. Pasarica: There also is a focus on interdisciplinary care in clerkships and in the student-run free clinic. It is important to teach interdisciplinary care in clerkships and volunteer settings.

Work with counseling students and pharmacy students to screen and manage substance use disorder.
Visit treatment and recovery sites during medical school to see interdisciplinary work in action.

General ways to teach about the opioid epidemic in medical education:

Focus on longitudinal educational experiences about pain and treatment.
Focus on interdisciplinary care.
Talk about pain in all different settings.
Create simulations and online training modules.
Use the medical school and GME network: Collaborate with other medical schools and hospitals about education and treatment.
Address the stigma that occurs in the health care setting:
- Stigma is a barrier to patients and family accessing treatment.
- Nonjudgmental education about opioids, the crisis, and treatment can decrease stigma from health care providers.

References

Department of Health & Human Services: 5-point Strategy to Combat the Opioid Crisis

Association of American Medical Colleges News: “Responding to the opioid epidemic through education, patient care, and research.”

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MDedge Psychiatry live Twitter chat on the aftermath of losing a patient to suicide.
April 24th, 6 - 7 p.m. EST.
@MDedgePsych, #MDedgeChats

Episode 54

Donald Black, MD, gives a masterclass lecture on behavioral addictions and Renee Kohanski talks about what normal is.

Show Notes
By Jacquiline Posada, MD.

Gambling disorder (previously pathological gambling) is widespread, though not commonly assessed
Patients may not volunteer information related to gambling unless asked, so questions about gambling should be included in routine questioning
Assessment should include questions about legal and illegal gambling
- Explore extent: Ask about the level of financial burden; impact on home life, such as marital problems and divorce; legal complications like bankruptcy. Finally, ask about suicide risk related to gambling
Treatment: There is strong data for SSRI medications and naltrexone for urges
- Therapy is more efficacious, such as CBT therapy and Gamblers Anonymous
- In certain states, such as Iowa, a person can ask for “self-exclusion,” which is essentially banning oneself from a casino or lottery. Also, participation in gambling results in arrest

Behavioral addictions: Behavior that is out of control and has qualities and consequences similar to drug and alcohol addiction

Examples include gambling disorder, compulsive buying, compulsive sexual behaviors (hypersexuality), and Internet addiction
- Gambling disorder is similar enough to substance addictions that it is included in the DSM-5 in the “substance-related and addictive disorder”
- Addiction neurocircuitry active in these behavioral addictions: Dopamine driven in the nucleus accumbens
Compulsive shopping: primarily a female disorder, onset in late 20s, with shopping and spending that are chronic and problematic
- CBT programs developed to target compulsive shopping, studies about medications for this disorder are mixed
Compulsive sexual behavior: Primarily a male disorder affecting 5% of the population; onset late teens, early 20s. The addiction will combine conventional sexual behaviors taken to extremes often combined with an addiction to pornography
- This disorder will often overlap with an Internet addiction
- No evidence-based treatments exist, though CBT-driven models and 12-step programs exist
- SSRI or TCA antidepressants may be helpful in dampening sex drive
Internet addiction has developed in our technologically enabled world; most psychiatrists have encountered this addiction.
- Most data come from Asia, where children are exposed to technology at an even earlier age than in the U.S.
- China has developed residential treatment programs involving individual and group therapies.

References

Black DW. Can J Psychiatry. 2013 May;58(5):249-51. “Behavioral addictions as a way to classify behaviors”
Dell’Osso B et al. Eur Arch Psychiatry Clin Neurosci. 2006 Dec;256(8):464-75. “Epidemiologic and clinical updates on impulse control disorders: a critical review”
National Council on Problem Gambling. State by state help for problem gambling
Zajac K et al. Psychol Addict Behav. 2017 Dec;31(8):979-94. “Treatments for Internet gaming disorder and Internet addiction: A systematic review”

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In this episode of the MDedge Psychcast, Sidney Zisook, MD, gives a Masterclass lecture on physician suicide and Dr. RK talks about what can be spoken into existence.

If you have ideas, suggestions, questions for Dr. Norris or Dr. RK, or feedback for the show, please email us at podcasts@mdedge.com. You can also follow us on Twitter @MDedgePsych.

Show Notes
By Jacqueline Posada, MD

Introduction

Suicide in general population increased by 30% since 1999. The suicide rate was 14 people in every 100,000 up from 10.5 people per 100,000 in 1999.
400 physicians die per year. However, there is not great data collection about profession-specific suicide
Suicide is the leading cause of death in male residents and the 2nd leading cause of death in female residents
This represents a serious loss of the medical profession as well as the thousands of patients who lose their physician as well

Risks factors for physician suicide

Psychological:

Physicians tend be contentious, perfectionistic, and compulsive. They are able to cope with delayed gratification, and this may lead to a false sense of ability to cope with all obstacles, without failures.
Medicine presents physicians with many obstacles such as the deaths of our patients and human frailty. Human imperfection and physician failures are juxtaposed against these traits listed above

Historical and genetic risk factors:

Past suicide attempt and presence of mood disorder
Untreated depression is an especially high risk for physicians as they may leave their mental illness untreated due to stigma
As of 2017, 32 of 48 state licensing boards continue to question doctors about their mental health history.
There is increased risk of suicide with the presence of the long arm version of the serotonin transporter gene and history of childhood trauma

Workplace risk factors:

Physicians identify electronic medical records (EMR) and increased documentation demands as contributing to burnout and less job satisfaction
EMR means that doctors feel like they spend more time with records than face to face with patients. With EMR there is less eye contact and direct connection with patients so it’s hard to foster relationships
Physicians feel the stress of increased use of technology and connectivity via cell phones and the need to “keep up”

Change in culture

As a profession we are starting to talk about physician suicide; acknowledgment of the issue can lead to change.
ACGME and other workplaces are starting to integrate physician wellness into curriculums and culture.

References:

NCHS Data Brief No. 330. 2018 Nov.“Suicide mortality in the United States, 1999-2017”
Yaghmour, NA et al. Acad Med. 2017 Jul. 92(7):976-83.“Causes of death of residents in ACGME-accredited programs 2000 through 2014” Implications for the learning environment”
Babbott S et al. J Am Med Inform Assoc. 2014 Feb;21(e1):e100-61. Electronic medical records and physician stress in primary care: Results from the MEMO Study”
Gold KJ et al.Gen Hosp Psychiatry. 2013 Jan-Feb;35(1):45-9. “Details on suicide among U.S. physicians: Data from the National Violent Death Reporting System”
ACGME Symposium on Physician Well-Being

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Charles Raison, MD, returns to the Psychcast this week to give a Masterclass lecture on the bidirectional relationship between inflammation and depression. There are links to relevant research below.

Dr. Raison discusses incorporating the science of inflammation into the pharmacologic treatment of depression. He addresses research suggesting that while depression as a whole isn’t an inflammatory condition, inflammation may be a depressive subtype. He also covered how inflammation might affect treatment.

You can listen to Dr. Raison's take-home messages by skipping to (19:45).

CHARLES RASION, M.D.

Dr. Raison is Mary Sue and Mike Shannon Chair for Healthy Minds, Children, & Families and Professor of Human Development and Family Studies at the School of Human Ecology as well as Professor in the Department of Psychiatry at the University of Wisconsin-Madison School of Medicine and Public Health.

Dr. Raison previously appeared on Psychast in a two-part lecture on ketamine. In episode 14, Dr. Raison talked on ketamine and PTSD and in episode 15, he talked about ketamine and depression. You can find those episodes by clicking the links below:

Psychcast Episode 14: Charles Raison, MD, Ketamine & PTSD.

Psychcast Episode 15: Charles Raison, MD, Ketamine & depression.

Relevant Research:

Use these links to find more on this Masterclass.

Rong, Carola, et al. Predictors of Response to Ketamine in Treatment Resistant Major Depressive Disorder and Bipolar Disorder. Int J Environ Res Public Health. 2018 Apr 17:15(4): doi: 10.3390/ijerph15040771.
https://www.ncbi.nlm.nih.gov/pubmed/29673146

Savitz, JB et al. Treatment of Bipolar Depression With Minocycline and/or aspirin: an adaptive, 2x2 double-blind, randomized, placebo-controlled, phase II-A clinical trial. Transl Psychiatry. 2018 Jan 24;8(1):27. doi: 10.1038/s41398-017-0073-7.
https://www.ncbi.nlm.nih.gov/pubmed/29362444

Raison, et al. A Randomized Controlled Trial of the Tumor Necrosis Factor-alpha Antagonist Infliximab in Treatment Resistant Depression: Role of Baseline Inflammatory Biomarkers. JAMA Psychiatry. 2013 Jan;70(1):31-41.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4015348/

Miller AH, Raison CL. Are Anti-inflammatory Therapies Viable Treatments for Psychiatric Disorders?: Where the Rubber Meets the Road. JAMA Psychiatry. 2015 Jun; 72(6): 527–528.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542670/

Adzic M, et al. Therapeutic Strategies for Treatment of Inflammation-related Depression. Curr Neuropharmacol. 2018 Jan 30;16(2):176-209.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883379/

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Episode 52: Tardive dyskinesia masterclass II

Leslie Citrome, MD, MPH, returns to the MDedge Psychcast to lecture on Tardive Dyskinesia. In episode 52, where we caught up with Dr. Citrome at the Psychopharmacology Update meeting in Cincinnati, he discusses how to evaluate treatments for TD within the context of P values and effect sizes.

Dr. Citrome joined Psychcast host Lorenzo Norris, MD, in the 13th edition of the Psychcast to talk about management of TD. In episode 13, Dr. Citrome said that you can start screening your patients in the waiting room as well as when they walk to the exam room.

He and Dr. Norris also discussed movement conditions and the role antipsychotics might play in patients with TD. You can listen to the conversation between Dr. Norris and Dr. Citrome from July of 2018 by clicking here.

TD has been a recent topic of interest at the Psychcast. In the 45th episode Johnathan Meyer, MD, noted that TD has been the bane of the psychiatrist's existence for the better part of a half-century. You can listen to our tardive dyskinesia Masterclass I by clicking here.

We would love to hear from you. Contact the show if you have feedback, questions, or ideas for segments, guests or topics. Email us at podcasts@mdege.com or Tweet at us @MDedgePsych.

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In this In this masterclass episode, Stephen Levine, MD, stops by to talk about how a person's sexuality flows throughout their lives.

And later, Dr. RK discusses bipolar in part I of her new series.

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Masterclass Lecture: What's New in Alzheimer's Disease.

Lecturer: George T. Grossberg, MD.

He is the Samuel W. Fordyce professor and Director of Geriatric Psychiatry at St. Louis University School of Medicine.

You can read more from Dr. Grossberg including video and writing, by clicking here.

Dr. RK:

Dr. RK's topic this week is the MDQ and how she uses in her practice. Learn more about the MDQ by clicking here.

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In this episode, Nicolas Badre, MD, talks with Lorenzo Norris, MD, about ways to approach reducing dosages or discontinuing medications that aren’t beneficial. And Renee Kohanski, MD, ponders the privilege of being part of patients’ gifted moments.

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In this episode, Marlene Freeman, MD, discusses the latest studies on the risks of treating, and not treating, women with bipolar disorder during pregnancy. And Renee Kohanski, MD, returns with part two of her feature on eating her own words.

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Twitter: @mdedgepsych

Richard Balon, MD, is professor of clinical psychiatry and anesthesiology and associate chair of education at Wayne State University in Detroit.

In this masterclass episode of psychcast, he lectures on the recent increase in the price of drugs.

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In this episode, Igor Galynker, MD, stops by to talk about suicide with Lorenzo Norris, MD. One major topic of conversation centers around the suicide-specific diagnosis. And later, Renee Kohanski, MD, talks about the importance of communication. You can listen to Dr. Galynker’s first appearance on the Psychcast here (http://bit.ly/2LGiRwn).

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Twitter: @mdedgepsych

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Twitter: @MDedgePsych

Johnathan Meyer, MD, notes that TD has been the bane of the psychiatrist's existence for the better part of a half century. In this Mastercalss edition, Dr. Meyer talks about this disease and analyzes where the field is today.

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Twitter: @MDedgePsych

Today, Dr. Gail Erlick Robinson (http://bit.ly/2AZXZx1) joins Dr. Lorenzo Norris (http://bit.ly/2z99Yrr) from the 2018 meeting for the group for the advancement of psychiatry or GAP (http://bit.ly/2FRn9Bj) to discuss violence against women.

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Psychcast: Recent Episodes

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