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Title
Pub. Date
Duration
The Psychcast goes on hiatus | Clinical Correlation
10 May 2021
00:16:17
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.
Creative approaches to treatment during the COVID-19 pandemic with Dr. Craig Chepke
05 May 2021
00:27:57
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.
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.
Psychedelics, violence, and psychiatric treatment: Assessing the early and emerging research with Dr. Brian Holoyda
24 Mar 2021
00:21:53
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.
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.
Identifying and treating postpartum psychosis with Dr. Susan Hatters Friedman
09 Oct 2019
00:25:14
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.
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.
Preventing murder in the family with Dr. Susan Hatters Friedman
02 Oct 2019
00:31:50
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.
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 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.”
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.
Evidence-based approaches to treating insomnia with Dr. Karl Doghramji
25 Sep 2019
00:17:08
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.
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.
Mental health disaster response with Dr. Judith Milner
18 Sep 2019
00:43:45
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.
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.
Aging, cognitive function, and technology with Dr. Phillip D. Harvey
04 Sep 2019
00:19:39
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.
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.
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.
The role of inflammation in mental illness with Dr. Roger McIntyre
28 Aug 2019
00:32:17
Show Notes
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.
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.
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.
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’sconceptualization 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.
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.
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.
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.
The ripple effects of the COVID-19 pandemic on mental health with Dr. Dost Öngür
17 Mar 2021
00:26:56
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.
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.
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.
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.
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.
Freedman R et al. Higher gestational choline levels in maternal infection are protective for infant brain development. J Pediatr. 2019 May. 208:198-206.
Identifying suicide crisis syndrome with Dr. Igor Galynker (Part 2)
07 Aug 2019
00:31:15
Show Notes
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.
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.
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.
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.
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.
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.
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.
Prepping patients for psych medication disruptions with Dr. Cam Ritchie
24 Jul 2019
00:31:38
Show Notes
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.
Benzodiazepines for patients with serious medical illnesses
17 Jul 2019
00:27:38
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.
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.
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.
Prescribing clozapine for patients with refractory schizophrenia
10 Jul 2019
00:31:05
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.
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.
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.
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.
Update on the American Psychiatric Association – Part 2
26 Jun 2019
00:26:36
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.
American Psychiatric Association updates from CEO – Part 1
19 Jun 2019
00:35:13
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.
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.
'The journey of a thousand miles begins with two roads diverged in a yellow wood' | Clinical Correlation
15 Mar 2021
00:15:03
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.
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, Porphyromonasgingivalis, 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.
Dominy SS et al. Porphyromonasgingivalis 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.
Suicide round table, when you lose a patient to suicide: Part II APA 2019
02 Jun 2019
00:24:32
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.
Suicide Round Table, when you lose a patient to suicide: Part I from APA 2019
01 Jun 2019
00:27:19
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.
Dr. Charles L. Raison discusses antidepressants -- risks and benefits
29 May 2019
00:25:21
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.
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.
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?
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.
Eating disorders: Masterclass lecture part I
15 May 2019
00:27:01
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?"
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.
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.
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.
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.
Physician burnout
01 May 2019
00:23:30
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.
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.
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.
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.
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.
Association of American Medical Colleges News: “Responding to the opioid epidemic through education, patient care, and research.”
Behavioral addictions, Donald Black, MD
17 Apr 2019
00:19:38
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.
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.
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”
Intervening in the lives of people who embrace White supremacy with Dr. Pete Simi
10 Mar 2021
00:54:48
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.
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.
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.
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).
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:
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/
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.
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.
Sexuality Throughout Life: Stephen Levine Masterclass
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.
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.
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).
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.
How schizophrenia patients are faring during COVID-19 with Dr. Frank Chen
03 Mar 2021
00:28:01
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.
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.
In this episode, Caroline Bonham, MD (http://bit.ly/2RMT5x8), and Avi Kriechman, MD (http://bit.ly/2FtFZPy), join Psychcast host Lorenzo Norris, MD, via phone to discuss enhancing resilience in rural communities.
Overall life expectancy decreased from 78.7 years to 78.6 years from 2016 to 2017. Researchers from the CDC noted that along with drug overdose deaths, suicide also drove the average lifespan over that time (http://bit.ly/2APzJxB). While suicide is an all-encompassing issue, suicide in rural communities presents unique challenges. Dr. Bonham is Vice Chair in the Department of Psychiatry and Behavioral Sciences at the University of New Mexico School of Medicine and Dr. Kriechman is assistant professor in the same department and a child psychiatrist with an aim of youth suicide prevention.
Masterclass: First episode psychosis with Henry Nasrallah
09 Jan 2019
00:19:48
If you would like to respond to any of Dr. Nasrallah’s comments in this masterclass, email us at podcasts@mdedge.com.
In this edition, the inaugural guest on the MDedge Psychcast, Henry Nasrallah, MD (http://bit.ly/2LZX7wC), returns to lecture on first-episode psychosis.
Dr. Nasrallah is Editor-in-Chief of Current Psychiatry and is the Sydney W Souers Endowed Chair and professor and charming of the department of Neurology an Psychiatry at the University of Cincinnati College of Medicine.