Psychcast

Psychcast host Lorenzo Norris, MD, talks with Peter Yellowlees, MBBS, MD, about the changes to clinical practice forced by the COVID-19 pandemic and the likelihood that many of these changes are here to stay. Dr. Yellowlees is a professor of psychiatry and chief wellness officer at the University of California, Davis. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures. Take-home points Prior to the COVID-19 pandemic, 1%-2% of psychiatric consultations occurred on telepsychiatry modalities. During the pandemic, however, telepsychiatry has become the norm for psychiatric patient encounters. With the pandemic, the federal government relaxed many regulations that limited the use of telehealth. For many, telepsychiatry is now a preferred modality, because it confers high patient satisfaction, and many view it as more egalitarian, convenient, and less intimidating. Some even consider it more private, because the patient does not have to come to the office, and they can remain in a safe personal space. Telepsychiatry can be used within a hybrid model, where a patient can see the psychiatrist in person, using video, and the modality changes based on the needs of the patient and the clinician. Telehealth has expanded access to care to many populations, so the American Psychiatric Association and other professional associations are lobbying the federal government to keep certain telehealth regulations relaxed beyond the pandemic. Summary Dr. Yellowlees sees telepsychiatry as the return of the home visit because the tool allows the clinician to see how the patient lives. He believes telepsychiatry fosters even more intimacy in the clinical relationship because of the extra distances created through the virtual space. In hybrid relationships, there are the physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. But the virtual space is convenient and provides a sense of physical and emotional space between the clinician and patient – which can make it easier to share intense emotions. The textbook that Dr. Yellowlees wrote with Jay H. Shore, MD, MPH, "Telepsychiatry and Health Technologies: A guide for mental health professionals," includes a chapter on clinical skills for seeing patients over video. Dr. Yellowlees points out that trainees need instruction about the work flow and clinical process, but most are savvy about how they should present themselves on screen. Dos and don'ts: The clinical space for teleconferencing for both the clinician and the patient must be private and secure. Ensure that everyone in either room is introduced. The webcam should be placed on top of the computer screen so that eye contact is maintained. The clinician's head should take up two-thirds of the screen. Use picture in picture setting, so you can monitor your body language during the session. The APA and other professional associations are lobbying the federal government to keep certain telehealth regulations relaxed beyond the pandemic. The changes would include removing the geographic restrictions on licensing, maintaining parity of reimbursement between telehealth and in-person visits, removing frequency limitations on telehealth services in nursing homes and inpatient settings, finalizing regulatory changes to the Ryan Haight Act, and allowing prescribers to continue to prescribe controlled substances without an initial in-person visit. References Yellowlees P, Shore JH. Telepsychiatry and Health Technologies: A guide for mental health professionals (Washington: American Psychiatric Association Publishing, 2018). Yellowlees P. Physician Well-Being: Cases and Solutions (Washington: American Psychiatric Association Publishing, 2020). Support for Permanent Expansion of Telehealth Regulations After COVID-19. American Psychiatric Association. 2020. Telepsychiatry Toolkit. American Psychiatric Association American Telemedicine Association Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Psychcast host Lorenzo Norris, MD, meets Renee Kohanski, MD, to announce the launch of Clinical Correlation. In Clinical Correlation, which will be released every other Monday, starting Sept. 14, Dr. Kohanski will expand on her "Dr. RK" segment and explore issues of interest to the practicing psychiatrist. And later, we will revisit four of Dr. Kohanski's "Best of" segments. Next week, Dr. Norris will return with an interview with Peter Yellowlees, MD, about clinicians' embrace of telepsychiatry during the pandemic. They also discuss whether many of the COVID-19–related changes – including those tied to reimbursement – are here to stay. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Anique K. Forrester, MD, joins host Lorenzo Norris, MD, to discuss the importance of continuing to work in academic medicine. Dr. Forrester is assistant professor at the University of Maryland, Baltimore. She also serves as director of the consultation-liaison psychiatry fellowship at the university. Dr. Norris and Dr. Forrester have no conflicts of interest. Take-home points Dr. Forrester recently wrote an article in the New England Journal of Medicine discussing minority underrepresentation in academic medicine and the persistent labor of love required to stay in departments that do not explicitly value diversity. Underrepresented minority colleagues leave for many reasons, and Dr. Forrester highlights the issues of invisibility, lack of mentorship and support, and burden of microaggressions. Dr. Forrester focused her article on why she stays in academic medicine, feeling that it is critical her voice is heard; she knows her presence has changed the tone and outcome of issues. As she says: "One of the things about representation is that someone has to be there to represent." Summary Staying in academic medicine with the presence of systemic racism is a difficult road; however, Dr. Forrester has stayed because of her desire to educate and mold the future of trainees. Underrepresented minority (URM) colleagues leave for many reasons, and Dr. Forrester highlights the issues of invisibility, lack of mentorship and support, and burden of microaggressions. The late Chester Pierce, MD, a psychiatrist and the first African American full professor at Massachusetts General Hospital, Boston, coined the term "microaggression" to describe subtle slights or snubs directed at minority and historically stigmatized groups. The cumulative effect of microaggressions is toxic and can lead to self-doubt, damaged self-esteem, and momentum that pushes a URM colleague to leave. When a URM colleague leaves a department, there is a short-lived conversation about what could have been done differently to retain them. Forrester speaks of the "double hit" that occurs when a URM colleague leaves because it is not just the loss of a colleague, but the additional connection about the shared sense of mission and about progressing conversations about equity and diversity in the department. Medical trainees at every level benefit from a diverse core faculty because such diversity provides different perspectives to situations and thus might also provoke an alternative response that is essential to growth. Research has also shown that patient outcomes improve in the presence of diverse medical teams. Dr. Forrester talks about using self-reflection to identify one's core mission as the commitment to stay in academic medicine and/or an underrepresented department. When we are stressed, it's instinctive to be reactive to negative situations. Identifying one's intention for being in academic medicine in the first place can reinforce the strength to stay and reach out for support. References Forester A. N Engl J Med. 2020 Jul 23;383:e24. DeAngelis T. Unmasking 'racial microaggressions.' American Psychological Association. Monitor on Psychology. 2009;40(2):42. Galinsky AD et al. Perspect Psychol Sci. 2015 Nov;10(6):742-8. Gomez LE, Bernet P. J Nat Med Assoc. 2009 Aug;111(4):383-92. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Philip Resnik, PhD, joins host Lorenzo Norris, MD, to discuss the use of AI and natural language processing to help clinicians identify patterns in the behaviors of patients with mental illness. Dr. Resnik is a professor in the department of linguistics at the University of Maryland, College Park. He also has a joint appointment with the university's Institute for Advanced Computer Studies. Dr. Resnik has disclosed being an adviser for Converseon, a social media analysis firm; FiscalNote, a government relationship management platform; and SoloSegment, which specializes in enterprise website optimization. Some of the work Dr. Resnik discusses has been supported by an Amazon AWS Machine Learning Research Award. Dr. Norris disclosed having no conflicts of interest. And don't miss the "Dr. RK" segment, with Renee Kohanski, MD. Take-home points Artificial intelligence (AI) refers to the effort to get computers to develop capabilities that humans would consider intelligent when people do them. For example, a "smart" thermostat learns patterns of behaviors and changes the temperature accordingly. Natural language processing (NLP), an AI approach, focuses on the content of language from the words used and looks for cues within the content. NLP technology allows computers to do things more intelligently with human language, and NLP has generated technologies such as Siri, Alexa, and Google Translate. Much of clinical work is focused on language, and clinicians look for cues within the content. Dr. Resnik is a technologist who believes that NLP can help facilitate clinical progress, especially in the face of a shortage of mental health clinicians and the limited amount of time that clinicians are able to spend with their patients. Research aimed at using machine learning and NLP to analyze social media and other types of online presence to evaluate for suicide risk and the presence of mood disorders is underway. Dr. Resnik imagines an ecosystem in which computers and humans balance their efforts, with each "brain" doing what they are best at; he believes in technology's ability to save us time so we can prioritize our efforts. Summary A common example of NLP is automatic dictation and transcription software embedded in medical records. Dr. Resnik thinks of technology as an enabler and augmentation strategy. Resnik and his wife, Rebecca Resnik, PsyD, completed a study using NLP to automatically detect clusters of language in the writing samples of college students. NLP software evaluated the natural patterns of language that might correlate with vegetative and somatic symptoms of depression and social isolation. His team was able to home in on language themes specific to college students that suggest specific symptoms of depression. Another example of NLP in mental health is using predictive modeling, taking in data, and then making a prediction about a pertinent variable to understand mental health outcomes. For example, Glen Coppersmith, PhD, and associates evaluated social media posts with NLP software and concluded that analysis of language in social media posts can accurately identify individuals at risk of suicide and facilitate earlier interventions. Resnik imagines a future in which speech and language samples are used to give a point-of-care evaluation of a patient's mood and suicide risk. "Clinical white space" is all the "space" (for example, the time between clinical encounters) and this is where decompensation occurs. Resnik suggests that NLP software could be used to fill this white space by using apps to collect text samples from patients. Software would analyze the samples and warn of patients who are at risk of decompensation or suicide. Barriers to using this technology include engaging the technologists and clinicians, and accessing data samples because of privacy concerns, especially because HIPPA was written before the emergence of mega data. References Coppersmith G et al. Natural Language Processing of Social Media as Screening for Suicide Risk. Biomed Inform Insights. 2018 Aug 27. doi: 10.1177/1178222618792860. Zirikly A et al. CLPsych 2019 Shared Task: Predicting the Degree of Suicide Risk in Reddit Posts. In Proceedings of the Sixth Workshop on Computational Linguistics and Clinical Psychology. 2019 Jun 6. 24-33. Lynn V et al. CLPsych 2018 Shared Task: Predicting Current and Future Psychological Health from Childhood Essays. In Proceedings of the Fifth Workshop on Computational Linguistics and Clinical Psychology: From Keyboard to Clinic. 2018. 37-46. Selanikio J. The big-data revolution in health care. TEDx talk. Graham S et al. Artificial Intelligence for Mental Health and Mental Illnesses: An Overview. Curr Psychiatry Rep. 2019 Nov 7;21(11):116. doi: 10.1007/s11920-019-1094-0. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr.

Abigail Kay, MD, MS, joins host Lorenzo Norris, MD, to discuss the treatment of patients with substance use disorders. Dr. Kay is an addiction psychiatrist at Thomas Jefferson University Hospital in Philadelphia and is associate dean of academic affairs and medical student education at Sidney Kimmel Medical College. Dr. Norris is assistant dean of student affairs, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Kay disclosed no conflicts of interest for the past year. Before that, she reported receiving payment from the American Society of Addiction Medicine, through a grant from the Substance Abuse and Mental Health Services Administration, to teach a free training to clinicians to be certified to prescribe buprenorphine. Dr. Norris, who also serves as medical director of psychiatric and behavioral sciences at George Washington University Hospital, disclosed no conflicts. Take-home points Substance use disorders have genetic and environmental factors. The genetic component is sometimes overlooked because the environmental factor – the exposure to using a substance – is heavily focused as the only trigger for addiction. Methadone is a pure agonist at the mu-opioid receptor so the higher dose the greater the effect. The average dose of methadone to achieve blocking of cravings, withdrawal, and opiate intoxication is 80-120 mg. Buprenorphine is a partial agonist: At low doses, it acts as an agonist, and at high doses it acts as an antagonist with quite high affinity for the receptor. As a partial agonist, it has a ceiling effect with more than 90% of opiate receptors occupied at 24 mg. Dr. Kay suggests a helpful rule of thumb is to assume that, if patients have an addiction, there's a 50/50 chance that they have another psychiatric disorder and vice versa. With this in mind, all patients with substance use disorder should be evaluated for comorbid psychiatric disorders and underlying medical conditions. Summary Dr. Kay breaks down human cognition into the primitive brain and thoughtful brain. The primitive brain keeps us alive by preferentially focusing on sleeping, drinking, and eating. Addiction to a drug hijacks the primitive brain, making it prioritize the substance of choice above all else. Methadone is the "gold-standard" treatment for opioid use disorder in the sense that all treatments are compared with its efficacy and mechanism of action. Methadone is a pure agonist at the mu-opioid receptor, meaning the higher dose the greater the effect; the average dose of methadone is 80-120 mg. The goal of treatment is to achieve a blocking dose, meaning a dose that blocks the craving, the withdrawal, and the high if people were to use illicit opiates on top of their methadone. Methadone is administered only at federally approved sites, and one advantage is that additional services, such as counseling, can be offered on site after daily administration. Buprenorphine as a partial agonist can play both "roles" on the mu-opioid receptor. At low doses, it acts as an agonist, and at high doses, it acts as an antagonist with quite high affinity for the receptor. In addition, as a partial agonist buprenorphine has a ceiling effect: At 24 mg of buprenorphine occupies 92% of opiate receptors and at 32 mg only an additional 1% of receptors are occupied. Buprenorphine must be administered when the person is already in withdrawal, because its affinity to the receptor dislodges other opiates from the mu receptor thus precipitating withdrawal. Buprenorphine works well for individuals who would require an average 40-60 mg of methadone to achieve their blocking dose. Because of the ceiling effect, some individuals continue to crave opiates while on buprenorphine. This means that, despite the greater convenience offered by buprenorphine, it is not the treatment of choice for everyone. Naltrexone is a pure opioid antagonist requiring 10-14 days of abstinence from opiates to prevent precipitating opioid withdrawal. Naltrexone can be given as a once-monthly injection to address cravings. The greatest risk with naltrexone is that, after 1 month of treatment, people lose their tolerance and are at risk of opioid overdose if they return to their previous amount of use. References Volkow ND. Hum Genet. 2012 Jun;131(6):773-7. Volkow ND, Blanco C. J Clin Invest. 2020 Jan 2;130(1):10-3. SAMHSA.gov. Overview of MAT: https://www.samhsa.gov/medication-assisted-treatment/treatment. Jones HE et al. N Engl J Med. 2010;363:2320-31. Kay A et al. J Addict Dis. 2010 Apr;29(2):139-63. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Derek M. Griffith, PhD, joints host Lorenzo Norris, MD, to discuss different ways to look at men's health within the context of COVID-19. Dr. Griffith is founder and director of the Center for Research on Men's Health at Vanderbilt University, Nashville, Tenn. He also serves as professor of medicine, health, and society at the university. Neither Dr. Griffith nor Dr. Norris have disclosures. And do not miss Renee Kohanski, MD, who offers a message of hope in the "Dr. RK" segment. Take-home points The confluence of the COVID-19 pandemic, the death of civil rights leader Rep. John Lewis, and the death of Herman Cain from COVID-19 requires us to reflect on race, gender, personal identity, and our own vulnerability. Sometimes denial in the form of thinking "that won't happen to me" is a trope within masculinity, especially black masculinity, and can lead to men delaying preventive treatments and interventions, which makes them more vulnerable to excess morbidity and mortality from preventable diseases. Some research suggests that men are more likely to suffer severe effects of COVID-19 than women. Personal preference and agency are hallmarks of the American ethos, and those attitudes made it difficult to accept new and challenging information during the beginning of the COVID-19 pandemic. Ironically, this fierce autonomy is celebrated and demonized in the male identity and will have an effect on their behavior in the environment. In terms of mental health, we must consider how schemas influence behavior, and one's ability to take in and act on relevant information. Any singular lens is limited when discussing an issue as complex as the current pandemic. Many perspectives must be examined if we are to work toward an effective solution. While society is examining COVID-19 morbidity and mortality through the lens of race, we may miss other essential perspectives, such as place, gender, age, etc. In a situation such as the COVID-19 pandemic, we must manage complexity by asking the hard questions. Dr. Norris asked Dr. Griffith to identify what factor in the pandemic we are missing from our current perspectives. Dr. Griffith suggested that our society continues to assume that we know more about COVID-19 than we actually know. Several times throughout the pandemic, we have assumed that we have it "figured out," only to be shown that the SARS-CoV-2 virus is more unpredictable than we realize. Race, gender, age, and health disparities also will be at play when it comes time to test and administer a COVID-19 vaccine. References Griffith DM et al. Prev Chronic Dis. 2020;17:E63. Griffith DM et al. The COVID-19 elephant and the blind men of race, place, and gender. Gender & COVID-19.org. 2020 Jul 26. Elder K and Griffith DM. Am J Public Health. 2016 Jul;106(7):1157. doi: 10.2105/AJPH.2016.303237. Peters JW. Will Herman Cain's death change Republican views on the virus and masks? New York Times. 2020 Jul 30. Cain H. This is Herman Cain!: My Journey to the White House. New York: Threshold Editions, 2011. Sharma G et al. JACC Case Rep. 2020 Jul 15;2(9):1407-10. Baker P et al. Lancet. 2020 Jun;395(10241):1886-8. Indini A et al. Crit Rev Oncol Hematol. 2020 Sep;153:103059. Chowkwanyun M and Reed AL. Racial disparities and COVID-19 – Caution and context. N Engl J Med. 2020 Jul 16;383:201-3. Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. Updated 2020 Jul 24. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Episode 128 interview: Philip G. Janicak, MD, joins MDedge Psychiatry Editor in Chief Lorenzo Norris, MD, to discuss device-based therapies for psychiatric patients. Dr. Janicak is adjunct professor of psychiatry and behavioral sciences at Northwestern University in Chicago. He serves as an unpaid consultant to Neuronetics and has a financial relationship with Otsuka. Dr. Norris, medical director of psychiatric and behavioral services at George Washington University Hospital in Washington, has no disclosures. Take-home points Therapeutic neuromodulation, including electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS), refers to the use of device-based therapies that alter neurocircuitry implicated in the pathophysiology of psychiatric disorders. Most available evidence is from studies in major depressive disorder, though more research is emerging for bipolar disorder and other diagnoses The advantage of TMS is minimal cognitive adverse effects, compared with ECT. Dr. Janicak recommends ECT over TMS when a patient requires inpatient psychiatric treatment, is acutely suicidal, has psychotic features, or is not taking care of basic needs. Summary TMS originated in England when Anthony T. Barker, PhD, began using TMS as a probe for the peripheral and central nervous systems. Imaging studies showed that, in the context of depression, the left dorsolateral prefrontal cortex had less metabolism and blood flow, and when TMS was applied, those phenomena were reversed. One large randomized, controlled trial showed that TMS treatment could lead to remission of depression and had a durable effect for most patients in the study. The recent goal of TMS research has been to improve the efficacy and decrease the length of treatment from 4-6 weeks of daily treatments to 1-2 weeks. In 2018, deep TMS (dTMS) was cleared by the Food and Drug Administration for the treatment of obsessive-compulsive disorder after first- and second-line pharmacologic and psychotherapeutic treatments. In dTMS, the medial prefrontal cortex and the anterior cingulate cortex are targeted. Several studies suggest the pro-cognitive effects of TMS, and Dr. Janicak hopes that TMS might be on the radar as treatment for mild cognitive impairment. TMS also is being used in combination with psychotherapy, such as cognitive-behavioral therapy, under the theory that TMS enhances the activity of the neurocircuitry and potentiates the effect of the psychotherapy. References Janicak PG. What's new in transcranial magnetic stimulation. Current Psychiatry. 2019 Mar;18(3):10-6. Dunner DL et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: Durability of benefit over a 1-year follow-up period. J Clin Psychiatry. 2014;75(12):1394-1401. Janicak PG and Dokucu ME. Transcranial magnetic stimulation for the treatment of major depression. Neuropsychiatr Dis Treat. 2015;11:1549-60. Vidrine R. Integrating deep transcranial stimulation into the OCD treatment algorithm. Psychiatric Times. 2020 Apr 7. Marra HLD et al. TMS in mild cognitive impairment. Behav Neurol. 2015;2015:287843. doi: 10.1155/2015/287843. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Dmitry M. Arbuck, MD, joins host Lorenzo Norris, MD, to discuss ways psychiatrists can help patients with treatment-resistant chronic pain. Dr. Arbuck is clinical assistant professor of psychiatry and medicine at Indiana University, Indianapolis. Dr. Arbuck also serves as president and medical director of Indiana Polyclinic, a multispecialty pain management facility, and is an associate editor of Current Psychiatry. Both Dr. Arbuck and Dr. Norris disclosed having no conflicts of interest. And do not miss the "Dr. RK" segment, where Renee Kohanski, MD, discusses part 2 of her examination of the constructs of medicine. Take-home points Acute and chronic pain are mediated by different mechanisms and therefore must be treated differently. Acute pain is caused by tissue damage leading to nociception, and it should heal. Chronic pain is the chronification of acute pain and more of an emotional state with sensations of pain without clear tissue damage. Many neurotransmitters are involved in pain, including dopamine, serotonin, norepinephrine, and the opioid system. The levels of neurotransmitters will change as the pain (emotional and physical) thresholds change. When patients with borderline personality disorder cut themselves, dopamine increases, and the patients, in turn, feel better. Likewise, when patients with PTSD reexperience negative events, this causes an increase in dopamine to protect against stress. Psychiatrists are particularly well positioned to help those with chronic pain because trauma and emotions are central to the perception of emotional and physical pain. Emotional trauma also influences the severity and chronicity of pain. Currently, pharmacogenetics are more of a general guide for clinicians than specific practice guidelines. But they can inform patients and physicians about drug metabolism and expression of receptors in difficult-to-treat patients. Summary Chronic pain can be understood as emotions colored by nociception, while acute pain is the tissue damage and subsequent nociception causing pain. Opioids suppress the nociception of pain and are appropriate in acute pain. However, opioids should be used only in the normal time of healing in acute pain. If their use is extended, opioids can cause hyperalgesia, thus worsening chronic pain. Many forms of chronic pain, such as fibromyalgia and chronic back pain, do not have tissue damage. The sensations of physical pain and the compounding emotional pain are mediated by central pain sensitization. The theory behind central pain sensitization helps explain why medications such as SSRIs, serotonin-norepinephrine reuptake inhibitors, and antipsychotics can come into play in chronic pain treatment. In some patients, there can be dopaminergic hyperactivity in chronic pain. Dr. Arbuck conceptualizes dopamine as a defensive neurotransmitter. Dopamine is secreted in response to fear and can result in a physical response, such as weakness in the legs, but it also leads to emotional consequences, such as dissociation. Dopamine is also secreted with emotionally painful stimuli, such as trauma, so an event such as a sexual assault that results in a physical and emotional injury may produce substantial dopamine secretion. When the defense becomes chronic, excessive dopamine secretion can be pathological. Pharmacogenetics inform clinicians about a patient's ability to benefit from medications by looking at the presence of specific alleles for enzymes that metabolize medications and for receptors upon which medications act. Currently, Dr. Arbuck uses pharmacogenetics in specific indications, such as for patients with a seemingly treatment-resistant condition or with excessive adverse effects from medications. The pharmacogenetics results are meant to help physicians and patients understand the body's role in medications. Psychiatry needs to look more into the medical aspects of mental health, and training in psychiatry needs to be more biological in nature. References Arbuck DM. Current Psychiatry. 2020 Jan;19(1):25-9;31. Clauw DJ. JAMA. 2014;311(15):1547-55. Nijs J et al. Expert Opin Pharmacother. 2014 Aug;15(12):1671-83. Dale R and Stacey B. Med Clin North Am. 2016 Jan;100(1):55-64. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Roger S. McIntyre, MD, returns the Psychcast, this time to talk with host Lorenzo Norris, MD, about the mental health hazards of COVID-19 and what clinicians can do to help protect patients. Dr. McIntyre is professor of psychiatry and pharmacology, and head of the mood disorders psychopharmacology unit at the University Health Network at the University of Toronto. He disclosed receiving research or grants from the Stanley Medical Research Institute and the CIHR/GACD/National Natural Science Foundation of China. Dr. McIntyre also disclosed receiving consultation/speaker fees from several pharmaceutical companies. Dr. Norris has no disclosures. Take-home points Uncertainty tied to the COVID-19 pandemic threatens to undermine mental health and exacerbate problems for those with mental illness. U.S. suicide rates, which were already rising after the Great Recession of 2007-2009, are likely to climb further because of the impact of COVID-19. Clinicians can take steps to prevent some of the negative mental health outcomes tied to the pandemic. Summary COVID-19 presents a triple threat to patients' mental health. The fear of viral infection is a mental health hazard. The financial shock that COVID-19 has had on the economy has not been seen since the Great Depression. Links between suicide and unemployment are powerful. In a study published in World Psychiatry, McIntyre and colleagues found associations between COVID-19 and major depression, PTSD, binge alcohol use, and substance use disorders. French social scientist Emile Durheim, PhD described the link between suicide and unemployment. Quarantining affects mental health, and there is nothing like COVID-19 in the history books. The Toronto experience with severe acute respiratory syndrome in 2003 offers lessons about the devastating impact of quarantining on mental health. "Deaths of despair" in the form of suicides have been on the increase in the United States. From the Great Recession, researchers found that for every 1% increase in unemployment, there is a commensurate 1% increase in suicide. U.S. unemployment stood at 8%-9% during the Great Recession, and now those percentages are much higher. Dr. McIntyre and his team projected that an unemployment rate of 14%-20% would lead to an additional 8,000-10,000 suicides could occur each year for the next 2 years. That's in addition to the current number of approximately 50,000 suicides annually. Express Scripts, a pharmacy benefits manager, recently reported a 40% increase in prescriptions for anxiety-related medications. This suggests that people are distressed. Clinicians should take an aspirational approach to addressing these issues by pivoting to virtual platforms to increase patients' access to care. Create medical homes that are HIPAA compliant. Look toward evidence-based models such as those found in Japan. That country found that, for every 0.2% increase in GDP spending on mental health care right after the Great Recession, the suicide rate fell by 1%. Encourage patients to structure the day and avoid consuming too much news or participating on social media. Two studies conducted in China found that people who spent more than 2-3 hours a day on news consumption were more likely to report clinical levels of depression, anxiety, and insomnia. Social media consumption has been associated with many adverse mental health outcomes, including loneliness. People who spent more than 3 hours a day were more likely to experience depression. Support programs for small-business people; jobs enhance resilience. Target the "basics" of self-care, such as getting enough sleep and engaging with others. References McIntyre RS, Lee Y. Psychiatry Res. 2020 May 19. doi: 10.1016/j.psychres.2020.113104. McIntyre RS, Lee Y. World Psychiatry. 2020 Jun;19(2):250-1. Shanahan L et al. Am J Public Health. 2012 Jun;109(6):854-8. Kang S, Chua HC. CMAJ. 2004 Mar 2;170(5):811-2. Express Scripts. America's State of Mind Report. 2020 Apr 16. Lee Y et al. Psychiatry Clin Neurosci. 2020 Jul 1. doi: 10.1111/pch.13101. Hao F et al. Brain Behav Immun. 2020 Jul;87:100-6. Tan W et al. Brain Behav Immun. 2020 Jul;87:84-92. Wang C et al. Brain Behav Immun. 2020 Jul;87:40-8. Harvey SB et al. Am J Psychiatry. 2018 Jan 1;175(1):28-36. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Jack Rozel, MD, MSL, returns to the Psychcast, this time to discuss with host Lorenzo Norris, MD, how to think about guns, gun violence, and the intersection with mental health. Dr. Rozel is medical director of resolve crisis services at the University of Pittsburgh Medical Center/Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis – rather than sell a gun. Dr. Norris has no disclosures. Take-home points In the United States, more guns were sold in the month leading up to the COVID-19 pandemic than were ever sold in 1 month since gun sales were recorded. Suicide risk with a new gun in the home peaks in the first days to weeks of ownership and then trails off, but there is a measurable difference in risk of suicide in the 5 years after the purchase. Any surge in gun sales leads to greater accidental deaths and homicides from firearms. Rozel reminds clinicians to ask their patients (again) about guns. A good question to start is: "Are there guns in the home or new guns in the home?" He also asks about gun storage and the number of guns. Dr. Rozel goes through the basics of gun safety, such as handling a gun only while sober; securing the gun in a locked box unless the owner/responsible adult is holding it; using a responsible means to carry the gun, such as a holster; and not handling the gun like a toy. If a patient is under financial pressure, the clinician might gently suggest that a way to remove some of that pressure might be to sell a weapon to a licensed gun dealer. Summary It is likely that fear and uncertainty of the future with broad social disorder are influencing gun sales. Most of the gun sales during the pandemic are to new gun owners. Unfortunately, the increase in gun sales tracks with other major risks for suicide, such as unemployment and unstable housing, which might get worse during the COVID-19 pandemic. During this period of unstable employment and house, people might be moving to different houses, or relatives and friends might be moving in. With this fluidity, it is essential to inquire about guns in the home where they are staying or whether new people brought in guns. Dr. Rozel also explores who is in the house with the patient and checks in about the home environment regarding arguments and abuse, especially as tensions run high during pandemic shutdowns. Make gentle assumptions by asking questions such as: "How do you store your guns?" Get a sense of how safe the patient's environment is while conducting telehealth, and be aware of patients' social determinants of health issues. As psychiatrists, it is our role to talk to patients about how their mental health influences their safety. If a patient is experiencing acute symptoms of their illness or perhaps has relapsed on substances, then it is imperative to ask about gun safety and whether the gun should be temporarily moved from the house. References Rozel J. Clinical Psychiatry News. 2020 Apr 2. Harvard School of Public Health. Means Matter: Firearm Access is a Risk Factor for Suicide Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.10.1001/jamapsychiatry.2020.1060. Rand Corporation. Gun Policy in America. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

This week, we decided to revisit three of the Psychcast episodes that examined various aspects of COVID-19. First, you will hear excerpts from the interview that host Lorenzo Norris, MD, did with Sheldon H. Preskorn, MD, on educating patients about SARS-CoV-2 and the disease. Next, Jay H. Shore, MD, MPH, conducts a Masterclass lecture on factors to consider while using telepsychiatry during the pandemic. And later, guest host Jacqueline Posada, MD, talks with Lynne S. Gots, PhD, about using cognitive-behavior therapy to treat patients with anxiety. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Thomas Abt, JD, spoke with Nick Andrews about his talk at the TEDMED 2020 conference in Boston. Mr. Abt (@Abt_Thomas), senior fellow at the Council on Criminal Justice, discussed his evidence-based and community-informed strategies for reducing urban violence. Mr. Abt earned an undergraduate degree in economics from the University of Michigan in Ann Arbor, and a law degree from Georgetown University in Washington. Mr. Abt also worked as a prosecutor in the Manhattan District Attorney's office in New York, and as a teacher in Washington. He has no conflicts of interest. Summary Mr. Abt said the three fundamental principles of focus, balance, and fairness are central to interventions for reducing urban violence. This means focusing on people and places in which urban violence is concentrated, balancing between positive and negative incentives to reduce violence, and facilitating trust between the state and its citizens to foster a sense of fairness. Mr. Abt's book, "Bleeding Out: The Devastating Consequences of Urban Violence - And a Bold New Plan for Peace in the Streets" is a compilation of 10- 12 strategies using evidence-based interventions. Mr. Abt promotes strategies informed by data and vetted by communities. Success stories can be found with deterrence in Boston; and Oakland, Calif; and Cincinnati; and Indianapolis; and with cognitive-behavioral therapy (CBT) in Chicago. Those strategies have not been brought to scale or sustained over time. The "Becoming a Man" program in Chicago is one the most promising examples of the power of CBT. The program focuses on at-risk youth in high school and teaches strategies for conflict resolution, interpersonal problem-solving skills, anger management, and future orientation. The program has three components: vigorous youth engagement; an intensive "man's work" educational program delving into positive masculine identity; and a CBT component. CBT is only part of the success, and Mr. Abt argues that a clinical component is necessary when working with groups with traumatic backgrounds. A psychotherapy modality is required to meaningfully alter the impulsive, automatic responses that can lead to violence. Street outreach workers, public health officials, and police officials have responded positively to the book. Criticism has come from political extremes. Conventional narratives about urban violence suggest that it is rooted in poverty or culture, or social and economic injustice. Yet research about urban violence suggests reducing violence must focus on urban violence itself and not on ancillary topics. Structural and historical factors, such as racism and de jure and de facto segregation, have produced high rates of urban violence, but we can't start over in a span of a few years to address those generational problems. Mr. Abt focuses on identifying interventions that target reducing violence, which has its own ripple effects on structural injustice. Abt emphasizes that urban violence is a concentrated problem with larger effects. The solutions need to be direct and focused so that the effect of the interventions is not diluted and able to be applied in multiple communities. The solutions direct and focused approaches so that the effect of the interventions is not diluted and able to be applied in multiple communities. References Abt T. Bleeding Out: The Devastating Consequences of Urban Violence – And a Bold New Plan for Peace in the Streets. (Basic Books, 2019). Obbie M. This man says his anti-violence plan would save 12,000 lives. The Atlantic. University of Chicago. Urban Labs. Becoming a Man program. Heller SB et al. Thinking, Fast and Slow? Some Field Experiments to Reduce Crime and Dropout in Chicago. National Bureau of Economic Research. Working Paper 21178. May 2015. Revised August 2016. Medscape Psychcast bonus episode transcript: Click Here. * * * Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Igor Galynker, MD, returns to the Psychcast, this time to discuss his most recent work on suicidal crisis syndrome with host Lorenzo Norris, MD. Dr. Galynker is professor of psychiatry and director of the Galynker Research and Prevention Laboratory at the Icahn School of Medicine at Mount Sinai, New York. He reported receiving funding from the National Institute of Mental Health and the American Foundation for Suicide Prevention. Dr. Norris has no disclosures. Take-home points Suicide crisis syndrome (SCS) is a state or syndrome that develops shortly before a suicide attempt. Since the last Psychcast with Dr. Galynker, SCS has been replicated in several cohorts and countries. SCS has been refined to three primary factors instead of five. The factors of SCS include a state of entrapment which includes cognitive rigidity and flooding, insomnia/agitation, and social withdrawal. New data are emerging about how to treat the acute syndrome with medications, because patients are not susceptible to psychotherapy or even safety planning in this state of mind. Galynker and colleagues have validated the suicide crisis narrative model and have found that the clinician's response to the narrative is predictive of risk of suicide. Summary In SCS, the two primary factors are a sense of entrapment and cognitive rigidity followed by insomnia or agitation and social withdrawal. The state of entrapment is characterized by frantic hopelessness with a sense of being trapped in a life situation that is painful, intolerable, and feeling that all escapes are blocked. Cognitive rigidity and dyscontrol can include ruminative flooding associated with headache or head pressure, and inability to suppress the ruminative thoughts. Cognitive rigidity, like psychosis, can make it difficult to engage in psychotherapy. SCS needs to be treated with medications such as an antipsychotic for cognitive rigidity, a benzodiazepine for the frantic hopelessness and sense of agitation, and something that targets the emotional pain. Antidepressants might make SCS worse because they can increase anxiety. The accompanying narrative crisis model of suicide behavior includes five components: High-risk traits, stressful life events, a narrative of hopelessness and failure, the suicide crisis syndrome, and then suicide attempt. Clinicians can think of the long-term risk factors for suicide as vulnerable traits such as fearlessness, perfectionism, insecure attachment, and childhood abuse. When these vulnerable individuals have stressful life events, they enter a subacute phase in which they create a life narrative that tells a story of falling short of their goals, feeling humiliation, being a burden to others, and being unable to achieve future goals, all of which lead to social withdrawal. SCS is treated with medications and means restriction, and the narrative is treated with cognitive restructuring through specific forms of psychotherapy. Three clinician emotions triggered by a suicidal patient's narrative are predictive of risk of suicide death. The first emotion is clinician distress and dread. The second is anxious overinvolvement, which is similar to a rescue fantasy with false hope. The third is a sense of distancing and resignation that the patient is going to kill themselves. Clinicians must be trained to listen to their own emotional reactions to a patient's suicidal narrative of how they arrived at this state to detect this risk. Using emotions and something like the SCS is important for suicide prevention, because only one-third of people report suicidal ideation. Sometimes the burden of EMR documentation or checkboxes can get in the way of accurately assessing a patient's risk. This type of work requires awareness of emotions and managing them to make sure they are attuned to the patient. Other emotions, such as fatigue and burnout, can interfere with the risk assessment. References Cohen LJ et al. Suicide Life Threat Behav. 2019 Apr;49(2):413-22. Hawes M et al. Compr Psychiatry. 2017 Jan;72:88-96. Galynker I et al. Depress Anxiety. 2017 Feb;34(2):147-58. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Lorenzo Norris, MD, spoke with Sheldon H. Preskorn, MD, about how to best educate patients about coronavirus. Dr. Preskorn is a professor in the department of psychiatry at the University of Kansas School of Medicine–Wichita. Neither Dr. Norris nor Dr. Preskorn have any relevant financial relationships to disclose. Take-home points Coronavirus 2019 (COVID-19) is the disease process caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 is different from the previous SARS-type coronaviruses and is having a greater impact on society as a pandemic for three reasons: It's highly transmissible person to person, it can be spread by infected individuals who are asymptomatic or presymptomatic, and it has a high level of morbidity but a lower level of mortality. Psychiatrists work with vulnerable populations, including older adults and individuals with medical comorbidities that put them at risk for COVID-19. Psychiatrists must understand the pertinent facts about COVID-19 to help their patients who are suffering the consequences of social distancing, a shuttered economy, and changes in their daily lives from COVID-19. Summary While coronaviruses are known to cause the common cold, some are more medically serious – and even lethal – based on their ability to cause a severe acute respiratory syndrome (SARS). SARS-CoV-2 is one in a line of several coronaviruses to make the leap from animals to humans and cause a severe acute respiratory syndrome with devastating effects. Previous coronaviruses include SARS-CoV-1, which caused an illness referred to as "SARS" that had a mortality rate close to a 10%, and MERS-CoV, which caused Middle East respiratory syndrome (MERS) and had an even higher mortality rate. The high mortality rate of these SARS-type coronaviruses is thought to be why they did not transition from epidemic to pandemic. SARS-CoV-2 is different from the previous SARS-type coronaviruses and is having a greater impact on society as a pandemic for three reasons: It's highly transmissible from person to person, it can be spread by infected individuals who are asymptomatic or presymptomatic, and it has a high level of morbidity but a lower level of mortality. In terms of transmissibility, each person infected can infect up to six additional people and individuals can spread the virus even while asymptomatic or presymptomatic. This is why wearing a mask and engaging in social distancing are essential to slowing the spread of COVID-19. SARS-CoV-2 is more lethal than influenza and is especially dangerous for certain populations, such as older adults and those with multiple medical comorbidities, including chronic pulmonary obstructive disease, hypertension, diabetes, obesity, and being immunocompromised. In the United States, 80% of COVID-19 deaths are in people older than age 65 years. Psychiatrists must understand these pertinent facts about COVID-19 to help their patients who are suffering the consequences of social distancing, a shuttered economy, and changes in their daily lives from COVID-19. Psychotropic medications that can lead to metabolic syndrome, such as second-generation antipsychotics, may put patients with serious mental illness at risk of worse outcomes if infected with COVID-19. Ultimately, psychiatrists are medical doctors who are helping treat the secondary mental health effects of the COVID-19 pandemic, so we have a responsibility to have a working knowledge of the epidemiology and basic science of the virus to help our patients. References Preskorn SH. Coronavirus Disease 2019: The first wave and beyond. Psychiatr Times. 2020 Apr 28. Preskorn SH. COVID-19: Protecting the vulnerable and opening the economy. Psychiatr Times. 2020 May 6. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Older adults. National Institute of Allergy and Infectious Diseases. Coronaviruses. * * * Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

SPECIAL: Lorenzo Norris, MD, welcomes fourth-year psychiatry resident Brandon C. Newsome, MD, for a discussion on race relations as a physician in the wake of the death of George Floyd, who was killed when a white police officer kneeled on his neck during an arrest. Dr. Newsome was raised in Alabama and currently lives in Boston. He shares his experiences with Dr. Norris in an important conversation. The pair discuss what their patients are experiencing and what they're experiencing as black physicians. Dr. Norris is a consultation-liaison psychiatrist and medical school dean affiliated with George Washington University, Washington (@GWSMHS). Dr. Newsome will begin a fellowship in July at Children's National Hospital (@ChildrensNatl). References American Medical Association (@AmerMedicalAssn) 2020 statement on police brutality (2020) American Psychiatric Association (@APAPsychiatric) statement National Medical Association (@NationalMedAssn) statement

Candrice R. Heath, MD, and Nicole B. Washington, DO, MPH, spoke with Psychcast host Lorenzo Norris, MD, about physician mental health. Dr. Heath is affiliated with Temple University Hospital, Philadelphia. She has no disclosures. Dr. Washington disclosed serving as chief medical officer and founder of Elocin Psychiatric Services, a telemedicine company that provides care to physicians. Dr. Norris is a consultation-liaison psychiatrist and medical school dean affiliated with George Washington University, Washington. He has no disclosures. And stick around for Renee Kohanski, MD, who talks about expectations. Take-home points Physicians often delay seeking mental health treatment. Compared with the general population, the risk of suicide is 2.27 times higher in female physicians and 1.4 times higher in male physicians. The COVID-19 pandemic has created additional risk factors for all physicians, including those on the front lines and others whose clinical practices and home lives have changed because of the pandemic. Prevention and mitigation of mental illness start with understanding your own risk factors and stressors and trying to address them before they become overwhelming. Summary During the best of times, physicians are at risk for anxiety, depression, and substance use disorders. The syndromes of demoralization and burnout should be seen as prodromes to clinical diagnoses, such as major depressive disorder. An estimated 300-400 physicians die from suicide each year. Prevention of mental illness starts with identifying one's stressors, such as balancing personal and professional demands on time; knowing one's risk factors, such as a history of substance use and previous episodes of distress or psychiatric diagnoses; and thinking about the phases of disaster response. When it comes to the COVID-19 pandemic, are you surging with adrenaline, hitting a plateau, or experiencing a decline? Dr. Washington suggests that her patients focus on what they can control in their lives, because uncertainty and loss of control of our usual routines contribute to stress, anxiety, and fatigue. It is also helpful to reflect on past periods of hardship and resilience to identify strengths and previous strategies used to overcome challenges. Physicians who are not on the front lines are experiencing different forms of hardship, such as financial stress from furloughs and loss of patient volume. There may also be guilt about not addressing the pandemic in the same way as frontline physicians. Even without direct patient care of COVID-19, it must be acknowledged that the impact of the pandemic is everywhere. Most physicians delay seeking mental health treatment. This may particularly occur for physicians with better "lifestyles," such as dermatologists, who some may view as suffering less. This pandemic is a reminder that all physicians need to take care of themselves, regardless of specialty. We are all adjusting to the "new normal," so in times like this, it is helpful to seek practices such as mindfulness and "radical acceptance," the latter of which is part of dialectical behavior therapy. Accepting reality with judging and setting expectations at a realistic level can help prevent suffering. References Phases of disaster timeline: https://www.samhsa.gov/dtac/recovering-disasters/phases-disaster American Psychiatric Association Well-being Toolkit: https://www.psychiatry.org/psychiatrists/practice/well-being-and-burnout/well-being-resources Radical acceptance by Tara Brach, PhD: https://www.youtube.com/watch?v=_K35O3G82L4 Facts about physician suicide: https://www.acgme.org/Portals/0/PDFs/ten%20facts%20about%20physician%20suicide.pdf * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Bill Scheidler, MD, is assistant clinical professor of psychiatry at the University of North Carolina, Chapel Hill. He also is associate training director for the consultation-liaison fellowship at UNC and is a lead consultant at UNC Hospitals Hillsborough. Dr. Scheidler spoke with host Lorenzo Norris, MD, about how to think through patients' decision-making capacity in medical (rather than psychiatric) hospitals. Neither Dr. Scheidler nor Dr. Norris have disclosures. Take-home points Decision-making capacity (DMC) is essential to informed consent, which is providing patients with the information necessary to make an informed decision about medical or surgical care. Standards differ, depending on the U.S. state. DMC has four components, as defined by Paul Appelbaum, MD, and colleagues: The ability to make and communicate a consistent choice The ability to understand the information provided about medical conditions and decisions The ability to appreciate the consequences of a choice The ability to reason through the decision In the sliding-scale model of DMC, not all decisions carry the same weight. The assessment evaluates the risk-benefit ratio of a particular decision, and the bar for capacity depends on the ratio. When a patient lacks capacity and treatment over objection is pursued, the outcome is highly dependent on the hospital and state laws. Clinicians should confer with their risk management and legal team. Summary A capacity assessment usually is implicit in the process of informed consent because clinicians usually are assessing whether the patient truly understands what they are consenting to. In the legal literature, "capacity" and "competency" are used interchangeably, but in the medical field they are different. It is easier to refer to adjudicated competency in which a judge legally determines a person's ability to make decisions. Usually, a person lacking adjudicated competency has a guardian to guide their decisions. In contrast, DMC is time and decision specific. A DMC assessment includes evaluation of the four components of capacity, including making a consistent choice, understanding the medical condition and decision, appreciating the risks, and using intact reasoning. It is a low bar of DMC for a decision that has a high benefit and low risk (e.g., a blood draw or an x-ray). An intervention that is high risk and low benefit, such as an experimental treatment, would require the highest bar of capacity for consent. The lowest bar for DMC is when the patient decides who should make medical decisions for them. In capacity assessments, clinicians must remember that a patient's desire for a certain outcome does not translate into DMC. In these impassioned cases, clinicians need to stick to the four components of capacity in their assessment. The presence of mental illness does not preclude DMC. It is helpful to consider whether the person's psychosis or symptoms of their disorder are influencing the decision. If a patient lacks capacity, a surrogate decision maker should be identified. With a surrogate decision maker, it's more likely the patient's wishes will be honored. The surrogate decision maker hierarchy differs state by state. Implicit in most DMC assessments are several questions, including: What do we do next if the person lacks capacity? Treatment over objection and the outcome are highly dependent on the hospital and state laws, so clinicians need to confer with their risk management and legal team. Usually, there are specific legal statutes to guide how to proceed if a patient's incapacity puts them at danger of harm. When treatment over objection is the only option, teams must consider whether treatment can be delayed, and what the alternative treatments should be. The mechanisms for keeping people in the hospital are usually are coercive. References Appelbaum PS. N Engl J Med. 2007;357(18):1834-40. Appelbaum PS, Grisso T. N Engl J Med. 1988;319(25):1635‐8. Wynn S. Decisions by surrogates: An overview of surrogate consent laws in the United States. American Bar Association. 2014 Oct 1. Centers for Disease Control and Prevention. Legal authorities for quarantine and isolation. National Conference on State Legislatures. State quarantine and isolation statutes. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Renae Beaumont, PhD, assistant professor of clinical psychology at New York–Presbyterian/Weill Cornell Medical Center, spoke with host Lorenzo Norris, MD, about the Secret Agent Society. The Secret Agent Society is a video gaming–based therapy program aimed at helping children with a range of social and emotional challenges learn the social skills required to make and keep friends. The program also helps children feel happier, calmer, and braver. Dr. Beaumont disclosed her role as creator of the Secret Agent Society program. Dr. Norris has no disclosures. Take-home points The Secret Agent Society is a video gaming–based program that helps children detect how another person is feeling through the interpretation of facial expressions, body language, and vocal tone; use skills to socially engage; and to internally detect their own emotions. Secret Agent Society is meant to engage children. It can be used during clinical/therapy sessions to stimulate discussion as well as at home with parents. The indicated age range is 8-12 years, and it is useful for children with autism and with average intellectual functioning. Summary The Secret Agent Society video game has four levels. Level one is about detecting emotions from facial expressions, vocal recognition, and body language. Level two is about detecting personal emotions and using scales to identify the components and range of emotions. Levels three and four are about navigating common social challenges in real time, from losing in a game to collaborating in a group project and learning calming techniques for themselves. To encourage practical application, there is a secret agent journal section where participants can chronicle how they used their skills. Beaumont initially developed the game to help children who are on the autism spectrum. For many children on the spectrum, social skills are not innate, but can be taught and developed into life skills to help children meet their potential. Parents might be conflicted about encouraging their children to play video games. It's important to consider the evidence behind the game and the age and skills of the research participants. In general, parents should favor video games that teach skills, have educational context, and allow parental involvement. Now that much of social interaction is over the virtual sphere and social media, games and exercises that teach social skills over these mediums help build skills early. The Secret Agent Society is meant to engage children. It can be used during a clinical/therapy to stimulate discussion and at home with parents. The game is also a helpful adjunct for psychological services offered online. The indicated age range is 8-12 years, as well as for children with autism and within average age intellectual functioning. New research is showing that the game may also be effective for children with social anxiety and ADHD. Gameplay can be integrated into what a clinician is already doing, or the Social Skills Training Institute offers online training for clinicians that would be helpful when using the game to treat patients with multiple comorbidities. Therapeutic gaming is useful during social distancing because it builds coping skills and helps children feel more in control of their emotions and actions. References Einfeld SL et al. J Intel Dev Disabil. 2018;43(1):29-39. Sofronoff K et al. Develop Disabil. 2015 Apr 28. doi: 10.1177/1088357615583467. Beaumont R, Sofronoff K. J Child Psychol Psychiatry. 2008 Jul;49(7):743-53. Dr. Renae Beaumont's TEDx Talk: https://www.youtube.com/watch?v=KQVv2hKipYQ Secret Agent Society/Social Skills Training Institute: https://www.sst-institute.net/ Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Frederick S. Barrett, PhD, is affiliated with the Center for Psychedelic & Consciousness Research (@JHPsychedelics) at Johns Hopkins University, Baltimore (@Hopkins Medicine). Dr. Barrett spoke with Nick Andrews (@Nick_Andrews_) at @TEDMED 2020, about the research that has been conducted by the Center for Psychedelic & Consciousness Research on the impact of psychedelics, or hallucinogens, on psychiatric disorders. He has no disclosures. Take-home points Dr. Barrett transitioned into neuroscience research through his interest in the effect of music on human emotions and the brain. Until 1970, psychedelics such as psilocybin were widely used in clinical research, with more than 1,000 academic papers published about their use. For example, psychedelics were used as a model for schizophrenia and helped identify the role of serotonin in psychosis. They were also studied to treat addiction and as a treatment for existential anxiety in cancer. In 1970, psychedelics were deemed illegal by the Controlled Substances Act which brought the United States in compliance with the 1971 Convention on Psychotropic Substances. Roland R. Griffiths, PhD, and a group at Johns Hopkins have led the way in reestablishing clinical research using psychedelics. Enthusiasm at the lab is borne out by the potential that this research might help many people. Institutional concerns also are at work because of the "rich and sordid history" of these compounds. In the next 10 years, Dr. Barrett would like to have a clear understanding of the effect size of psychedelics on mood and substance use disorders. Psychedelic agents have a novel therapeutic quality: Studies support that a few or even one exposure to a psychedelic compound has a short-term biological effect and can lead to a long-lasting therapeutic effect, such as remission of mood disorder or change in personality characteristics. The clinical outcomes are mediated by the intensity of the psychedelic experience. Summary The Center for Psychedelic & Consciousness Research is working to discern which medical indications have the most promise for being treated with psychedelics. Its goal is a balanced and rational approach to psychedelic research and subsequent treatment considering the societal and political contexts around these drugs. Dr. Barrett trained in music education and psychology and has been a musician all this life. He moved into neuroscience during graduate school and used music as a tool to study emotions and the brain. Music, meditation, and psychedelics have the similar flow component that inspires converging research questions and a desire to analyze the brain and understand this experience that is central to consciousness. Music is fundamental to the human experience, and it is exciting to try to describe the neural circuitry of how music affects the brain and emotions. Music is useful in therapy because it can regulate emotions. There has long been an overlap of the use of psychedelics and music in therapy. A prime example of this is guided imagery and music (GIM), which is a specialized form of therapy that arose out of work done by Helen Bonny, PhD, a nurse, music therapist, and concert violinist. Bonny developed a protocol for using music to regulate emotions during psychedelic experiences. In the next 10 years, Dr. Barrett would like to have a clear understanding of the effect size of psychedelics on mood and substance use disorders. It will be interesting to see whether and how psychedelics are efficacious in treating an array of substance use disorders. If effective, they would be a single-use treatment for addiction to substances that interact with diverse neural circuits. References Barrett FS et al. Sci Rep. 2020 Feb 10. doi: 10.1038/S41598-020-59282-y. Barrett FS, Griffiths RR. Curr Top Behav Neurosci. 2018;36:393-430. Barrett FS et al. Int Rev Psychiatry. 2018;30(4):350‐62. Griffiths RR et al. J Psychopharmacol. 2018 Jan;32(1):49-69. Barrett FS, Janata P. Neuropsychologia. 2016 Oct;91;234-46. Johnson MW et al. Am J Drug Alcohol Abuse. 2017 Jan;43(1):55-60. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Anne Marie Albano, PhD, professor of medical psychology and psychiatry at Columbia University, New York, and director of the Youth Anxiety Center at New York–Presbyterian Hospital, discusses strategies for treating childhood, youth, and young adult anxiety with Nick Andrews. Dr. Albano (@AnneMarieAlbano), who also is director of Modern Minds, an anxiety and depression program in Charleston, S.C., spoke with Nick (@Nick_Andrews_) at @TEDMed 2020. Dr. Albano has no conflicts of interest. Take-home points Early identification of activity avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance. Parents should validate that facing anxiety is difficult and that the child might be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears rather than to accommodating and enabling. In 2008, Dr. Albano and colleagues published a randomized, controlled trial in the New England Journal of Medicine showing that sertraline, cognitive-behavioral therapy, or a combination of both are all more effective treatments for anxiety than placebo. The treatment effect degrades over time as the developmental challenges change, so children will need booster sessions or must return to treatment. Young adults sometimes misinterpret "normal" emotions of apprehension with overwhelming anxiety that disincentivizes them to engage in activities. Therapy teaches children to "ride the wave" of anxiety and continue to move toward new experiences. Dr. Albano is currently developing a program that uses virtual reality to role-play difficult developmental experiences that cause anxiety and help young adults learn how to advocate for themselves and problem-solve through anxiety. Summary Dr. Albano noticed that, when parents do not push children to participate or let them get out of activities, this can exacerbate the child's anxiety. Early identification of avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance. As a strategy, parents can offer children a choice of activities and push for the child to choose one of them. Parents should validate that facing anxiety is difficult and the child may be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears instead of accommodating and enabling. The psychotherapy treatments focus on "riding the wave" of emotions that come with new or intimidating experiences and pushing toward exposures. Young adults sometimes misinterpret "normal" emotions of apprehension with overwhelming anxiety, and this confusion disincentivizes engaging in activities. Dr. Albano has always integrated parents into treatment. Working with parents means finding the balance between the parents swooping in to help or rescue the child with coaching, setting limits, and pushing children toward experiences that will be exposures to anxiety. The biggest challenge is the extent to which technology tethers parents to children and builds dependency. More research needs to be done on what types of children progress with specific types of treatment, how long to stay in treatment, how to transition out of treatment, and when to offer booster sessions. Dr. Albano wants to expand treatment out of clinics and to the places in the community where anxiety happens and is at risk of hindering child development. References Walkup JT et al. N Engl J Med. 2008 Dec 25;359(26):2753-66. Kagan ER et al. Child Psychiatry Hum Dev. 2020 Apr 6. doi: 10.1007/s10578-020-009883-w. Hoffman LJet al. Current Psychiatry Rep. 2018 Mar 27. doi: 10.1007/s11920-018-0888-R. Chen A. For kids with anxiety, parents learn to let them face their fears. NPR. Morning Edition. 2019 Apr 15. McGuire JF et al. Depress Anxiety. 2019 Aug;36(8):744-52. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Cheryl A. King, PhD, clinical psychologist and professor in the department of psychiatry at Michigan Medicine, the academic health system at the University of Michigan, Ann Arbor, joined Nick Andrews at TEDMED2020. Dr. King spoke with Nick (@Nick_Andrews_) at @TEDMed about a suicide risk screen for teens that is based on computerized algorithm. Take-home points Dr. King is a longtime researcher in teen suicide, and her current project is creating a personalized adaptive suicide risk screen for teens called CASSY (Computerized Adaptive Screen for Suicidal Youth). In an adaptive algorithm, subsequent questions will change based on the previous answer. The aim is to create a profile of risk factors and warning signs to generate a risk level that will guide the type of mental health interventions required in the ED and beyond. CASSY also is being developed as a universal screen for those who might come to the ED without a mental health history. Many teens who die by suicide do not have previous contact with mental health professionals. More research is being done to create and validate treatment interventions for at-risk teens so the risk levels generated in the ED can be met with evidence-based interventions for preventing suicide. With the scarce mental health resources in some areas, Dr. King and associates have created an intervention that trains youth-nominated adults from within families to intervene in times of crisis. Summary The CASSY is based on computerized algorithms from data collected by the Pediatric Emergency Care Applied Research Network (PECARN). Within this network, thousands of teens in mental health crisis, after suicide attempt or not, have completed a suicide risk survey aimed at modeling specific warning signs and risk factors for predicting suicide attempts in the next 3 months. In an adaptive algorithm, subsequent questions will change based on the previous answer. The risk factors for teen suicide are well established, but teens who attempt are a heterogeneous group. The key to predicting an imminent risk of suicide depends on developing profiles of risk based on how the risk factors and warning signs group together. The result of the CASSY is a level of risk. Individual institutions can set their risk levels. CASSY is being developed as a universal screen for those who might come to the ED without a mental health history. Many teens who die by suicide do not have previous contact with mental health professionals. The goal is for CASSY to be integrated into a medical system's EHR in order to make it easier to use on a broad population. The most common intervention in an ED for suicide risk is creating a safety plan that involves identifying warnings signs for decompensated mood, brainstorming coping skills, and delineating emergency contacts and a plan of action for suicidal emergency. Dr. King and associates developed the Youth-Nominated Support Team intervention, which harnesses the strength of the adults in the family to bolster treatment as usual. The teens nominate "caring adults" who they want to support them after hospitalization, and the adults are provided psychoeducation and training to more effectively support the teens. Dr. King is also working on a National Institute of Mental Health–supported study to identify the 24-hour warning signs for suicide attempts. Dr. King thinks there is more work to be done combining the screening tools with interventions in the ED and beyond. References King CA. J Am Acad Child Adolesc Psychiatry. 2019 Oct;58(10):S305. King CA et al. J Clin Psychol Med Settings. 2017 Mar;24(1):8-20. King CA et al. JAMA Psychiatry. 2019 Feb 6;76(5):492-8. King CA et al. J Am Acad Child Adolesc Psychiatry. 2019 Dec 9. doi: 10.1016/j.jaac.2019.10.015. ASQ toolkit for suicide screening: https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Lorenzo Norris, MD, touches base with Nick Andrews to discuss COVID-19 and to welcome Jacqueline Posada, MD, as an occasional cohost of the MDedge Psychcast. Dr. Posada, associate producer, interviews Lynne S. Gots, PhD, about treating anxiety, obsessive-compulsive disorder, and other disorders in the midst of the COVID-19 pandemic. Dr. Gots is an assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington. She has a private psychotherapy practice and has no financial relationships to disclosure. Take-home points Anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. Anxiety is an adaptive response to a threat, and COVID-19 and its repercussions makes this a threatening time. In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety. Consider the following suggestions for working with anxious patients and clinicians: Acknowledge that social media has the potential for shaming and worsening social anxiety. Limit exposure to news and social media as much as possible. Monitor patients for excessive reassurance-seeking behaviors, and enact ERP plans. Establish a regular but flexible routine with boundaries between work, home, and rest. Practice self-compassion by lowering expectations and even using formal self-compassion practices. Summary Cognitive-behavioral therapy is an evidence-based therapy for obsessive-compulsive disorder (OCD) and many forms of anxiety and depression. Acceptance and commitment therapy (ACT) is considered a third-wave modality of CBT. The acceptance component is based on mindfulness and acceptance of "what is." The commitment component involves identifying core values and actions so that a person can use his/her values as a guide to behaviors. The goal is not to eliminate anxious or obsessional thoughts but to accept they are there and work alongside them. Clinicians should be aware that anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. For example, a person's OCD rituals may not be worsened, but an underlying tendency for perfectionism could be triggered as he/she tries to practice "the perfect quarantine." Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety. Clinicians can look for reassurance-seeking behaviors that have cropped up with increased anxiety. For example, for a person with contamination anxiety, it might be tempting to wash for longer than 20 seconds or to wipe things down compulsively. Advise patients to pick a routine, such as washing for 20 seconds and no more. Individuals can choose a reputable source and follow its guidelines. The key is to avoid falling into the trap that more reassurance-seeking behaviors will alleviate anxiety. Using excessive reassurance-seeking behaviors can lead to increased anxiety through the conditional learning mechanism of negative reinforcement. Other helpful suggestions Social media contains a potential for shaming based on comparing oneself and behaviors to others, so individuals should limit exposure to it. News intake should be limited to 1 hour a day, and only reputable sources should be used. Video calls also can trigger social anxiety because individuals literally have to see themselves more often than usual. Ways to minimize this anxiety include minimizing your personal image or covering the image with a Post-it note. For people who are at home all day, establish a routine with a regular wake and sleep time and scheduled breaks. Some type of boundary between home and work life should be created. Self-compassion should be practiced. The first step is to lower expectations and live according to your values and what is realistically possible given the extensive changes in the past month. Professionals need to seek support from other professionals going through the same thing, so connect with a colleague who can relate to your situation. Remember that, as mental health professionals, we are a repository for everyone else's anxiety and suffering, so we need to be kind to ourselves. Consider using a self-compassion practice. Recognize that you are suffering. Connect with the community: Everyone is suffering. Hold that suffering and offer yourself words of compassion and loving kindness. References and resources Dr. Gots's website: https://cognitivebehavioralstrategies.com/ Blog post by Dr. Gots that summarizes her clinical advice

Lorenzo Norris, MD, interviews Mary D. Moller, DNP, MSN, about taking advantage of the polyvagal theory of anxiety and social engagement during psychotherapy. Dr. Moller is associate professor of nursing at Pacific Lutheran University in Tacoma, Wash., where she coordinates the psychiatric mental health nurse practitioner doctorate nursing practice program. She also is in practice at Northwest Integrated Health. Dr. Moller has no conflicts of interest. Later, Renee Kohanski, MD, discusses the sacred relationship that exists between doctors and patients. Take-home points The polyvagal (PV) theory relates autonomic nervous system functions to human behavior and response to trauma. The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which together regulate the autonomic state in response to the environment and influence behavior. The unmyelinated dorsal vagus nerve controls the "freeze response," while the myelinated ventral vagus nerve modulates social communication and can inhibit the arousal state. This theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagus nerve. It's easier to apply the insights of polyvagal theory in person, but Dr. Moller suggests specific techniques during teletherapy. She prioritizes eye contact, which has to be done by looking at the camera; modulating your tone of voice to be more soothing; and having the patient use biofeedback techniques, such as taking their pulse during a session to make note of their physical response to anxiety. Summary The association between the sympathetic nervous system and "fight or flight" is well known. The polyvagal theory relates autonomic nervous system functions to behavior and response to trauma. The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which regulate the autonomic state in response to the environment and influence behavior. The unmyelinated dorsal vagus nerve innervates from the diaphragm down, controlling the "freeze" response. When the dorsal vagus nerve is activated, physical signs can include bradycardia or tachycardia, shallow breathing, and a "pit in the stomach" feeling from slowing down the GI tract. The myelinated ventral vagus nerve innervates from the diaphragm up, and modulates social communication and engagement, which can inhibit the arousal state. Social engagement is attunement to the subtle cues occurring during engagement with another person. The PV theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagal nerve. In the PV theory, the concept of "neuroception" is likened to an unconscious threat detector sensed by the vagus nerve before the threat is registered by the brain. Coregulation is using the environment, most commonly the physical and emotional response of another person, for emotional regulation. This occurs in the therapeutic dyad when the therapist is attuned by and not enmeshed with the patient. Think of coregulation as akin to attachment theory; when the parent is attuned and present, the child feels safer and is able to relax. Dissociation is the "freeze" mechanism of reacting to traumatic events in the moment, and again when the memories are triggered by stimulus in the environment. One way to treat dissociation is through engaging the ventral vagus nerve using social connection, such as gentle voice, gentle touch, and deep breathing or other grounding exercises. The PV theory connects the physical and emotional responses to trauma. It is impossible to physically connect through telehealth, so Dr. Moller prioritizes eye contact by looking at the camera, though this means taking one's eyes off the patient, as well as having the patient take their own pulse to reinforce the use of biofeedback, and "breathing together" over the video treatment. References Dana DA, Porges SW. The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation (New York: W.W. Norton & Co., 2018). Porges SW. The polyvagal perspective. Biol Psychol. 2007;74(2):116-43. Beauchaine TP et al. Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biol Psychol. 2007 Feb;74(2):174-84. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Jay H. Shore, MD, MPH, returns to the Psychcast, this time to conduct a Masterclass lecture on using telepsychiatry in a regulatory environment that is quickly changing because of the physical distancing forced by the COVID-19 pandemic. Dr. Shore is director of telemedicine at the Helen and Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also directs telemedicine programming at the medical center's department of psychiatry. He disclosed serving as chief medical officer of AccessCare Services and receiving royalties from American Psychiatric Association Publishing and Springer. Take-home points Practicing telepsychiatry has administrative, technological, and clinical considerations. Administrative concerns include licensure, prescribing, billing, and establishing a procedure and protocol, especially about emergencies. Technological considerations include choosing software, understanding HIPAA compliance during the current COVID-19 crisis (and afterward), and incorporating a virtual clinic workflow, such as scheduling and billing. Clinical considerations include understanding how to manage a hybrid relationship with patients and tailoring your clinical style to teleconferencing, such as reading body language through video and directing the environment as the clinician. Basic dos and don'ts: The clinical space for teleconferencing of both clinician and patient must be private and secure. Every person in each room must be introduced. The webcam should be placed on top of the computer screen that so eye contact is maintained, and the clinician's head should take up two-thirds of the screen. Administrative considerations To practice telepsychiatry, typically psychiatrists must be licensed in the state in which the patient is located, with some exemptions within federal systems. During the COVID-19 pandemic, however, many states have waived this requirement. Inform your malpractice company that you are now participating in telepsychiatry to ensure that you are covered. During the COVID-19 crisis, the federal government has waived the Ryan Haight Act to allow the prescription of controlled substances without an initial in-person visit. Tips for dealing with an emergency: The psychiatrist should establish the physical location of the patient at the start of every appointment and document how to get a hold of them if the connection is lost. It's helpful to know how and when to contact local emergency services; 911 is often a local call based on the GPS of the cell phone. American Telemedicine Association and American Psychiatric Association guidelines suggest using a patient support person. That person would either be a family member or close friend who is onsite during the event with whom you have preconsent to contact the clinicians if an emergency occurs. Technological considerations Telepsychiatry services should have a procedures and protocol document to outline scheduling, billing, documentation, and how to address psychiatric emergencies. For telemedicine, the videoconferencing software must be HIPAA compliant. During the COVID-19 emergency declaration, the Department of Health & Human Services' Office for Civil Rights will exercise "enforcement discretion" and, in most cases, waive penalties of HIPAA enforcement for clinicians who are serving their patients in good faith. Use only technologies such as FaceTime or Skype if you are unable to make adequate connection with HIPAA-compliant technology. Take your in-person operational workflow and try to replicate it virtually. Make sure that people's responsibilities are clearly delineated. Clinical considerations "Hybrid relationships" are increasingly more common with in-person and virtual interactions from videoconferencing, patient portals, email, etc. In hybrid relationships, there are both physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. The virtual space often is convenient and provides a sense of physical and emotional space between clinician and patient, with advantages and disadvantages. The virtual space means rendering care to the patient in their home and gives insight into their environment. The virtual space can also decrease stigma because the patient does not have to seek care in a physical clinic. Sometimes, more small talk than usual about the environment is helpful to bridge that virtual gap. Use more active inquiry into emotions or body language if these are not clearly communicated over videoconference. Dos and don'ts: Make sure that the lighting is good. Use the picture setting, so you can monitor your body language during the session. Make sure you are not too passive during the session. Be proactive. Animate yourself a little more than you would in person. Ask patients questions about their environment. Have a lower threshold for asking how patients are doing. More active inquiry can prove helpful. References American Psychiatric Association T

As the nation's health care system braces for COVID-19 cases, physicians who've faced the pandemic first have critical lessons for everyone. In this bonus episode, two Seattle-area critical care leaders explain how their medical centers are preparing for and responding to their region's early outbreaks. And they share some creative approaches that are uniting Seattle's critical care departments.

MDedge Psychcast host Lorenzo Norris, MD, interviews Steven Wengel, MD, about the challenges of loneliness in geriatric populations in nursing homes, especially during the current COVID-19 pandemic. Dr. Norris also discusses potential interventions with Dr. Wengel, who is a geriatric psychiatrist at the University of Nebraska Medical Center in Omaha. And later, in the "Dr. RK" segment, Renee Kohanski, MD, talks about how, in the midst of the pandemic, we are slowing down while we're speeding up … and are learning how to use – and not abuse – technology. Take-home points Loneliness has been defined as a form of social pain; it is more than sadness or a "state of mind." Loneliness and being alone are separate issues suggesting that loneliness is more of an emotional state and being alone is often a choice. Loneliness can be characterized as deficits in authentic interactions and connection because you can be surrounded by people and still feel lonely. Loneliness has been studied as a predictor of health problems and is identified as a risk factor for early mortality and dementia and as a predictor of chronic illnesses such as depression. When it comes to treating loneliness in the geriatric population, favor any type of intervention over none and avoid chalking up symptoms as "just loneliness." Basic interventions include providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive type symptoms with an SSRI. Summary In a study of nursing-home patients, 9% report loneliness often or always and 25% report loneliness sometimes; older adults are more susceptible to loneliness secondary to frailty and limited transport options. Loneliness is an independent risk factor for early mortality and a predictor for other chronic diseases including dementia, hypertension, depression, and overall poor health. During the COVID-19 pandemic, most nursing homes are under lockdown, and all visitors are barred to minimize the introduction of COVID-19 to the facilities. This means residents are unable to see family and loved ones. This necessary intervention brings up the question of quality of life over quantity of life for older individuals. Isolation and social distancing have also taken away group activities like communal meals and games with socializing. Children of institutionalized patients might also feel a sense of loss and guilt as they are not allowed to see their loved ones. Particular to geriatrics, physical touch is essential to healing emotional pain, for example, a gentle touch or massage to relieve anxiety or physical redirection to ease agitation secondary to dementia. Two primary means of addressing loneliness for the geriatric population include providing structure and finding opportunities for volunteerism such as helping other residents or completing simple tasks within the institution. Loneliness and major depressive disorder are difficult to differentiate in the older population. Dr. Wengel recommends favoring intervention over none. This means using basic interventions like providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive symptoms with an SSRI. References Jansson AH et al. Loneliness in nursing homes and assisted living facilities: Prevalence, associated factors and prognosis. Jour Nursing Home Res. 2017;3:43-9. Social isolation, loneliness in older people pose health risks. National Institute on Aging. https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks. Cacioppo JT. Loneliness: Human Nature and the Need for Social Connection. New York: W.W. Norton and Company, 2008. * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

MDedge Psychcast host Lorenzo Norris, MD, interviews Sy Atezaz Saeed, MD, MS, about his annual analysis of the key studies that could change day-to-day psychiatric practice. Dr. Norris's conversation with Dr. Saeed is based on a two-part evidence-based review that identified the top 12 research findings for clinical practice from July 2018 to June 2019. Part 1, which Dr. Saeed wrote with Jennifer B. Stanley, MD, and Part 2 were published in Current Psychiatry. Take-home points Each year, Dr. Saeed identifies 10-20 high-quality journal articles with direct impact on clinical practice that, if used appropriately, can generate better outcomes for psychiatric patients. The goal of the list is to close the gap between cutting-edge science and clinical practice. Secondary literature (for example, Cochrane Reviews, NEJM Journal Watch, and so on) is used to differentiate the clinically relevant "signal" from the noise of all the research produced. Knowledge changes over time, so it's important to be up to date but flexible in how the knowledge is applied. Summary The methodology used to generate the list is aimed at identifying 10-20 useful articles. Dr. Saeed took a three-pronged approach that reviewed research findings suggesting readiness for clinical utilization published between July 1, 2018, and June 30, 2019; asked several professional organizations and colleagues: "Among the papers published from July 1, 2018, to June 30, 2019, which ones in your opinion have (or are likely to have or should have) impacted/changed the clinical practice of psychiatry?"; and looked for appraisals in postpublication reviews such as NEJM Journal Watch, F1000 Prime, Evidence-Based Mental Health; commentaries in peer-reviewed journals; and other sources that suggest an article is of high quality and clinically useful. This approach generated a solid list of articles to consider presenting at journal clubs or a topic to present at grand rounds. Studies on this list also might overlap with research covered in popular media, so the list is a tool that clinicians can use to answer questions patients raise. The secondary literature is used to differentiate the clinically relevant "signal" from the noise of all the research produced. Those secondary sources include Cochrane Reviews, BMJ Best Practice, NEJM Journal Watch, Evidence-Based Mental Health, and commentaries in peer-reviewed journals to help distill the clinically useful articles for a busy clinician. Four of the 12 articles that affected Dr. Saeed's practice covered the risk of death associated with antipsychotic medication usage in children, the role of antipsychotic polypharmacy in schizophrenia to decrease inpatient hospitalizations, the outcomes associated with prescribing different adjunctive medications in combination with antipsychotics, and the use of prazosin for nightmares in PTSD. References Saeed SA et al. Top research findings of 2018-2019 for clinical practice. Part 1. Current Psychiatry. 2020 January;19(1):12-8. Saeed SA. Top research findings of 2018-2019 for clinical practice. Part 2. Current Psychiatry. 2020 February;19(2):22-8. Ray WA et al. Association of antipsychotic treatment with risk of unexpected death among children and youths. JAMA Psychiatry. 2019;76(2):162-71. Tijhonen J et al. Association of antipsychotic polypharmacy vs. monotherapy with psychiatric rehospitalization among adults with schizophrenia. JAMA Psychiatry. 2019;76(5):499-507. Stroup TS et al. Comparative effectiveness of adjunctive psychotropic medications in patients with schizophrenia. JAMA Psychiatry. 2019;76(5):508-15. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507-17. Show notes by Jacqueline Posada, MD, associate producer of the MDedge Psychcast. Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, conducts a Masterclass on what psychiatrists and other mental health clinicians can do to mitigate the impact of COVID-19. Dr. Ritchie is writing additional commentaries on this topic for MDedge Psychiatry. And later, in the "Dr. RK" segment, Renee Kohanski, MD, says that, with simple tools or guidelines, humans have the ability to withstand adversity that is stronger than we will ever know. Take-home points Epidemics and pandemics are characterized by fear and anxiety. Quarantine will be a challenge for patients with addictions and vulnerable populations such as individuals who are homeless. Psychiatrists can aid with social distancing by providing patients refills for psychotropic medications without requiring an in-person visit and switching to telepsychiatry where possible. The Coronavirus Preparedness and Response Supplemental Appropriations Act waives Medicare telehealth reimbursement restrictions for mental health services during certain emergency periods. Inpatient psychiatric units must take special precautions to prevent spread of COVID-19, such as improving procedures for sanitizing communal areas and items, limiting visitation, screening patients for symptoms, and arranging transfer when appropriate. COVID-19 infection can spread on units to patients and staff and may compromise clinicians' ability to provide care safely. Psychiatrists also play a role in helping address the shortage of personal protective equipment (PPE) by talking to patients about the appropriate use of PPE and sanitizer. Summary Emotional response to pandemics: Epidemics and pandemics are characterized by fear and anxiety as people worry about their risk of exposure, infection, and spreading the pathogen. Clinics can alleviate the anxiety by transitioning to telehealth when possible, discouraging handshakes, keeping a distance from patients, and rearranging waiting rooms and other spaces to provide more room between chairs and tables. Psychiatrists can encourage patients and fellow clinicians to engage in activities that normally reduce anxiety, such as exercising, setting aside time for relaxation at home, and taking regularly prescribed or over-the-counter medications. Quarantine considerations: Quarantine and isolation will be difficult for most people, and especially so for patients with psychiatric disorders, including substance use disorders. Psychiatrists can prepare themselves and patients for quarantine by refilling medications for more than 30 days. The Centers for Disease Control and Prevention recommends clinicians refill nonurgent medications without an in-person visit. Patients who are addicted to alcohol or other substances may be tempted to leave the house to acquire those substances. It may be a physician's responsibility to either suggest to patients that they have enough of their substance at home or give them something to treat withdrawal or cravings. Considerations for inpatient psychiatric units: Psychiatric units are built for socialization and communal treatment; thus, psychiatric units will have to change policies, including limiting visitors; decreasing occupancy on the units; and ensuring that communal items such as phones, chairs, and books are properly sanitized. Long-term psychological impact of a pandemic: The negative economic impact of the pandemic, such as unemployment in the tourism and service industries, may have consequences including rising rates of depression and anxiety, suicides, and increases in domestic violence and substance abuse. Psychiatrists can help address the shortage of PPE by talking to patients about the appropriate use of PPE and sanitizer. It is wise to have a stock of food, medications, and supplies for 14-21 days of quarantine, but in a public health emergency we can urge patients and ourselves to be mindful of the needs of others and avoid hoarding. We need to remind ourselves, our patients, and our colleagues to stay healthy by getting enough sleep, taking on the appropriate level of readiness, and remaining flexible as our daily lives are changed by the pandemic. References Centers for Disease Control and Prevention. Interim guidelines for healthcare facilities: Preparing for community transmission of COVID-19 in the United States. H.R. 6074: Coronavirus Preparedness and Response Supplemental Appropriations Act. Passed Congress 2020 Mar 6. Brooks SK et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet. 2020 Mar 14;395(10227):912-20. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Lorenzo Norris, MD, interviews Nina J. Gutin, PhD, a psychologist with a private practice in Pasadena, Calif., about losing patients and loved ones to suicide. Dr. Gutin wrote two evidence-based reviews on the topic late last year. The reviews were published in Current Psychiatry. * * * Take-home points When mental health clinicians lose a patient to suicide, the sequelae can include stigma, potential legal consequences, impact on future clinical work, and restraints on processing the loss because of confidentiality concerns. The American Association of Suicidology founded the Clinician Survivor Task Force (CSTF), which provides consultation, support, and education to mental health professionals to help them respond to the personal/professional loss from the suicide of a patient or loved one. Mental health institutions can benefit from protocols on how to respond to a potential completed suicide, so clinicians and families are not left in a vacuum of uncertainty and blame. After a patient suicide, clinicians need an anonymous or safe space to talk about the patient and the suicide without breaking confidentiality. This can be an online forum, such as the one sponsored by the CSTF, or an institution can identify a supportive colleague who has suffered a similar loss. The CSTF forum allows clinicians to remain anonymous. Summary Several domains require attention after the loss of a patient from suicide: Confidentiality restrains the ability to talk about the details of the loss, which stymies grief and learning from the event. Restraints of confidentiality pertain to individual clinicians and clinical teams. On a team, it might feel as if the clinicians are unable to process the loss as a group and talk about important details. Legally, clinicians worry about potential lawsuits, and "psychological autopsies" can lead to retraumatization. Clinicians might struggle with how – or whether – to talk to a patient's family after suicide. Some lawyers advise compassion over caution. In collaboration with lawyers who advise what can be disclosed, a clinician can speak with a family, and this compassion toward families might decrease the risk of a lawsuit. Clinicians should be prepared for a patient suicide to affect their clinical work. A clinician might become hypervigilant about suicide risk and overreact, or they might experience denial about the risk and avoid asking questions about suicide. Ethically, suicide is an "occupational hazard" of working in the mental health field. Blaming clinicians for patient suicide hampers the depth of working with people with mental illness by causing some clinicians to avoid "high-risk" patients. The stigma around death by suicide extends to the survivors of the loss. When clinicians express vulnerability about loss, it can be interpreted as guilt. Clinicians are expected to keep going no matter what, which is unrealistic. Grief over a patient's death should be neither pathologized nor shamed. Guilt and blame are the flip sides of each other; both express the complexity and ambiguity of these kinds of losses. Institutions should have "postvention" protocols in place to respond to the likely event of a completed suicide. Guidelines can address what needs to be covered in a review of the case while also supporting clinicians, so they don't feel like it's a tribunal. Clinicians should be warned of the normal sequelae of a client suicide, and institutions can make accommodations based on the expected impact of suicide on a clinician's work. Institutions can provide support by connecting clinicians who have also lost clients to suicide to dispel the belief that they are alone in their loss and to mitigate self-blame. The CSTF provides support through in-person and online support groups, and postvention protocols for institutions. It also and maintains a bibliography of research on clinician survivorship. References Gutin NJ. "Losing a patient to suicide: What we know." Current Psychiatry. 2019 Oct 18(10):14-6,19-22,30-2. Gutin NJ. Losing a patient to suicide: Navigating the aftermath. Current Psychiatry. 2019 Nov 18(11):17-18,20,22-4. American Association of Suicidiology. Clinicians as Survivors: After a Suicide Loss. Owen JR et al. Suicide symposium: A multidisciplinary approach to risk assessment and the emotional aftermath of patient suicide. MedEdPORTAL. 2018 Nov 28;14:10776. Myers MF and Fine C. Touched by suicide: Bridging the perspectives of survivors and clinicians. Suicide Life Threat Behav. 2007 Apr;37(2):119-26. * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Jonathan Meyer, MD, returns to the Psychcast, this time to conduct a Masterclass lecture on treating patients with lumateperone. Dr. Meyer, of the University of California, San Diego, disclosed receiving either speaking honoraria or advising fees from several companies, including Intra-Cellular Therapies, which developed lumateperone (Caplyta). Later, Renee Kohanski, MD, discusses tailored interventions psychiatrists can incorporate into their practices to address overweight and obesity resulting from medications tied to weight gain. Take-home points Lumateperone, an atypical antipsychotic, was approved by the Food and Drug Administration for the treatment of adults with schizophrenia on Dec. 20, 2019. It has only one approved effective dose of 42 mg given with food. Further studies might define doses higher or lower, but those data are not available yet. The only adverse effect found with lumateperone was somnolence or sedation. Lumateperone was 24%; placebo was 10%. The medication has a low affinity and occupancy of the dopamine D2 receptors. This pharmacodynamic trait is reflected by the relatively low rates of extrapyramidal side effects in the clinical trial data. For now, the short-term studies of lumateperone suggest limited metabolic and endocrine effects, compared with other atypical antipsychotics. The primary indication for using lumateperone may be its tolerability profile, because nonadherence contributes to the morbidity of schizophrenia. Lumateperone is not a drug that should be used for treatment-resistant schizophrenia. The only drug that should be used for refractory patients with schizophrenia is clozapine (Clozaril). Summary Lumateperone has a unique pharmacologic profile. It has a low affinity for muscarinic, histaminergic, and alpha-adrenergic receptors. In the clinical trials, the primary side effect reported was somnolence and/or sedation. The medication also has a lower affinity for dopamine D2 receptors and occupies less than 40% of these receptors even at peak-dose timing. Conventional treatment of psychosis suggests that antipsychotic properties of D2 antagonist medications occur when 60%-80% of D2 receptors are occupied. Yet, there may be other properties of atypical antipsychotics that can increase the efficacy with lower levels of D2 blockade. Knowledge of alternative mechanisms comes from studying other antipsychotics. For example, pimavanserin (Nuplazid), an antipsychotic medication for treatment of psychosis in Parkinson's disease, has no affinity for any dopamine receptors. Instead, it has a high affinity for serotonin 5-HT2A receptors as an inverse agonist and antagonist likely in cortical circuits with downstream glutamate signaling to dopamine circuits in the ventral tegmental area, which then decreases the amount of dopamine released in the mesolimbic pathway. Pimavanserin does not have any activity on the presynaptic D2 autoreceptors. Though counterintuitive, other atypical antipsychotics block the D2 presynaptic autoreceptor, which increases dopamine release. This mechanism is possibly why other antipsychotics require a 60%-80% D2 blockade to be effective in treating psychosis. In vitro studies suggest that lumateperone does not have presynaptic autoreceptor antagonism, which could be another reason why it doesn't need as much D2 antagonism to be an effective antipsychotic agent. Lumateperone also is a weak inhibitor of serotonin reuptake occupying 30% of the serotonin receptors. Given its diverse pharmacologic mechanisms, lumateperone may confer antidepressant properties, and clinical trials are in the process to evaluate the use of lumateperone in bipolar depression. The drug is expected to be available at the end of March 2020. References Meltzer HY et al. Pimavanserin, a selective serotonin (5-HT)2A-inverse agonist, enhances the efficacy and safety of risperidone, 2 mg/day, but does not enhance efficacy of haloperidol, 2 mg/day: comparison with reference dose risperidone, 6 mg/day. Schizophr Res. 2012;141(2-3):144-52. Correll CU et al. Efficacy and safety of lumateperone for treatment of schizophrenia: A randomized clinical trial. JAMA Psychiatry. 2020 Jan 8. doi: 10.1001/jamapsychiatry.2019.4379. Corponi F et al. Novel antipsychotics specificity profile: A clinically oriented review of lurasidone, brexpiprazole, cariprazine, and lumateperone. Eur Neuropsychopharmacol. 2019;29(9):971-85. U.S. National Library of Medicine. Lumateperone drug label * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Patricia Westmoreland, MD, returns to the Psychcast to conduct a Masterclass on treating bulimia. Dr. Westmoreland, an attending psychiatrist at the Eating Recovery Center in Denver, previously discussed eating disorders. She is an adjunct assistant professor in the department of psychiatry at the University of Colorado at Denver, Aurora, and has a private forensic psychiatry practice in Denver. Takeaway points Anorexia nervosa and bulimia nervosa can have life-threatening medical complications. All medical complications can resolve with consistent nutrition and full weight restoration. Eating disorders must be treated and associated behaviors stopped to prevent complications from returning. Anorexia-related medical complications usually are attributable to weight loss and malnutrition. Bulimia-related medical complications can occur at any weight, and are related to the mode and frequency of purging. Complications include metabolic abnormalities, such as electrolyte and acid-base disturbances, volume depletion, and damage to the colon. Patients with bulimia have a lower mortality rate than do those with anorexia. However, the mortality of patients with bulimia is two times higher than that of age-matched healthy controls because of acid-base disturbances and severe electrolyte abnormalities. The weight of the patients with bulimia does not matter. Acid-based disturbances and severe electrolyte abnormalities can kill patients at any time without warning and at any weight. Summary About 90% of purging behaviors consists of self-induced vomiting and/or laxative abuse. Self-induced vomiting can cause local complications such as gastric reflux, which can lead to dysphagia and dyspepsia; hematemesis from Mallory-Weiss tears in the esophagus; nosebleeds and subconjunctival hemorrhages; and parotid gland enlargement, known as sialadenosis, which is a chronic, noninflammatory cause of swelling of the major salivary glands. Systemic complications of self-induced vomiting include metabolic derangements, such as hypokalemia, metabolic alkalosis, and volume depletion, which can lead to pseudo-Bartter syndrome from chronic aldosterone secretion as the body attempts to maintain blood pressure; the syndrome is characterized by hyperaldosteronism, metabolic alkalosis, hypokalemia, and normal blood pressure. Treatment of local complications: Gastric reflux can be treated with proton pump inhibitors, and the patient should be screened for Barrett's esophagus with esophagogastroduodenoscopy. Dental complications such as erosion of the enamel should be addressed with fluoride-based mouthwashes and toothpastes, and gentle toothbrushing. Parotid gland enlargement is treated by sucking on sour candies, applying hot packs, and using anti-inflammatory medications. Treatment of systemic complications: Hypokalemia, which is diagnosed on a basic metabolic panel, needs immediate repletion orally or intravenously. Depending on the severity of the hypokalemia, the patient may need cardiac monitoring in the hospital or ICU to prevent mortality from a lethal arrhythmia. In pseudo-Bartter syndrome, the elevated aldosterone does not normalize until a few weeks after purging stops, so individuals can develop edema and the other electrolyte abnormalities. Treatment is spironolactone, 25-200 mg/day. Complications from laxative abuse occur primarily from stimulant laxatives, which stimulate the myenteric plexus, the nerves of the intestines, and increase intestinal secretions and motility. Cathartic colon syndrome occurs from continued use of stimulant laxatives, which damage the nerves of the colon by rendering it incapable of peristalsis without continued use of laxatives. Individuals who abuse laxatives more than three times per week for at least 1 year are at risk of cathartic colon syndrome and need to stop laxatives immediately. References Westmoreland P et al. Medical complications of anorexia nervosa and bulimia. Am J Med. 2016;129(1):30-7. Mehler PS, Walsh K. Electrolyte and acid-base abnormalities associated with purging behaviors. Int J Eat Disord. 2016 Mar;49(3):311-8. Gibson D et al. Medical complications of anorexia nervosa and bulimia nervosa. Psychiatr Clin North Am. 2019 Jun;42:263-74. Sato Y, Fukado S. Gastrointestinal symptoms and disorders in patients with eating disorders. Clin J Gastroenterol. 2015 Oct;8(5):255-63. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

Charles L. Raison, MD, returns to the Psychcast to conduct a Masterclass on psychedelics for patients with major depressive disorder. Dr. Raison, professor of psychiatry at the University of Wisconsin–Madison, previously conducted a Masterclass on the risks and benefits of antidepressants. He disclosed that he is director of translational research at the Usona Institute, also in Madison. Later, Renee Kohanski, MD, raises questions about the felony child abuse case of pediatric emergency department doctor John Cox. Takeaway points Psychedelics are a range of compounds that share a common mechanism as agonists at the postsynaptic 5-HT2A serotonin receptor. Psychedelic agents have a novel therapeutic quality. Studies suggest that a few or even one exposure to a psychedelic compound, which has a short-term biological effect, leads to long-lasting therapeutic effect, such as remission of mood disorder or change in personality characteristics. The clinical outcomes are mediated by the intensity of the psychedelic experience. A psychedelic experience is characterized by profound, rapid alterations in what is seen, sensed, felt, and thought. It often leads to personal growth with experiences of transcendence. Subjects in trials often report a "mystical experience" they describe as a sense of unity with the universe and understanding of one's deeper purpose. Psychedelic experiences also are characterized by a difficulty in describing them with words. Because psychedelics are illegal substances, the traditional route of pharmaceutical companies' funding the research for clinical trials is not available. Organizations such as Usona Institute and MAPS (Multidisciplinary Association for Psychedelic Studies) are leading the way. The Food and Drug Administration has granted psilocybin a "breakthrough therapy designation" for the treatment of major depressive disorder. Summary Psilocybin, lysergic acid diethylamide (LSD), mescaline, ayahuasca (active ingredient: N,N-dimethyltryptamine [DMT]), and 3,4-methylendioxy-methamphetamine (MDMA) are all classified as psychedelics. Psychedelics have been used for thousands of years for spiritual ceremonies. Psychedelics came to the attention of medicine and science after 1943 when Albert Hofmann, PhD, a chemist at a Sandoz Lab in Basel, Switzerland, synthesized LSD and accidentally ingested it, serendipitously identifying its mind-altering properties. Until 1970, psychedelics were widely used in clinical research, and more than 1,000 academic papers about their use were published. For example, psychedelics were used as a model for schizophrenia and helped identify the role of serotonin in psychosis. They also were studied to treat addiction and as a treatment for existential anxiety in cancer. In 1971, psychedelics were declared illegal under the U.N. Convention on Psychotropic Substances. Researchers returned to psychedelics in the 2000s, examining a variety of uses, including the capability to reliably induce psychedelic experience in healthy normal volunteers (no previous psychiatric diagnosis) and promote emotional well-being in healthy normal volunteers. The role of psychedelics as medicine are once again being studied in a variety of contexts, such as mood disorders, PTSD, addiction, and phase-of-life problems. Most notable from the research is the capability of psychedelic compounds to induce long-lasting effects on personality, mood disorders, and PTSD after one or a few ingestions. What is remarkable is how the therapeutic effect remains long after the biological presence of the compound is gone from the body. The clinical outcomes are mediated by the intensity of the psychedelic experience. The Usona Institute, a medical research organization, started as a nonprofit to advance the research into psychedelics needed for the FDA to approve psychedelics as a treatment. Because psychedelics are still illegal, the traditional route of pharmaceutical companies funding this type of research is not available. The FDA has granted psilocybin a "breakthrough therapy designation" for the treatment of major depressive disorder. The breakthrough therapy designation "indicates that the drug may demonstrate substantial improvement on a clinically significant endpoint(s) over available therapies." The breakthrough therapy designation is for major depressive disorder, not for treatment-resistant depression, suggesting that the FDA recognizes the shortcomings of current treatments for depression. References Johnson MW, Griffiths RR. Potential therapeutic effects of psilocybin. Neurotherapeutics. 2017 Jul;14(3):734-40. Griffiths RR et al. Psilocybin-occasioned mystical-type experience in combination with meditation and other spiritual practices produces enduring positive changes in psychological functioning in trait measures of prosocial attitudes and behaviors. J Psychopharmacol. 2018 Jan;32(1):49-69. Johnson MW et al. Long-term follow-up of psilocybin-facilitated smoking cessation. Am J Drug

William Lynes, MD, joins guest host Michael F. Myers, MD, to discuss his struggles with medical and psychiatric hardships, his suicidality, and the eventual suicide attempt that changed his life. Dr. Myers is professor of clinical psychiatry, State University of New York, Brooklyn. Dr. Lynes, a retired urologist, author, and speaker/advocate on physician burnout and suicide, divides his professional life into two distinct eras: 1987-1998, during which he had a successful practice and happy life, and after 1998, when he spiraled downward medically and psychiatrically. After meeting another physician with a similar experience who had published her story of burnout and mental health struggles in 2015, Dr. Lynes decided to speak out. Eventually, he published an essay about his experience in the Annals of Internal Medicine. Take-home points Being open with close colleagues or supervisors about mental health struggles and/or burnout can provide a much-needed lifeline to struggling physicians. Addressing burnout and mental health diagnoses of physicians requires medical groups and institutions to provide access to psychiatric treatment from clinicians outside of the professional network in which the physician practices. Practicing medicine can be a 24/7 profession, and being "on" all the time can contribute to burnout. Lifestyle choices such as exercise, hobbies, family, and spirituality are all helpful outlets to address the constancy of practicing medicine. Giving in to the notion that you can treat yourself is not a good idea. Decreasing the stigma tied to mental illness can be helped by people with lived experience, such as Dr. Lynes. * * * References Lynes W. The last day. Ann Intern Med. 2016 May 3;164(9):631. Myers MF and Freeland A. The mentally ill physician: Issues in assessment, treatment and advocacy. Can J Psychiatry. 2019 Dec 6;64(12):823-37. Forbes MP et al. Optimizing the treatment of doctors with mental illness. Aust NZ Psychiatry. 2019 Feb;53(2):106-9. Myers MF. "Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared." 2017 Feb 14. (Self-published). Bird JL. "Using Narrative Writing to Enhance Healing." Medical Information Science Reference, 2019. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected]

George T. Grossberg, MD, conducts a Masterclass on treating mood disorders in geriatric patients from the CP/AACP Psychiatry Update 2019 meeting in Las Vegas. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Grossberg is the Samuel W. Fordyce professor and director of geriatric psychiatry at St. Louis University School of Medicine in St. Louis. Later, Renee Kohanski, MD, discusses the first thing psychiatrists can do for patients. Take-home points from Dr. Grossberg: The prevalence of major depressive disorder among older adults who reside in the community is similar to that of the general population (6%). In nursing homes, the prevalence of significant clinical depression is close to 25%. Depression in older adults in long-term care facilities is underrecognized and undertreated. Risk factors for depression include advanced age (80-90 years), loneliness and lack of social support, painful conditions, frailty, and medical comorbidities. Medications that are central nervous system depressants, such as opiates and benzodiazepines, also can contribute to depression. Alcohol can also be a depressant. Depression in the face of cognitive impairment is extremely common and can even speed cognitive decline. Apathy, defined as lack of motivation, can look like depression. However, depression will have amotivation coupled with vegetative symptoms, such as disrupted sleep and loss of appetite, and mood changes, such as sadness and tearfulness. Low-dose stimulants are effective for apathy, but antidepressants are not; so, it's important to differentiate the two. Undiagnosed and untreated depression contributes to a significant degree of morbidity because it can slow recovery in rehabilitative settings and impair adherence to essential medications. Treating depression also can improve pain control by making it more tolerable as a somatic symptom. Individuals older than 65 years account for more than 20% of all completed suicides in the United States. Psychological autopsy studies suggest that many of these individuals had undiagnosed depression. Clinicians should not shy away from treating geriatric patients for depression with medication and interventions such as cognitive-behavioral therapy. With pharmacotherapy, start low, go slow, and titrate up to a therapeutic dose. Older adults may take longer, up to 8-12 weeks, to respond to SSRIs, so it's imperative not to give up on medications too soon. Electroconvulsive therapy is the most effective treatment for severe depression in geriatric patients. Some consider advanced age an indication for ECT; medical comorbidities are not a contraindication for ECT. It is unclear how effective ketamine is in older patients, but it deserves consideration. Prompt diagnosis and treatment of mood disorders is paramount in patients of advanced age and those living in long-term care facilities. Treating depression in the older patient also improves the quality of life for caregivers and professional staff. References Birer RB et al. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician. 2004 May 15;69(10):2375-82. Sjoberg L et al. Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults. J Affect Disord. 2017 Oct 15;221:123-31. Grossberg GT et al. Rapid depression assessment in geriatric patients. Clin Geriatr Med. 2017 Aug;33(3):383-91. *** For more MDedge podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

In this, the 100th episode of Psychcast, Nick Andrews talks with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about the January front-page article in Clinical Psychiatry News that featured Matthew E. Seaman, MD, an emergency physician with depression who took his own life. The article describes the Dr. Seaman faced. Later, Christine B.L. Adams, MD, a psychiatrist who practices in Louisville, Ky., discusses her book, "Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships" (Santa Barbara: Praeger, 2018), with Dr. Norris. Take-home points from Dr. Adams Children learn emotional patterns in families. These behaviors get reinforced. As children form dating relationships, for example, those patterns continue to be reinforced. People may go on autopilot and have knee-jerk reactions in response to people, which allows them to react emotionally without thinking about what's necessary for each person. Long-term dynamic psychotherapy can help patients observe what they are doing in relationships and what others are doing. Ultimately, patients can be taught to look at and uncover their automatic responses. Once these patterns are uncovered and moved from the emotional realm to the intellectual realm, they can be interrupted. Genesis and development of the book's principles Homer B. Martin, MD, a Louisville, Ky.–based adult psychiatrist who worked with Dr. Adams for 30 years, developed the original premise of the book. When he died, his wife asked Dr. Adams, who was his protégé, to finish it. The book is based on the observations made by Dr. Martin during his 40 years of conducting psychotherapy with patients. It is designed to be accessible both to psychiatric trainees as well as to general readers. Dr. Adams started teaching the concepts in the book during a 6-week university class to determine whether the ideas were digestible and useful. Mainstream movies were used to help people learn to observe and identify roles that were emotionally conditioned and to determine how a character's change in behavior would change the other person. Movies that can be used to help people identify problematic patterns include "Ordinary People," "Gran Torino," "The Remains of the Day," "The Door in the Floor," and "When Harry Met Sally." References Yazici E et al. Use of movies for group therapy of psychiatric inpatients: Theory and practice. Int J Group Psychother. 2014 Apr;64(2):254-70. Ross J. You and me: Investigating the role of self-evaluative emotion in preschool prosociality. J Exp Child Psychol. 2017 Mar;155:67-83. Werner AM et al. The clinical trait self-criticism and its relation to psychopathology: A systematic review – Update. J Affect Disord. 2019 Mar;246:530-47. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

In episode 99 of the Psychcast, Frank Yeomans, MD, PhD, clinical associate professor of psychiatry at the Weill Medical College of Cornell University, Ithaca, N.Y., spoke with Dr. Norris at the Group for the Advancement of Psychiatry (GAP) fall 2019 meeting about treating patients with personality disorders. Characteristics of personality disorders A personality disorder affects the quality of a person's experience and his or her ability to deal with challenges in life, including comorbid psychiatric disorders. A personality disorder is not based on symptoms alone and determines how people engage with their environment; it is a part of the biological side of psychiatry. The DSM traditionally relied on a traits-based definition of personality disorders. Yet, in the "emerging measures and models" section, the DSM-5 describes a dimensional/categorical model of personality disorders, which looks at personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. This harkens back to the concept of borderline personality organization as outlined by Otto F. Kernberg, MD. The dimensional model suggests that individuals with personality disorders benefit from behavioral therapies, such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT), to treat problematic traits. Exploratory and insight-focused psychotherapies can help individuals understand their personality organization. Ideally, the treatments for personality disorders would be sequenced, starting with CBT or DBT and transitioning into exploratory therapy. Much like borderline personality disorder, at the core of narcissistic personality disorder is a fragmented sense of self, but in the latter disorder, a self-centered narrative exists that is coherent to the person but does not support reality. If mental health is defined as the ability to adapt to the different circumstances of life, people with narcissism cannot adapt and instead, develop a grandiose narrative to soothe the fragmented self. Therapeutic interventions for narcissism focus on disrupting the narrative in a gentle way that allows patients to understand the model in which they currently experience the world and then reconstitute an adaptive narrative. An effective treatment approach is psychodynamic therapy, with a focus on a treatment contract and specific, explicitly agreed-upon goals. Try to focus more on the interaction with the patient than on the narrative content of the session. The therapy must focused on how the patient acts in therapy, and their adaptations and reactions, because these are the actions that negatively affect their relationships and daily lives. The biological part of a person is processed at the psychological level, so psychiatrists must be interested in psychological aspects of treatment. References Sharp C et al. The structure of personality pathology: Both general ('G') and specific ('S') factors? Abnorm Psychol. 2015 May;124(2):387-98. Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry. 2009 May 1;166(5):530-9. Caligor E et al. Narcissistic personality disorder: Diagnostic and clinical challenges. Am J Psychiatry. 2015 May;172(5):415-22. Morey LC et al. Personality disorders in DSM-5: Emerging research on the alternative model. Curr Psychiatry Rep. 2015 Apr;17(4):558. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Alberto J. Espay, MD, MSc, conducts a Masterclass lecture on treating patients with Parkinson's-related psychosis from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Espay is professor of neurology at the University of Cincinnati. He also serves as director of the James J. and Joan A. Gardner Family Center Research Chair for Parkinson's Disease and Movement Disorders. And later, in the "Dr. RK" segment, Renee Kohanski, MD, asks you to think about some of the complex issues tied to getting treatment for people who are both homeless and have serious mental illness. * * * Treatment of Parkinson's-related psychosis Psychosis related to Parkinson's disease (PD) is a common reason for hospitalization, institutionalization, and decline of patients with PD. The diagnosis of PD is required before the development of psychosis to diagnose patients with Parkinson's-related psychosis. Parkinsonism that appears after development of psychosis is Lewy body dementia. Many factors influence the development of psychosis in PD. Extrinsic factors include medical illnesses or metabolic derangement causing delirium with psychosis; nonessential dopaminergic medications such as ropinirole and selegiline; anticholinergic medications such as benztropine, amantadine, and bladder antispasmodics; and insomnia. The last resort for treatment of psychosis is levodopa because patients will experience motoric decline and loss of functioning. There are several mechanisms for psychosis to occur via the dopaminergic, serotonergic, and glutamatergic pathways; thus, three neurotransmitters – serotonin, dopamine, and glutamate – can be manipulated to treat psychosis. Quetiapine, clozapine, and pimavanserin are the three antipsychotics safe for use in Parkinson's disease. Clozapine is infrequently used, because of the risk of neutropenia and required blood work monitoring, but evidence shows that the benefits usually outweigh the risks of motor decline. Quetiapine is commonly used, because it has a favorable effect on sleep and psychosis, but it negatively affects the movement disorder of Parkinson's disease. Pimavanserin (Nuplazid), the only medication FDA approved for hallucinations and delusions associated with psychosis in Parkinson's disease, is highly selective for the 5-HT2A receptor as both an inverse agonist and antagonist. Primary adverse effects are peripheral edema and confusion, but overall the adverse effects profile is similar to that of placebo. In the pimavanserin clinical trials, a subset of patients worsened and experienced more visual hallucinations. In addition, pimavanserin can prolong the QT interval, so patients taking other QT-prolonging medications or who have cardiac comorbidities should be monitored with an EKG. Post hoc data analysis from as pivotal phase 3 study suggests that patients with cognitive impairment and dementia may receive more benefit from pimavanserin. * * * References Cruz MP. Pimavanserin (Nuplazid): A treatment for hallucinations and delusions associated with Parkinson's disease. P T. 2017 Jun;42(6):368-71. Cummings J et al. Pimavanserin: Potential treatment for dementia-related psychosis. J Prev Alzheimers Dis. 2018;5(4):253-8. Huot P. 5HT2A receptors and Parkinson's disease psychosis: A pharmacological discussion. Neurodegenerative Disease Management. 2018 Nov 19. doi: 10.2217/nmt-2018-0039. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Michael A. Norko, MD, professor of psychiatry at Yale University in New Haven, Conn., spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about incorporating patients' spiritual and religious histories into psychiatric evaluations. Dr. Norko, lead author of a paper exploring whether religion is protective against suicide, sat down with Dr. Norris at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP. Evidence, questions to consider about religion and spirituality Various spiritual and religious factors are linked to decreased rates of suicide behaviors and attempts, including weekly attendance to worship services, personal beliefs about the preciousness of life, and commitment to a faith practice. Which specific parts of religious and spirituality are protective? Are the protective factors the social connection or the spiritual connection alone? Those who attend worship services weekly are at lower risk of suicide. It's unclear whether weekly attendance is a proxy for the social connectedness or for the level of internalization of the religious beliefs. Commitment to a faith is measured by a consistent and strong belief in the faith tradition. Just because someone says they belong to a faith tradition does not automatically mean a person is at lower risk of suicide. Strong alignment with the faith also is protective. Alignment is different from commitment, because if patients are doubting or their personal beliefs conflict with long-held religious traditions, this can increase patients' suicide risk. Questions to ask about spirituality and religion in clinical practice A spiritual and religious history is essential to a psychiatric evaluation, because asking about religion lets the patient know that this is a welcome topic. Examples of questions a clinician can ask include: "Is there any faith tradition that you belong to? How important is your faith or beliefs? Is there anything about your religious beliefs you think are important to your mental health treatment?" Difficult areas to navigate with religion and spirituality Lack of expertise or personal experience with religion can be a barrier. It is important to remember that patients usually welcome curiosity about their religious beliefs and emotional lives. Clinicians need not be experts in religion, but they can be alert to the salient values and notice whether the person is struggling with certain beliefs. Clinicians also can encourage patients to talk to their clergy. When someone asks a clinician, "What is your faith practice?" this can be approached as an informed consent question. The clinician can ask how talking about their own beliefs or faith practices will deepen and help the therapeutic work of the patient. If a person is feeling let down by a certain failing of their religious community, therapy is a good place to explore what strengths and succor they had received from their religion. Therapy also can be used to guide patients toward additional places, or even substitutes, to meet their needs. Understanding patients' faith background and beliefs can help clinicians reframe certain crises, especially if the psychiatrist and therapist have talked discussed those crises with patients over time. It's more useful to understand patients' faith before the crisis, because grasping for a spiritual or religious answer at the last moment can feel inauthentic. References Norko et al. Can religion protect against suicide? J Nerv Ment Dis. 2017. Jan;205(1):9-14. Kruizinga R et al. Toward a fully-fledged integration of spiritual care and medical care. J Pain Symptom Manage. 2018 Mar;55(3):1035-40. Thomas LP et al. Meaning-centered psychotherapy: A form of psychotherapy for patients with cancer. Curr Psychiatry Rep. 2014 Oct;16(10):488. Lawrence RE et al. Religion and suicide risk: A systematic review. Arch Suicide Res. 2016;20(1):1-21. D'Souza R, George K. Spirituality, religion and psychiatry: its application to clinical practice. Australas Psychiatry. 2006 Dec;14(4):408-12. FICA Spiritual History Tool: https://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool, which is based on Puchalski C and Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000 Spring;3(1):129-37. George Washington University Institute for Spirituality and Health (GWISH): https://smhs.gwu.edu/gwish/

Lorenzo Norris, MD, and Roger McIntyre, MD, talk about obesity, inflammation, and mental illness. The conversation, which originally dropped a few months ago, took place at the Focus on Neuropsychiatry 2019 meeting. The meeting was sponsored by Current Psychiatry and Global Academy for Medical Education. The original podcast included robust Show Notes by Jacqueline Posada, MD. Also, you can watch the conversation between Dr. Norris and Dr. McIntyre on video or on YouTube. Later, Renee Kohanski, MD, talks about different ways to think about resolutions and behavioral change. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

In this episode of the MDedge Psychcast, we revisit an interview that Lorenzo Norris, MD, MDedge Psychiatry editor in chief, conducted earlier this year by phone with two psychiatrists working in New Mexico. Dr. Norris spoke with Caroline Bonham, MD, and Avi Kriechman, MD, about enhancing resilience in rural communities. Dr. Bonham is vice chair in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is assistant professor in that department, and a pediatrician who works on youth suicide prevention and school mental health. Understanding risks of suicide in rural communities Nationally, suicide rates have been going up across the United States, including in rural communities. Paucity of mental health clinicians supporting youth and their families has implications for youth suicide. Impact of structural poverty and the opioid epidemic also have implications for these rising rates. Identifying resources within small, rural communities Communities have resources that are not tapped into enough by clinicians, such as churches, teachers, and community health workers. Recent studies show that most communities have members who know people at risk and want to help. It is important for clinicians to think outside of the box so that they help facilitate the use of natural resources/strengths that exist within small communities, such as food pantries that operate out of mental health centers, spiritual organizations, and aftercare programs in schools. Building resilience among individuals The literature shows that engaging people in a collaborative, transparent process of care is effective. If community members who do not have problems, such as suicidality, physical ailments, or a severe mental illness, are taught to reach out, destigmatize, and facilitate treatment, the mental health outcomes of patients are better. Concrete, feasible intervention would be to work with gun store owners about the risk factors for suicide, how to encourage people to seek help. Some police departments provide education about the safe storage of firearms. References Curtin SC and Heron M. Death rates due to suicide and homicide among persons aged 10-24: United States, 2000-2017. NCHS Data Brief. 2019 Oct;(352):1-8. Altschul DB et al. State legislative approach to enumerating behavioral health workforce shortages: Lessons learned in New Mexico. Am J Prev Med. 2018 Jun;54(6 suppl 3):S220-9. Bonham C et al. Training psychiatrists for rural practice: A 20-year follow-up. Acad Psychiatry. 2014 Oct;38(5):623-6. Kriechman A et al. Expanding the vision: The strength-based, community-oriented child and adolescent psychiatrist working in schools. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):149-62. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Ruta Nonacs, MD, PhD, conducts a Masterclass lecture on treating women with postpartum depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Nonacs is a staff psychiatrist with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital in Boston. * * * Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * Features of postpartum depression Postpartum depression (PPD) affects 10%-15% of women after delivery. For many women, their depression starts in the third trimester and worsens after delivery. Unique symptoms of PPD include difficulties bonding with the baby, feeling like an inadequate mother, and experiencing severe sleep disturbance with anxiety and edginess. In a common scenario, the mother will not be able to sleep at night, though her baby is sleeping well. Anxiety is a common comorbidity, especially obsessive thoughts about the baby's safety. Treatment of PPD Treatment in this population is complicated by many demands placed on a mother as the primary caregiver of an infant. The medication chosen must target depression and anxiety, improve sleep, yet not be too sedating. The concentration of antidepressants in breast milk is low, but many women will defer treatment for their depression until they've stopped breastfeeding. Treatment of mild PPD includes recruiting more support to help the mother with care of the infant and psychotherapy to identify stressors and coping skills. In moderate to severe PPD, antidepressants are needed. Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are the preferred treatments, and studies support the use of sertraline, fluoxetine, paroxetine, and venlafaxine at their standard dosages. SSRIs and SNRIs are compatible with breastfeeding, because the medications are detected in the breast milk at very low levels. Brexanolone (Zulresso) is the only Food and Drug Administration–approved medication for postpartum depression. It is a neurosteroid and derivative of allopregnanolone, which is a positive allosteric modulator of the gamma-aminobutyric acid receptor. Brexanolone has low oral bioavailability and is administered only as a 60-hour infusion in a certified medical setting with continuous monitoring. The trials for brexanolone included women with moderate to severe PPD, and Hamilton Depression Rating Scale scores (HAM-D) scores ranging from 20 to 25. After the 60-hour infusion, 45% of the subjects with severe PPD in the brexanolone group achieved remission by the end of treatment, compared with 23% in the placebo group. Women retained the antidepressant effect at the 30-day follow-up. The results in the moderate PPD group were not as impressive; these women had a decrease in their depression HAM-D scores, but the antidepressant effect did not continue to the 30-day follow-up. The FDA approval came with a Risk Evaluation Mitigation Strategy in place. Currently, approximately 100 sites are ready to administer brexanolone; however, some obstacles remain: Obstacles to using brexanolone The medication costs more than $30,000 per infusion, and it is uncertain how much insurance will cover. Since brexanolone is administered in hospital settings, women must be separated from their children for several days. Breastfeeding must be stopped while women are on the medication because of the lack of data about excretion in breast milk. Brexanolone is labeled as a Schedule IV medication because it has a similar mechanism of action to midazolam and diazepam. Likelihood of diversion is low, but some women with substance abuse histories might be concerned about this treatment. References Leader LD et al. Brexanolone for postpartum depression: Clinical evidence and practical considerations. Pharmacotherapy. 2019 Nov;39(11):1105-12. Meltzer-Brody S et al. Brexanolone injection in postpartum depression: Two multicenter, double-blind, randomized, placebo-controlled, phase 3 trials. Lancet. 2018 Sep 22;392(10152):1058-70. Nonacs R. A Deeper Shade of Blue: A Woman's Guide to Recognizing and Treating Depression in Her Childbearing Years. New York, NY: Simon & Schuster; 2006. Massachusetts General Hospital Center for Women's Mental Health. womensmentalhealth.org National Institutes of Health. Drugs and Lactation Database (LactMed). * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Roberto Lewis-Fernández, MD, returns to the MDedge Psychcast, this time to discuss ways to approach pharmacotherapy for Latino patients with depression. Previously, on episode 36 of the Psychcast, Dr. Lewis-Fernández discussed the role of cultural assessments in providing person-centered mental health care. Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University and director of the New York state Center of Excellence for Cultural Competence and the Hispanic Treatment Program at the New York Psychiatric Institute, spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP. And later, in the "Dr. RK" segment, Renee Kohanski, MD, asks whether some euphemisms that are becoming more common in society keep us from finding real solutions to problems. * * * Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * How Latino patients typically think of illness and medications Commonly, patients of Latino descent seek mental health treatment after trying other interventions, such as talking with family, clergy, and primary care clinicians. Latino patients, similar to other patient populations, sometimes present with ambivalence about medications and concerns that the medications might be "fairly strong" or addictive. The need to take medications is seen as an admission of sorts that the presenting problem of depression or anxiety is serious. Specifically, Latino patients are concerned about medications and risk of physical and psychological addiction and being reliant on a crutch. For example, a Latino patient might worry that by taking an antidepressant medication, they will lose their innate ability to improve on their own. This belief plays out when Latino patients stop medication prematurely, just as it begins to be effective, in order to "poner de mi parte," which translates to "do my share." The Latino culture puts weight on self-reliance. Latino patients often look for flexibility in medications and express concern about their effect on the body. For example, some patients might want to take medication only on days in which they feel sick. Others might ask for days off from the medication to ensure that the body does not weaken from being dependent on medications. Natural remedies often are favored by Latino patients. In some Latino communities, there might be natural pharmacies and "botanicas," which provide herbal and vitamin remedies. Natural medicines are viewed as "gentle" and more in line with what the body needs. Psychotherapy for the treatment of mild depression often is favored by patients who want to use therapy before medications. Latino patients usually prefer more "advice"-driven psychotherapy that focuses on problem solving. Possible structural barriers to treating Latino patients Common structural barriers to accessing care include limited time to make appointments because of work and family obligations as well as a fragmented health care system with ever changing clinicians. Stigma and concerns about "harm to the body" can prove to be barriers. How clinicians might work with Latino patients Be open to being flexible to patients' requests, such as the desire to perhaps skip a day each week or even stop medications. Exerting clinical authority based on biological understanding of the medication and diagnosis can backfire and can result in patients stopping the medication altogether. Understand different conceptions in the Latino community about how and when emotions should be expressed. The "ataque de nervios" ("attack of nerves") presented in the DSM-5 as a culture-bound syndrome is indicative of the Latino attitude that emotions are meant to be expressed but also controlled. So "un ataque de nervios" represents a situation that is so overwhelming that emotions take over, such as an attack and cannot be controlled. Know that warmth is more important than expertise in the eyes of some Latino patients. References Vargas SM et al. Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy. Transcult Psychiatry. 2015 Apr;52(2):244-73. Lewis-Fernández R et al. Impact of motivational pharmacotherapy on treatment retention among depressed Latinos. Psychiatry. 2013 Fall; 76(3):210-2. Moitra E et al. Examination of ataque de nervios and ataque de nervios like events in a diverse sample of adults with anxiety disorders. Depress Anxiety. 2018 Dec;35(12):1190-7. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Martha Sajatovic, MD, conducts a Masterclass lecture on older-age bipolar disorder from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Sajatovic is professor of psychiatry and of neurology at Case Western Reserve University in Cleveland. She also directs the Neurological and Behavioral Outcomes Research Center at University Hospitals Cleveland Medical Center. * * * Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * Conceptualizing OABD Older–age bipolar disorder (OABD), defined as a person aged 60 years or older with bipolar disorder, makes up one-quarter of bipolar patients. It is a heterogeneous population that includes early- and late-onset disease. Late onset is diagnosed when a person has a manic or hypomanic episode at or after the age of 50 years. Bipolar depression in later life has long been seen as a "special population," and the treatment has been extrapolated from larger clinical trials of younger patients. Late–onset bipolar disorder usually has attenuated manic episodes and depressive episodes are prolonged and severe. In OABD, the patients are more likely to have multiple morbidities, which makes medication management more complex. People with bipolar disorder lose 1-2 decades of life, compared with the general population. No medications are specifically approved by the Food and Drug Administration for bipolar disorder or bipolar depression in older adults. However, the treatment follows general geriatric psychiatry principles: Start low and go slow. International guidelines on treating bipolar disorder Starting low means using half or even less of the recommended dose that a clinician would use in mixed-aged populations. Titrate slowly to allow the person time to acclimate to side effects that usually resolve. Bipolar disorder is a chronic disease, so medication adherence is paramount. Adherence can be jeopardized when a person experiences excessive side effects from the beginning of treatment. First-line treatment for bipolar depression in OABD include lurasidone (Latuda) or quetiapine (Seroquel) with low dosing and slow titration. This recommendation is supported by data from a post hoc analysis of the clinical trial data of lurasidone for bipolar depression. Lithium is also recommended and underused. The level should be lower for OABD; an appropriate target for older adults with bipolar disorder is 0.4-0.8 mEq/L, especially in people who are older and frailer. Lamotrigine (Lamictal) also is helpful and fairly well tolerated. Clinicians need to be attentive to a patient's medical comorbidities and psychosocial support to enhance adherence and improve outcomes. This approach would entail working closely with primary care clinicians and using an integrative approach as the medical comorbidities will influence the success of bipolar treatment. References Sajatovic M and Chen P. Geriatric bipolar disorder. Psychiatr Clin North Am. 2011 Jun 3;34(2):319-33. Eyler LT et al. Understanding aging in bipolar disorder by integrating archival clinical research datasets. Am J Geriatric Psychiatry. 2019 Oct;27(10):1122-34. Shulman Kl et al. Delphi survey about using lithium in OABD. Bipolar Disord. 2019 Mar;21(2):117-23. Forester BP. Safety and effectiveness of long-term treatment with lurasidone in older adults with bipolar depression: Post hoc analysis of a 6-month, open-label study. Am J Geriatr Psychiatry. 2018 Feb;26(2):150-9. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

This week, we are replaying five interviews that MDedge Psychiatry editor in chief Lorenzo Norris, MD, conducted at the 2019 American Psychiatric Association annual meeting. Dr. Norris spoke with Igor Galynker, MD, (Mount Sinai Beth Israel, N.Y.) about identifying suicide crisis syndrome; Jonathan M. Meyer, MD, (University of California, San Diego) about prescribing clozapine for treatment refractory schizophrenia; Robert M. McCarron, DO, (University of California, Irvine) about psychiatry and primary care; Cam Ritchie, MD, MPH, about preparing patients for disruptions in psychiatric medications; and Richard Balon, MD, (Wayne State University, Detroit) about overcoming resistance to prescribing benzodiazepines for patients with serious mental illnesses. * * * Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Jack Drescher, MD, returns to the MDedge Psychcast, this time to discuss ethical issues raised by the treatment of gender-variant prepubescent children with MDedge Psychiatry editor in chief Lorenzo Norris, MD. The two spoke at the 2019 Group for Advancement in Psychiatry (GAP) meeting in White Plains, N.Y. Dr. Drescher is a Distinguished Life Fellow of the American Psychiatric Association, past president of GAP, and a past president of the APA's New York County Psychiatric Society. He has a private practice in New York. And later, in the "Dr. RK" segment, Renee Kohanski, MD, says artificial intelligence is much more powerful than we imagined. * * * Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * Three approaches used to address gender-variant children Despite the acceptance of gender dysphoria as a diagnosis with standardized treatments, the treatment of gender-variant prepubescent children remains a controversial area. There are several treatment approaches regarding how and when a child should have a social transition to their desired gender. The oldest treatment approach is based on research that shows that most children will grow out of their gender dysphoria when the therapies applied help the children get used to living in the body of their assigned gender. Essentially, this approach discourages public or private social transition. The Dutch Protocol is based on research that shows the difficulty in predicting which children will continue to have gender dysphoria and which will not. Some children will have persistent gender dysphoria and become transgender; some may become homosexual; and others may identify with their own biological sex. The Dutch approach encourages children to have cross-gender interests and to privately identify with their desired gender, but there is not a public social transition. Families and clinicians use watchful waiting to see whether the gender dysphoria persists. It's based on the idea that one cannot predict the future and so parents accept the child wherever they are. The final approach focuses on social transition without a medical or surgical treatment. Therefore, if the child's gender dysphoria desists, they can "detransition," since there was no medical intervention. The gender-affirmative approach, mostly found in the United States, presupposes that it is possible to identify which children will persist in their transgender presentations and encourages a public, social transition to living as their identified gender. In case the child "makes a mistake," they can transition back to their biological sex. A social transition occurs when a child, with the help of clinicians, explains to the family that they believe the gender dysphoria is going to last and that the child should be allowed to present publicly as their desired gender. This includes communicating with the school, family, and friends to help the child to be treated respectfully in the gender they desire. Treatments for gender-variant children Puberty suppression is a medical treatment used by physicians in all three approaches. These medications block sex hormone action and are used to delay puberty and prevent the development of undesired secondary sex characteristics of the biologic sex. Adolescents frequently experience anxiety, depression, even suicidal ideation during this period because they feel pressured to choose their gender and avoid developing the secondary sexual characteristics of their biological sex. Social changes are outpacing the science. More frequently, children show up at gender clinics already socially transitioned by their parents; these children outnumber the subjects in the persist and desist literature. Regardless of the approach used, parents and clinicians should try to act on the exigent circumstances to relieve the distress of the child. Patients who are transitioning should be referred to a specialist, because this is a sensitive topic and treatment requires expertise. References Shumer DE et al. Advances in the care of transgender children and adolescents. Adv Pediatr. 2016 Aug;63(1):79-102. Reed GM et al. Disorders related to sexuality and gender identity in the ICD-11: Revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21. Zraick K. Texas father says 7-year-old isn't transgender, igniting a political outcry. New York Times. 2019 Oct 28. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Michelle Magid, MD, conducts a Masterclass lecture on botulinum toxin for depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Magid is associate professor University of Texas in Austin, and associate professor of Texas A&M University in College Station. She disclosed serving as a speaker for Ipsen, maker of Dysport (abobotulinumtoxinA, or ABO), and as a consultant for Allergan, maker of Botox (onabotulinumtoxinA). * * * Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * This week in psychiatry: Conduct disorder in girls gets overdue research attention by Bruce Jancin The physiological and emotion-procession abnormalities that underpin conduct disorder in teen girls are essentially the same as in teen boys. however, the clinical presentation of conduct disorder in the two groups is often different. What we know about botulinum toxin Botulinum toxin is the product of Clostridium botulinum. The neurotoxin inhibits the release of acetylcholine, resulting in flaccid muscle relaxation. Its clinical use started in 1989 to treat strabismus (crossed eyes) and blepharospasm, a dystonic reaction in the eyes. Currently, botulinum is a Food and Drug Administration–approved treatment of chronic migraine in adults. For use in depression, 30-40 units of botulinum toxin is injected into the glabellar region of the face (the forehead). A purported mechanism of action of botulism for depression includes the "facial feedback hypothesis," in which the activation of muscles of facial expression, consciously or unconsciously, influences emotions. Botulinum toxin for depression is an off-label treatment with four case series, five randomized, controlled studies, and a phase 2 trial by supported by Allergan. New findings on use of botulinum toxin for depression Magid and colleagues completed a pooled analysis of three randomized, controlled trials totaling 134 patients. Fifty-nine people were included in the botulinum toxin intervention group with a Beck Depression Inventory (BDI) score of 29, and 75 individuals in the placebo group with BDI of 26. In each group, 64% of patients were continued on other medications for depression, and the groups had similar histories of long-standing depression. In the botulinum toxin group, 52% had a response to the intervention, with an at least 50% reduction in their baseline depression scores, compared with a limited response in the placebo group. In the pooled analysis, Dr. Magid's group analyzed whether the cosmetic effect of botulinum toxin could be a confounding factor. The investigators ruled out that effect by using a subanalysis to evaluate whether the decrease in wrinkles correlated with decrease in depression, and it did not. Allergan moved forward with a phase 2 proof-of-concept trial; the results were mixed. The endpoint was response rate in Montgomery-Åsberg Depression Rating Scale (MADRS) at week 6. With a 30-unit Botox dose, there was a statistically significant decrease in MADRS at week 9, but not at week 6. There was no statistically significant divergence in data between the placebo and intervention group with the 50-unit dose. Given the response rate at week 9, Allergan is proceeding with a phase 3 trial. The cost is about $400 per treatment, and the treatment is given three to four times a year, which makes the cost comparable to that of other psychopharmacologic treatments. Adverse events are mild and include headache and local site irritation. In the current studies, botulinum treatment has been used as both monotherapy and augmentation; however, there are not enough data to know whether one is more effective than the other. In conclusion, burgeoning psychopharmacology research on treatments such as botulinum toxin for depression and novel medications, such as esketamine and brexanolone, broaden our understanding of the etiology of depression. This research is generating novel modes of treatment that will help more patients with refractory illness. References Magid M et al. Treating depression with botulinum toxin: A pooled analysis of randomized controlled trials. Psychopharmacology. 2015 Sep;48(6):205-10. Magid M et al. Treatment of major depressive disorder using botulinum toxin: A 24-week randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2014 Aug;75(8):837-44. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Andrew Penn, MS, NP, conducts a Masterclass lecture on psychedelic-assisted psychotherapy from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Mr. Penn, a psychiatric nurse practitioner, is associate clinical professor of community health systems in the School of Nursing at the University of California, San Francisco. Later, Dr. Renee Kohanski is back – this time to discuss the need to call out the truth when we see it. * * * Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * Reemergence of MDMA for PTSD and psilocybin for MDD Psychedelic-assisted psychotherapy is currently being investigated with 3,4-methylenedioxy-methamphetamine (MDMA) for treatment-resistant post-traumatic stress disorder (PTSD) and psilocybin for the treatment of major depressive disorder (MDD). The use of these compounds would be highly regulated. These are not medications that would be dispensed for a patient to take home. Both would be given in the clinical setting of one or more psychotherapy sessions with two therapists who would continue to work with the patient over time. MDMA was first patented by Merck in 1912, synthesized again in the 1970s, and used by psychotherapists to assist treatment. However, its recreational use spread, leading to its classification as a Schedule I controlled substance, thus prohibiting research or use in a medical setting. Lobbying through the Multidisciplinary Association for Psychedelic Studies, also known as MAPS, managed to bring MDMA into phase 3 clinical trials, and in 2017 the Food and Drug Administration granted breakthrough therapy designation for its use with psychotherapy for PTSD. MDMA is a potent releaser of serotonin, oxytocin, and prolactin, which in combination, allow the patient to feel less fear, trust the psychotherapist more, and overcome the defenses blocking them from talking about traumatic experiences. MDMA permits patients to stay in the optimal arousal zone to discuss the traumatic event. After the psychedelic-assisted session, patients continue to process memories and sequelae of the event and integrate changes into their lives to overcome trauma. If MDMA is approved by the FDA, it would be available only under a REMS, or Risk Evaluation and Mitigation Strategy, or drug safety program. Psilocybin is a partial agonist on 5-HT2A serotonin receptors. The brain of a severely depressed person is extremely rigid with limitations on the usual predictive capacity of the human brain. Psilocybin facilitates plasticity to "reset" and see a situation as it truly is, rather than through the rigid cognitive distortions of depression. Although MDMA and psilocybin are controlled substances, we can think of these medications like anesthetics, which are drugs that can be prescribed in clinical settings under supervision only. These are old compounds used in a novel manner that can reduce suffering for patients who have not responded to the current modes of therapy for PTSD and MDD. References Mithoefer MC et al. MDMA-assisted psychotherapy for treatment of PTSD: Study design and rationale for phase 3 trials based on pooled analysis of six phase 3 randomized trials. Psychopharm (Berl). 2019 Sep;236(9):2735-45. Carhart-Harris RL et al. Psilocybin with psychological support for treatment-resistant depression: An open-label feasibility study. Lancet. 2016 Jul 1:3(7):619-21. Pollan M. The Trip Treatment. New Yorker. 2015 Feb 9. Cooper A. Psilocybin sessions: Psychedelics could help people with addiction and anxiety. 60 Minutes. 2019 Oct 13. Sessa B. "The Psychedelic Renaissance: Reassessing the Role of Psychedelic Drugs in 21st Century Psychiatry and Society." London: Muswell Hill Press, 2012. Usona Institute: News on Psychedelics For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Mark S. Gold, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to discuss the intersection between the rise in suicide and the opioid crisis in the United States. Dr. Gold is adjunct professor of psychiatry at Washington University in St. Louis. He also serves on the editorial advisory board of MDedge Psychiatry. Previously, Dr. Gold served as distinguished professor and chairman of the psychiatry department at the University of Florida, Gainesville. * * * Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * Timestamps: This week in Psychiatry (01:11) Interview with Dr. Gold (03:40) This week in Psychiatry Demeaning patient behavior takes an emotional toll on physicians by Steve Cimino Suicide and the opioid crisis In 2017, more than 70,000 people died from overdose, and 47,600 of those deaths involved prescription or illicit opioids. Most coroners list the deaths as "accidental" unless there is a suicide note or the deceased spoke about an intent to die. Chronic opioid self-administration changes the brain. The person becomes less high and more depressed over time. The prevalence of depression is at least 50% in those with opioid use disorder. Some experts estimate that up to 30% of opioid overdoses are intentional and count as suicide. A person with opioid use disorder has 13 times the risk of attempting and completing suicide, compared with the general population. Until recently, psychiatric evaluations and suicide assessments were not routine in the chain of events from opioid use to overdose to transition to medication-assisted treatment (MAT). People whose overdoses are reversed by naloxone are prime candidates to ask whether an overdose was accidental. In an emergency department in Flint, Mich., 30% of overdose patients rescued with naloxone described their overdose as a suicide attempt. Although some people revived with naloxone are angry, it is important to consider irritability and anhedonia that come from giving an opioid antagonist during a high. Future of treatments in the opioid crisis Much is still unknown. For example, there are no MAT options for either stimulant or cannabis use disorders, which are implicated in the morbidity and mortality of the overdose crisis. More research is needed to determine how long patients should be on MAT and when their brains "reset" after addiction. Also, in the pipeline is advanced imaging showing how drug use changes a person's neurocircuitry and genetics. The OPRM1 gene, for example, is a polymorphism whose presence predicts whether a person is more likely to become addicted after their first use of opiates and determines treatment resistance to recovery. In the next year, efforts aimed at preventing overdoses and investigating the risk and rates of suicide are likely to continue. If every patient with a high-dose opioid prescription were offered naloxone, nearly 9 million more naloxone prescriptions could have been dispensed in 2018. So, we might see state-level policies that seek to increase naloxone prescriptions to patients based on morphine equivalents. Looking beyond overdoses and relapse prevention, the National Institute on Drug Abuse (NIDA) has identified novel targets focused on regenerating the reward system in order to return the brains of people with addictions to premorbid function after years of abuse. References Volkow N and Gordon J. Suicide deaths are a major component of the opioid crisis. NIDA. 2019 Sep 19. Oquendo MA and Volkow ND. Suicide: A silent contributor to opioid-overdose deaths. New Engl J Med. 2018;378:1567-9. 5-point strategy to combat the opioid crisis. U.S. Department of Health & Human Services. Still not enough naloxone where it's most needed. Centers for Disease Control and Prevention. 2019 Aug 6. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Dinah Miller, MD, returns to the MDedge Psychcast, this time to do a Masterclass lecture on involuntary commitment. Dr. Miller is coauthor of "Committed: The Battle Over Involuntary Psychiatric Care." She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. In addition, Dr. Miller is a columnist for Clinical Psychiatry News and serves on the editorial advisory boards of CPN and MDedge Psychiatry. Timestamps: This week in Psychiatry (00:37) Masterclass lecture (02:00) Dr. RK (40:50) This week in Psychiatry: Duloxetine 'sprinkle' launches for patients with difficulty swallowing by Christopher Palmer Drizalma Sprinkle (duloxetine delayed-release capsule) has launched for the treatment of various neuropsychiatric and pain disorders in patients with difficulty swallowing. Overview of the involuntary commitment debate Four main controversies surround involuntary treatment First, standards for involuntary commitment vary by state; most states require that a person be diagnosed with a mental illness and is imminently dangerous to self or others. Some states extend their parameters to include those who are "gravely disabled" or need of psychiatric treatment. Second, as involuntary beds decrease, there is no place for involuntary treatment. Third, involuntary treatment includes outpatient civil commitment (OCC), and policy groups differ in their opinions of involuntary inpatient and outpatient treatments. Laws defining the need and amount of mandated outpatient services vary, based on geographical area. Also, outpatient commitment is difficult to enforce. The final controversy addresses a patient's right to refuse treatment with medication. Groups hold wide-ranging positions along policy spectrum The Treatment Advocacy Center is a strong proponent of involuntary hospitalization. The group advocates for more state hospital beds in the United States, monitors the number of state hospital beds, proposes an involuntary standard of based on need for treatment, and argues that anosognosia justifies involuntary hospitalization. The National Alliance on Mental Illness (NAMI) is a grassroots organization founded by parents of individuals with serious mental illness (SMI) and initially represented a view in favor of involuntary hospitalization based on protecting those with SMI. However, as NAMI has grown to represent a broad swath of people with mental illness, the organization has struggled with whether it represents the interests of people with SMI only or a broader group of people with any mental illness. The American Psychiatric Association holds the middle ground, identifying dangerousness as the standard of involuntary care. In 2015, the APA released a carefully worded stance in support of outpatient commitment on a limited basis. Organizations strongly against involuntary treatment include the Bazelon Center for Mental Health Law, whose mission is to protect and advance the rights of adults and children with mental illness. The Bazelon Center opposes anything that restricts the rights of people with mental illness. The recovery movement, which developed as a backlash against the perceived paternalism of psychiatry, prioritizes the mental health consumer's autonomy with an emphasis on peer support and being proactive in health care choices. On the antipsychiatry spectrum are the groups MindFreedom International and the Citizens Commission on Human Rights. Both of those groups oppose involuntary treatment. Violence and mental illness In the community, psychiatric illness is thought to be responsible for 4% of total violence and 7%-10% of murders. The MacArthur Foundation investigated rates of violence in people with mental illness 10 weeks after an inpatient hospitalization. It found that, compared with community samples, people with mental illness following hospitalization have higher rates of violence. The rate of violence was 8% for people with schizophrenia, 15% for bipolar disorder, 18% for depression, and 23% for personality disorder. Twenty weeks after discharge, patients with more treatment contacts were less likely to be violent. Mental illness does not belong in conversations about violence prevention because violence is more strongly correlated with substance use, anger, and early exposure to violence. Thus, mass murder cannot be prevented with forced care or institutionalization. The case is less clear for involuntary treatment for suicide prevention. For example, we know that two-thirds of gun deaths are suicides; however, we do not have statistics to elucidate whether involuntary hospitalization would prevent suicides. Final thoughts Involuntary hospitalization should be the treatment choice of last resort. A psychiatrist should pursue careful assessment with as many sources as possible and strongly suggest alternatives, such as voluntary hospitalization. Involuntary hospitalization could be less traumatizing by implementing

Kent A. Kiehl, PhD, joins host Lorenzo Norris, MD on the MDedge Psychcast to discuss the use of MRI scans to provide information about the brains of people who exhibit antisocial behaviors. The goals are to use the information to treat patients and prevent violent crimes. Timestamps: This week in Psychiatry (00:33) Meet the guest (03:35) Interview (04:25) Credits (54:10) Dr. Kiehl is professor of psychology, neuroscience, and law at the University of New Mexico, Albuquerque. He also codirects a nonprofit mental health research institute called the Mind Research Network, also in Albuquerque. He also helps run a for-profit consulting firm that helps attorneys do better science, called MINDSET. This week in Psychiatry: Suicide attempts up in black U.S. teens by Randy Dotinga Overall rates of suicide dipped from 1991 to 2017, according to research published in Pediatrics. However, the rate of suicide attempts grew slightly in black adolescents during that time. SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI: 10.1542/peds.2019-1187. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Brain imaging can support diagnoses Dr. Kiehl works with cutting-edge technology using noninvasive structural and functional brain imaging; machine learning, such as artificial intelligence; and algorithms to evaluate forensic patients and understand psychopathology, predict outcomes, and measure the impact of interventions. Dr. Kiehl and his team travel to prisons across the country with two mobile MRI units imaging incarcerated individuals and forensic patients. More and more, brain imaging is considered in capital cases, because MRI provides valuable information for defense attorneys and prosecutors. For example, a man was charged with murder and his MRI supported a diagnosis of frontotemporal dementia with a behavioral variant, so he was able to plead not criminally responsible based on his illness – and was sent to a state mental hospital rather than to death row. The case of John W. Hinckley Jr., who shot former President Ronald Reagan and his press secretary, James Brady in 1981, was an initial case in which neuroscience and imaging influenced the verdict. The shooter's brain imaging showed enlarged ventricles and cortical atrophy, which supported a diagnosis of schizophrenia – particularly when compared with the imaging of age-matched controls. Structural and functional MRI is an adjunct to neuropsychological tests. Neuroscientists are elucidating patterns through artificial intelligence and algorithms that can be useful to civil and criminal cases. For example, age is considered a strong predictor of antisocial behaviors. To enhance accuracy, Dr. Kiehl's team has developed a neuroprediction model in which MRI quantifies brain age, which correlates closely with cognitive testing scores. So, brain age might be more useful for predicting behavior than chronological age. This study used more than 1,000 imaging studies of inmates. The data were analyzed using an algorithm called independent component analysis, which evaluates distinct neural circuits to identify components that predict age. In the next step of analysis, the algorithm identifies patterns associated with reoffending. Younger brain age in the anterior temporal lobe and orbitofrontal cortex – brain areas associated with decision making – accurately estimates the risk of reoffending better than just chronological age. Based on an understanding of brain plasticity, dogma suggesting that people who commit violent crimes cannot be changed should be challenged. A group at the University of Wisconsin, Madison, was asked to create an evidence-based, multimodal treatment program for the hardest-to-treat violent juvenile offenders. The program, which includes interventions such as multisystemic family therapy and positive reinforcement contingency treatment, resulted in a decrease in reoffending and violent crimes in participants who received 10 months of treatment. Dr. Kiehl's group followed up with those juvenile boys using MRI to evaluate what had changed in their brains, how much treatment is required, and how or whether those brain changes can be reinforced. Reduction in incarceration costs is a return on investment for the states that fund those types of programs. Take-home points If scientists can identify useful interventions and identify brain changes though imaging, perhaps science can affect outcomes such as societal violence and incarceration rates. Implementation is the primary short-term obstacle. This type of research needs more funding and institutional change to identify programs that work. The brain has an incredible amount of plasticity, which translates into opportunities for change. References The Mind Research Network Kiehl KA. The Psychopath Whisperer: The Science of Those Without Conscience. Random House, 2014. Kiehl KA