Psychcast

Susan Hatters Friedman, MD, returns to the MDedge Psychcast to join host Lorenzo Norris, MD, to discuss postpartum psychosis. Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman and colleagues recently wrote an article published in Current Psychiatry examining this topic, Postpartum psychosis: Protecting mother and infant. Timestamps: This week in psychiatry (01:09) Interview (05:07) Dr. RK (22:07) Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Overview of postpartum psychosis Postpartum psychosis is a medical emergency with a fulminant development occurring within 1-4 weeks after delivery. Onset is usually 3-10 days postpartum, and women experience a spectrum of symptoms from psychosis to dysphoric mania and confusion. Many women who experience postpartum psychosis do not have a past psychiatric history, although they might go on to develop bipolar disorder. Symptoms change quickly, with risks of devastating consequences. A woman with postpartum psychosis might minimize or even conceal her symptoms to avoid being separated from her child or out of fear that her child will be taken away. Collateral information is extremely important. A woman is at the greatest risk of developing a mental illness in the period around childbirth. The rate of postpartum depression is 1 in 9, and the baseline rate of postpartum psychosis is 1/500. Women with bipolar disorder (which may be undiagnosed until the postpartum psychosis) or a previous episode of postpartum psychosis are at highest risk of postpartum psychosis. Prevention and intervention Clinicians must be proactive with their psychoeducation about pregnancy, contraception, and the natural course of mental disorders during pregnancy and postpartum. If a patient with bipolar disorder is of childbearing age, the clinician should consider having her on medications that are relatively safe during pregnancy. In 2011, 45% of pregnancies in the United States were unintended; thus, preconception counseling is necessary. Medications for bipolar disorder can help prevent postpartum psychosis. Other preventive measures include using sleep strategies after childbirth, such as arranging support to assist at night and weighing the risks of breastfeeding. Breastfeeding can lead to sleep deprivation, which in turn, increases the risk of decompensation. If a woman wants to breastfeed, the psychiatrist should be in touch with the pediatrician and plan for breastfeeding by having the mother on medications that are safe for breastfeeding. Involuntary hospitalization might be required if the postpartum psychosis puts the mother or child at imminent risk of harm. Family and nonpsychiatrists on the health care team might be resistant to psychiatric hospitalization because it would mean separating the mother from the child. Psychiatrists can broach resistance by explaining the details of a thorough risk assessment and emphasizing that, while bonding is important, the hospitalization is meant to prevent the worst outcomes of suicide or infanticide. Review of key points Postpartum psychosis can present with mood symptoms or delirium, so those signs should make a clinician vigilant for postpartum psychosis. The symptoms of postpartum psychosis change rapidly with escalating danger, such as infanticide and suicide, so collateral from family and speedy treatment are essential. Focused early collaboration and education with team member such as ob.gyns. and pediatricians help make future interventions go more smoothly. References Friedman SH et al. Postpartum psychosis: Protecting mother and infant. Curr Psychiatr. 2019 Apr 1;18(4):13-21. Sit D et al. A review of postpartum psychosis. J Womens Health (Larchmt). 2006 May;15(4):352-68. Harlow BL et al. Incidence of hospitalization for postpartum psychosis and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry. 2007;64(1):42-8. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Susan Hatters Friedman, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about family murder. Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman is editor of Family Murder: Pathologies of Love and Hate, which was written by the Group for the Advancement of Psychiatry's Committee on Psychiatry & Law. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Overview of family murder Family murder is defined as situations in which any member of a family kills another family member. It encompasses a wide scope of violence that includes intimate partner homicide; infanticide, including purposeful feticide; neonaticide (murder in first day of life); siblicide; and parricide (a child killing a parent). The book, Family Murder: Pathologies of Love and Hate, discusses the epidemiology and public health implications of family murder, various motivations, and pertinent psychiatric assessments, including risk assessments and sanity evaluations. It was written to prompt better screening and risk assessments, with the goal of prevention. Motivating factors leading to murder Phillip J. Resnick, MD, who also works in forensic psychiatry at Case Western, identified five main motives of parent-child violence. Fatal maltreatment is the result of fatal neglect or abuse by a parent. This type of family murder is common and is most likely to be prevented, especially with intervention by Child Protective Services. Altruistic murder occurs in three categories in which a parent wants to spare a child from perceived suffering: Psychotic parents with delusions about their children being harmed. Murder-suicide, such as when a severely depressed and suicidal parent kills their child to avoid leaving them without a parent after their suicide. Parents who kill a child with serious, chronic physical illness as a means of "saving" the child from a "worse" fate. Acutely psychotic murder occurs in the context of serious mental illness such as schizophrenia, bipolar disorder, or postpartum psychosis. Preventing this type of murder means monitoring the content of delusions and hallucinations related to family members. The Andrea Yates murders are a prime example of this type of murder. Unwanted child motive is most common in neonaticide cases. The child is considered a hindrance to something the parent wants, such as a relationship. To screen for this risk, physicians can ask whether the pregnancy was planned and observe the interaction between child and parent, especially during the first hours to days of life. Partner revenge is rare but is most likely to occur in context of a custody battle, with one partner seeing murder as a means of revenge. Psychiatrists can observe interactions between partners and inquire about threats from partners. Screening and preventing violence Psychiatrists can screen for violence by asking: "How are disagreements handled in your family?" This broad, neutral question elucidates family dynamics about partner violence, anger, and negative parental practices. It can generate information aimed at preventing fatal outcomes. Strong human emotions, such as anger, jealousy, and pride, combined with risk factors such as a history of violence and access to weapons, drive family murder. Psychoeducation about childhood development can decrease the risk of violence, especially in the fatal maltreatment category. Addressing countertransference issues Family murder stimulates strong countertransference in response to the perpetrator. Working as a team can diffuse these emotions and allows a venue for processing. Building rapport with patients and recognizing their humanity by using phrases such as "When he died," rather than "When you killed him." References Family Murder: Pathologies of Love and Hate. Group for the Advancement of Psychiatry, 2018. Hatters Friedman S. Filicide-suicide: Common factors in parents who kill their children and themselves. J Am Acad Psychiatry Law. 2005 Jan. 33(4):496-504. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Henry Nasrallah, MD, was the first-ever guest on the MDedge Psychcast. In a three-part series, he joined Lorenzo Norris, MD, host of the Psychcast and editor in chief of MDedge Psychiatry, to talk about schizophrenia. In this throwback episode, the three-part conversation has been edited together into one episode. Part I: Etiology, presentation, and recent advances Part II: Manifestations; treating early Part III: Treatment of first-episode schizophrenia In part I, Dr. Nasrallah and Dr. Norris talk about the etiology, presentation, and the recent advances in how schizophrenia is conceptualized. In part II, the two discuss the need for clinicians to treat the schizophrenia as early in the disease process as possible. In part III, the conversation continues, as they talk about treatment of a patient's first episode of schizophrenia. Henry Narallah, MD, is Sydney W. Souers Endowed Chair and professor and chairman of psychiatry and behavioral sciences at Saint Louis University. He also is editor in chief of Current Psychiatry. You can read some of Dr. Nasrallah's work in Current Psychiatry here. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Karl Doghramji, MD, is professor of psychiatry with secondary appointments in neurology and medicine at Thomas Jefferson University in Philadelphia. He also directs the Sleep Disorders Center at Thomas Jefferson. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Classification and consequences Insomnia is defined by the DSM-5 as dissatisfaction with sleep quantity or quality, difficulty falling asleep or staying asleep, or both. The symptoms need to occur at least three times per week for more than 3 months and cause dysfunction or distress in the patient. 20%-30% of the population reports insomnia; within inpatient psychiatry populations, the rates rise to up to 80%. Insomnia is thought to be caused by central nervous system hyperarousal or hyperactivity of unclear etiology, and there is evidence of genetic vulnerability. Insomnia is associated with significant impairments, such as diminished ability to enjoy life and sleep during inappropriate times (i.e., while driving or in occupational settings). In addition, insomnia confers increased risk for chronic illnesses such as major depressive disorder, substance use disorder, as well as diabetes, hypertension, and dementia. Treating insomnia It is best to first treat the comorbidities of insomnia, such as mood disorders and anxiety, and then target insomnia with both behavioral modifications and medications. When prescribing medications, choose a pharmacologic agent that targets the period of sleep difficulty. Evaluation of insomnia must examine the dimensions of sleep, including falling asleep (sleep initiation), compared with staying asleep (sleep maintenance). Behavioral techniques Stimulus control therapy: If a person is unable to fall asleep within 20-30 minutes, either at initiation or in the middle of sleep cycle, he/she should get out of bed and do something outside of the room and return to bed only when feeling sleepy. Relaxation therapies, such as progressive muscle relaxation, can improve sleep if performed once a week for 12 weeks. Sleep hygiene improvements, such as addressing late caffeine consumption, room brightness, and daytime napping can mitigate insomnia. Pharmacologic interventions Over-the-counter options include valerian root and histamine1 antagonists, such as diphenhydramine and melatonin. Melatonin is modestly effective at low doses, though the effects have not panned out in meta-analyses. At low doses, melatonin may increase total sleep time or improve sleep initiation by a few minutes. Watch out for adverse effects with long-term use of melatonin, such as disruption of other receptors, decreased fertility, and altered efficacy of chemotherapeutic agents. Prescription drugs approved by the Food and Drug Administration Benzodiazepines approved for insomnia include flurazepam (Dalmane), temazepam (Restoril), estazolam (Prosom), and triazolam (Halcion). However, those medications have long half-lives and tend to contribute to excessive daytime sedation. "Z-drugs" are the selective benzodiazepine receptor agonists. Zaleplon (Sonata) and zolpidem are useful for sleep initiation but might not help with sleep maintenance through the entire night. Eszopiclone (Lunesta) and zolpidem extended release (Ambien CR) can help with sleep initiation and sleep maintenance through the entire sleep period. Z-drugs, especially if mixed with alcohol, can contribute to parasomnias such as sleep walking and sleep driving. The FDA counsels that if patients develop parasomnias, they should not be rechallenged with those drugs. Nonscheduled medications include ramelteon (Rozerem), a melatonin receptor agonist that is effective for sleep initiation, and low-dose doxepin (Sinequan), which is effective for middle to late portions of the night. References Pavlova MK and Latreille V. Sleep disorders. Am J Med. 2019 Mar 132(3):292-9. Clark J. Slumber Camp. Conquer insomnia. For clinicians. Slumber Camp is an award-winning, 28-day, online course that teaches the principles of cognitive-behavioral therapy for insomnia. Cui R and Fiske A. Predictors of treatment attendance and adherence to treatment recommended among individuals receiving cognitive behavioral therapy for insomnia. Cogn Behav Ther. 2019 Mar 14:1-7. Christensen MA et al. Direct measurements of smartphone screen-time: Relationships with demographics and sleep. PLoS One. 2016 Nov 9;11(11):e0165331. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Judith R. Milner, MD, MEd, SpecEd, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about steps psychiatrists can take to address the mental health needs of people traumatized by a natural disaster, such as Hurricane Dorian survivors. In This Week in Psychiatry, Katherine Epstein, MD, and Helen M. Farrell, MD, write about miracle cures in psychiatry. You can read the article online by clicking here or you can access the downloadable PDF by clicking here. Time Stamps: This Week in Psychiatry (02:37) Interview with Dr. Milner (06:33) Dr. RK with Dr. Renee Kohanski (39:31) Dr. Milner is a general and child and adolescent psychiatrist in private practice in Everett, Wash. She has traveled across the globe with various groups in an effort to alleviate some of the suffering caused by war and natural disaster. Don't miss the "Dr. RK" segment by Renee Kohanski, MD, who discusses the extent to which people choose what is important and meaningful. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. STAGES OF NATURAL DISASTERS Devastation stage During the devastation stage, the primary objectives are giving basic first aid and attending to the sick, searching for those who are missing, and getting people safely into shelters. Psychological first aid (PFA) is the primary form of mental health treatment. PFA addresses basic needs by helping people find shelter, food, water; assisting with communication; reuniting families; and conducting case management to address acute needs. Normalization stage The normalization stage continues for several months after the disaster and includes the honeymoon phase, in which people are grateful to have survived and the community unites to rebuild; and then the disillusionment phase, during which frustrations and hopelessness arise as communities and individuals realize the limits of disaster assistance. Psychiatric disorders are likely to develop during the normalization stage. Acute stress disorder (ASD) typically occurs 3-30 days after the event with cardinal symptoms such as hyperarousal, hypervigilance, and negative cognitions that affect relationships. Medical professionals should monitor for development of chronic disorders such as PTSD, major depressive disorder, and anxiety disorders. Prolonged stressors, such as living in a damaged home, increase the risk of depression and anxiety. Those with preexisting vulnerabilities – such as past traumatic experiences from physical, sexual, or emotional abuse; previous natural disasters; or other chronic stressors of poverty and medical illness – are at greatest risk of developing a trauma-related disorder after a natural disaster. The normalization stage is a critical period to use the "training the trainer" model. Because many locations do not have a surplus of mental health clinicians, psychiatrist volunteers can train local individuals to provide services. For example, mental health professionals can train the trainers to recognize symptoms of common psychiatric conditions and to provide basic treatment. Manualized therapies are useful but require in-depth training. Other simple modalities, such as deep breathing, visualization, and relaxation techniques, can be useful. Acceptance stage During the acceptance stage, rates of persistent PTSD range from 25% to 40%. Ongoing therapy is helpful, especially group therapy, which is an effective use of resources. Facilitation of group therapy can be taught while training the trainers. If a mental health professional volunteers and participates in the training the trainers' model, there must be follow-up, which should include providing intellectual support and refresher courses, evaluating how training is being used, and checking up on patients/clients who have received services. Predisaster advice: Do not go it alone. Affiliate with a group that has a plan, so that your presence on the scene does not add to the chaos. Postdisaster advice: Be aware of compassion fatigue and take time away from volunteerism. Recognize signs of secondary traumatic stress. Counsel volunteers upon their return from the disaster site. References Substance Abuse and Mental Health Services Administration. Phases of disaster. Last updated 2018 Oct 1. Pfefferbaum B et al. Practice parameter on disaster preparedness. J Am Acad Child Adolesc Psychiatry. 2013 Nov;52(11):1224-38. World Health Organization. Psychological first aid: Guide for field workers. 2011. National Child and Traumatic Stress Network. Psychological first aid online. International Institute for Psychosocial Trauma. Clinical assessment of survivors of trauma. U.S. Department of Veterans Affairs. PTSD: National Center on PTSD. Compassion Fatigue Awareness Project

Show Notes J. John Mann, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about the need for medicine to shift its approaches to preventing suicide. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education. Dr. Mann is professor of translational neuroscience at Columbia University in New York. For a complete video of this interview, see this vodcast. Don't miss the "Dr. RK" segment by Renee Kohanski, MD, who discusses how a religious wedding she attended made her think about the distinction between cults and cultures. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Why are suicide rates on the rise? In the United States, between 2001-2017, the suicide rate increased by 33%, making suicide the second-leading cause of death for people aged 15-34 years. Why the suicide rate has increased is unclear. Factors influencing rising suicide rates include the 2008 recession and the opioid crisis; however, these events cannot fully explain the trend because they occurred in the middle of the rising rates. As suicide rates increase, the medical community missed opportunities for prevention at both primary care and psychiatry visits. A Centers for Disease Control and Prevention study that examined suicide rates and psychiatric illness found approximately half of suicide decedents did not have a known mental health condition. Connections to untreated psychiatric illness Only 22% of people with psychiatric illness who die by suicide had their mental illness treated. The age of onset for major depressive disorder has been occurring earlier and indicates a greater pool of individuals is at risk of suicide. For example, during 2005-2014, major depressive episodes in adolescents increased by nearly one-third. Individuals who attempt and die by suicide have a predisposition to respond to their mental illness with suicidal behaviors. This trait poses a challenge in the face of rising rates of mental illness in the United States. Role of treatment by primary care physicians 45% of individuals who die from suicide see their primary care clinician within a month of their death. If nonpsychiatrist doctors or primary care physicians are trained to recognize depression and suicide, the rates of death and disability from depression can be decreased. Most people who die by suicide are seeking help by going to a health care professional. How should the clinician respond? If a person presents with somatic complaints with no clear causes (for example, normal lab values), this is a time for the primary care physicians to ask about depression and suicide. What steps can be taken to prevent suicide? Medicine needs an updated approach in education about depression and suicide that is similar to the changes that have taken place during the opioid crisis. Now all clinicians must complete continuing medical education about pain management and opioid prescribing, which has led to a decrease in deaths from prescription pain medications. All clinicians must be able to recognize and treat depression, because it is becoming a leading cause of death and disability. Clinicians need to do a better job of making connections between somatic complaints and mood disorders. References U.S. Department of Health and Human Services, National Institutes of Health. Mental health information: Suicide. Updated August 2019. Stene-Larsen K and A Reneflot. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019 Feb;47(1):9-17. Reed J. Primary care: A crucial setting for suicide prevention. SAMHSA-HRSA Center for Integrated Solutions. U.S. Department of Health and Human Services. Adolescent mental health basics. Rising rates of MDD in adolescents. Bruce ML et al. Reducing suicidal ideation and depressive symptoms in depressed older patients. JAMA. 2004 Mar 3;291(9):1081-91. DA Brent and N Melhem. Familial transmission of suicidal behavior. Psychiatr Clin North Am. 2008 Jun;31(2):157-77. Mohatt NV et al. A menu of options: Resources for preventing veteran suicide in rural communities. Psychol Serv. 2018 Aug;15(3):262-9. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

In this masterclass, Philip D. Harvey, PhD, professor of psychiatry and behavioral sciences at the University of Miami, discusses the relationships between aging, neurocognition, and functional outcomes. And in a new segment from MDedge, called This Week in Psychiatry, we'd like to share a Current Psychiatry evidence-based review on using antidepressants for pediatric patients (PDF) by Jennifer B. Dwyer, MD, PhD, and Michael H. Bloch, MD, MS. Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Introduction to normal aging Changes in cognitive abilities are part of normal aging. Crystalized intelligence, the storage of information learned throughout life, does not change over time in normal, healthy aging. Fluid intelligence, the ability to learn new information, solve problems, concentrate, and rapidly process information, starts changing at age 65 or so. Episodic memory performance, the ability to learn new verbal information, declines 30% between ages 65 to 80, followed by another equivalent decline from ages 80 to 90. Alzheimer's disease and amnestic mild cognitive impairment are characterized by signature memory loss called rapid forgetting, which occurs in cases in which a person is unable to remember information right after being told. Older people who are self-aware and sensitive to their age-related cognitive changes have a better prognosis. Technology and aging Individuals in their 80s to 90s might have retired before the advent of technological advances such as ATMs, cell phones, the Internet, smartphones, and other touch screen devices. For these individuals, vital aspects of daily living, such as accessing finances online, requires using Internet navigation skills, and those skills were not acquired at a younger age. A direct connection exists between cognitive abilities and learning how to use technology for the first time. Healthy older people will be challenged by new technology the first time because of their lack of exposure. Yet, their ability to learn how to use technology is comparable to that of younger people. Embracing technology to prevent normative cognitive decline The ACTIVE study, sponsored by the National Institute on Aging, enrolled 2,800 older healthy adults, with a mean age of 75, to evaluate the effectiveness of cognitive interventions in maintaining cognitive health and functional independence in older adults. Participants were randomized to either computerized speed training, memory training, problem solving training, or psychosocial intervention. The computerized speed training produced the most significant benefit in cognitive functioning. Participants randomized to computerized speed training sustained their functioning of instrumental daily activities of living and had a 50% lower rate of at-fault motor vehicle collisions, compared with controls, over a 6-year follow-up period. The ACTIVE study results suggest that age-related changes might be reversible with 14 1-hour sessions of brain training. Normative age-related cognitive decline can be attenuated through the use of affordable, accessible technology. In summary, not all age-related cognitive complaints are pathological Clinicians must ask specifically about memory loss and rapid forgetting of information to differentiate normative age-related changes from Alzheimer's dementia. Patients should be empowered to use technology to intervene for their cognition. Both brain and physical fitness are paramount to preventing dementia. Physical fitness is essential to prevention, because chronic illnesses such as type 2 diabetes are primary risk factors for dementia, and being overweight in middle age is a major predictor for developing type 2 diabetes. Physical exercise, brain exercise, and embracing technology are essential to preventing social isolation and subsequent dementia. References Antidepressants for pediatric patients by Jennifer B. Dwyer, MD, PhD; Michael H Bloch, MD, MD An evidence-based review from Current Psychiatry: 2019 September:18(9):26-30,32-36,41-42,42A-42F Click here for the webpage Click here for the downloadable PDF Tennstedt SL and FW Unverzagt. The ACTIVE study: Study overview and major findings. J Aging Health. 2013 Dec;25(8 0):3S-20S. doi: 10.1177/0898264313118133. Rebok GW et al. Ten-year effects of the ACTIVE cognitive training trial on cognition and everyday functioning of older adults. J Am Geriatr Soc. 2014 Jan;62(1):16-24. Harvey PD and MT Strassnig. Cognition and disability in schizophrenia: Cognition-related skills deficits and decision-making challenges add to morbidity. World Psychiatry. 2019 Jun;18(2):165-7. Brem AK and SL Sensi. Towards combinational approaches for preserving cognitive function in aging. Trends Neurosci. 2018 Dec;41(2):885-97.

Show Notes Roger McIntyre, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about obesity, inflammation, and treatment implications for mental health conditions. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education. Dr. McIntyre is a professor of psychiatry and pharmacology at the University of Toronto, and head of the mood disorders psychopharmacology unit at the University Health Network, also in Toronto. For a complete video of this interview, please visit the vodcast. Don't miss the "Dr. RK" segment by Renee Kohanski, MD, who discusses how to think through whether sharing personal information with patients helps move their therapy forward. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Reconceptualizing mental illness by looking at inflammation Mental illness should be viewed as a disease involving many organs – including the brain – and psychiatry should expand its understanding of the etiology of mental illness. Increasingly, research suggests that a subgroup of people with mental disorders, including those with a variety of diagnoses, have symptoms related to alterations in their immune system and inflammation. Inflammation plays a role in disparate psychiatric diagnoses, including childhood disorders such as obsessive-compulsive disorder, ADHD, and autism, and adult disorders such as schizophrenia, depression, and Alzheimer's disease. Currently, psychiatry uses the monoamine paradigm to explain psychiatric diagnosis, and most medications were developed using that paradigm. A subgroup of people is not sufficiently helped by current medications, so looking at inflammation as a driver of mental illness provides another biological avenue to pursue drug development. Role of obesity and chronic health conditions in worsening inflammation Obesity, particularly abdominal obesity, is overrepresented in people with mental illness and is not fully explained by either social determinants of health or medication side effects. Obesity and mental illness have a bidirectional relationship; each affects the body as multiorgan system diseases. Mental illness can be conceptualized as a kind of "metastasis to the brain." Adipose tissue releases a surfeit of neurochemicals hazardous to brain function and that disrupt neurocircuitry. For example, compared with an individual with major depressive disorder (MDD) only, an individual with MDD and obesity is more likely to have symptoms driven by inflammation, such as anhedonia, cognitive impairment, limited motivation, and a dysregulated reward system. Obesity should also be a target symptom worthy of a focused treatment plan. Heart disease is the leading cause of death in schizophrenia, and coronary artery disease is an inflammatory illness. Research is identifying connections between psychiatric illness such as schizophrenia and potentially inflammatory driven symptoms, often called "sickness behaviors," such as low motivation, anhedonia, and cognitive impairment. Clinical implications of obesity and inflammation Alterations in inflammation and metabolism are not just a consequence of obesity. For example, patients will bipolar disorder who report sexual or physical trauma are more likely to be in a proinflammatory neurochemical state and benefit from anti-inflammatory interventions. Are patients with early trauma who do not respond fully to "traditional" monoamine medications part of the subpopulation who respond to anti-inflammatory interventions because trauma is driving inflammation? The genetics of mental illness already are complicated and will be influenced by the environment and a "proinflammatory milieu." Which tests show inflammation? Current inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein, are not specific enough to direct treatment of inflammation in mental illness. Elements of a patient's history, including history of trauma, disrupted sleep and circadian disturbances, cigarette smoking, poverty, housing dislocation, and exposure to racism, can indicate inflammation. We can conceptualize as anti-inflammatory several current treatments, such as mindfulness-based therapy, electroconvulsive therapy, and selective serotonin reuptake inhibitors. Alternative treatments to treat inflammation exist; however, specific anti-inflammatory treatments, such as NSAIDs, cyclooxgenase-2 inhibitors, and minocycline, are not yet recommended for patients with mental illness. Targeting inflammation as prevention of psychiatric illness Clinicians can target drivers of inflammation as a means of treatment and prevention of mental illness. They can also target the basics

Show Notes Jack Rozel, MD, returns to the MDedge Psychcast to discuss gun violence and a new report from the National Council for Behavioral Health. In episodes 29 and 33, Dr. Rozel talked with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about this topic in the wake of the shooting last year at the Tree of Life synagogue in Pittsburgh. Dr. Rozel is medical director of resolve Crisis Services at the Western Psychiatric Institute and Clinic of the University of Pittsburgh. He also is president-elect of the American Association for Emergency Psychiatry and a member of the National Council. Dr. Rozel can be found on Twitter @ViolenceWonks. Later, Renee Kohanski, MD, discusses betrayal in the context of Erik Erikson's conceptualization of trust vs. mistrust. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Gun violence in the United States Mass violence with guns is a distinctly American problem occurring with greater frequency and severity in the United States, compared with other countries. The United States has a broad swath of firearm violence: Deaths by suicide account for 60% of gun deaths, and the remaining 40% are deaths by homicide. 1%-2% of homicides are completed in mass shootings, which are defined as an event in which a gunman indiscriminately shoots four or more people. Firearm homicides have been trending downward, while mass shootings have increased. Mass shootings might be influenced by media coverage; media exposure about mass shootings can incite possible perpetrators. Mass shootings are shown to cluster in ways similar to suicide contagion. Responses to mass shootings/violence The National Council for Behavioral Health addresses mass violence by releasing a new report: The report, called "Mass Violence in America: Causes, Impacts and Solutions," was written by a group of 30 multidisciplinary experts, including Dr. Rozel. It was released in response to stigma and incorrect messages linking psychiatric diagnoses to mass violence. The report reviews models aimed at preventing violence and understanding threat assessment. Predicting violence and diffusing threats Pathway to violence is a model for predicting mass violence generated by data and analysis of violent acts by the Los Angeles Police Department, U.S. Capitol Police, U.S. Marshals Service, and the U.S. Secret Service. Grievances: Violence often starts with a grievance. Clinicians might be familiar with patients who are "grievance collectors" and do not get along with any person, whether at work, family, or society at large. The pivot: A transition from simply having a grievance to violent ideation and wanting vengeance through violence. Psychiatrists certainly will see people who express violent fantasies. Perpetrators of violence shift from fantasy into research about planning and preparing to attack. Clinicians want to identify the point at which people feel aggrieved and should become most concerned when these people begin to get certain fixations. Preparation: The person will start to acquire weapons and tactical clothing; probe into vulnerabilities of their targets, conduct "test attacks"; and eventually carry out the final attacks. Identification: The grievance stage is the most effective place to intervene, once the identification has been made, and potentially diffuse a violent outcome. The United States holds a unique position when it comes to gun ownership, violence The United States is one of the three countries in the world that allow citizen access to firearms in their constitutions. With 393 million civilian-held firearms, the United States has more civilian-owned firearms than the next 39 countries combined. India, which has 70 million civilian-held firearms, ranks No. 2. Regardless of what happens with gun control following each mass shooting, the guns already are out there in civilian hands. Behavioral health clinicians must talk with patients about firearms safety. A person living in the United States is 10 times more likely to die of firearm-related suicide and 25 times more likely to die of firearm-related homicide, compared with people living in other economically developed countries. Components of proposed legislation that could reduce gun violence: Increasing mental health access: Violent acts can be attenuated through access to mental health with anger-management classes and interventions at emotional regulation. Implementing universal background checks for gun purchases. Currently, this policy varies from state to state. Requiring a background check to obtain a concealed carry permit. Testing competency/shooting ability with guns before giving a permit. Increasing access to gun violence restraining orders, also called gun vio

Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, interviews the psychiatry residents who produce the PsychEd podcast, which as they put it, is "created by medical learners, for medical learners." Dr. Norris speaks with some of the members of PsychEd podcast team: Sarah Hanafi, MD, a first-year resident in psychiatry at McGill University, Montreal; Alex Raben, MD, a fourth-year resident in psychiatry at the University of Toronto; Lucy Chen, MD, a fourth-year psychiatry resident at the University of Toronto; and Bruce Fage, MD, a fifth-year psychiatry resident at the University of Toronto. And later, in the "Dr. RK" segment, Renee Kohanski, MD, discusses the role of the placebo in the modern setting. Dr. Kohanski is a member of the MDedge Psychiatry Editorial Advisory Board and is a psychiatrist in private practice in Mystic, Conn. Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Why podcasting? The PsychEd podcast originated when the team identified a gap in podcast-mediated learning for psychiatry trainees. In psychiatry, there have been podcasts that reviewed recent publications, but none that examined foundational topics. Other specialties, such as emergency medicine, have several podcasts covering basic topics aimed at trainees. Podcasts are identified as an asynchronous educational material. They are a medium that can be used in "downtime," especially because many trainees commute or have other time during which they can consume information. At the American Psychiatric Association's 2019 Annual Meeting, the PsychEd team presented on the integration of podcasting into medical education. Materials should focus on digital natives vs. digital immigrants. In 2015, one research group polled emergency medicine residents and found a differential in the use of podcasts; 90% of users were residents and 45% were program directors. Podcasts are a supplement to other types of learning Podcasts can distill information as well as engage with information and experts in an alternative fashion. Podcasts are efficient in their use of time and broaden listeners' exposure to information and experts. Podcasts offer one modality of learning and are not meant to replace other sources. Resources should focus on what information is needed and be tailored to where students, residents, and all learners spend their time. PsychEd beginnings After the team identified the need for a psychiatry education–focused podcast, they started meeting to create an environment for collaboration. Learning how to podcast – using the equipment, editing the recording, and uploading to relevant platforms – was the hardest part. All PsychEd podcasting is done "live." The team takes their recording equipment to the experts they interview. Presently, their guests are located in Toronto. The team has expanded to Montreal with a new team member, Sarah Hanafi, a first-year psychiatry resident at McGill University. Formatting The podcast started with a case-based format, using a composite case presented to an expert, followed by a junior learner asking questions. Now the team does more prep work to create a structured script that includes educational objectives. Using a script allows for the interview to flow in a more organized structure, which makes for easier editing. Meeting and preparing the script with experts demands time and preparation in order to create the milieu for a generative interview. Most often, the "pearls" come from the unscripted questions that elicit reflections. Experts have been willing and excited to participate in the podcast and to disseminate their knowledge in a format that will reach trainees. PsychEd topics So far, PsychEd has covered basic topics of psychiatry, including major depressive disorder, schizophrenia, bipolar disorder, and anxiety, and it is now expanding to more complex topics. An initial idea was to incorporate the patient perspective to add nuance to the foundational-level topics. Listeners were indifferent to this idea since they already encounter the patient experience on a regular basis and incorporating the patient voice did not necessarily target the educational content. This scenario illustrates in difficulty of choosing topics: Subject matter that will draw in listeners but also are creative and add meaning. There is space for societal topics in psychiatry such Big Data, climate change, technology, and loneliness. PsychEd has been awarded a grant through the University of Toronto to expand subject matter focused on clinical skills to target priorities identified by the Royal Board of Canada through its "Competency by Design" initiative. Other challenges in podcasting Choosing topics is a balance of identifying cutting-edge topics vs. issues universal to all psychiatrists. Should popular topics be revisited? Deciding how to identify topics th

Welcome to this bonus episode of the MDedge Psychcast. In this episode, as a tribute to the late Carl C. Bell, MD, we would like to replay highlights from the interview that Lorenzo Norris, MD, did with him last year at the annual IPS (Institute on Psychiatric Services) Mental Health Services conference in Chicago. Dr. Norris, host of the MDedge Psychcast, is assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Bell, who died Aug. 1, was a psychiatrist at Jackson Park Hospital in Chicago and an emeritus professor of psychiatry at the University of Illinois at Chicago. He spoke with Dr. Norris in episodes 26 and 27 about identifying and preventing fetal alcohol spectrum disorders. Conceptualizing intellectual disabilities in children In the late 1960s, African American children had twice the rates of mild intellectual disabilities as did white children. Some clinicians thought that the intellectual disabilities they were seeing among African American children were the result of social-cultural mental retardation, but that conclusion did not make sense to Dr. Bell. Julius B. Richmond, MD, former surgeon general, cocreated Head Start as a way to address some of the educational disadvantages faced by low-income children. African American psychologists began to suggest that standardized tests were biased against certain racial and low-income groups. Bell thought some African American and low-income children might have knowledge that their counterparts in other communities might not have. Fetal alcohol exposure emerges as an explanation A few years ago, Dr. Bell was talking with a woman patient with three children in the Illinois Department of Children and Family Services. The children had poor tempers, social/emotional skills. And when he looked at their mother, he saw fetal alcohol facies. After talking with the patient longer, he learned that she had not gotten far in school. She also had problems with simple subtraction. At that point, he thought that the patient might have had fetal alcohol exposure. He then began looking at family medicine patients at Jackson Park Hospital in Chicago. The question at that time was: "Were you drinking while you were pregnant?" That question did not explain why patients had children who could not do basic subtraction and had ADHD, for example. Bell realized that the right question was: When did you realize you were pregnant? In many cases, they would say that they had learned they were pregnant at 4-6 weeks. Choline deficiency and fetal alcohol exposure The Institute of Medicine recommended that pregnant women consume 450 mg/day of choline each day. Robert Freedman, MD, and his colleagues found that higher amounts of choline as a prenatal supplement are tied to more self-regulation among infants who had common maternal infections during gestation. Bell began giving choline to patients. In one example, a patient's ability to relate to others improved dramatically after taking choline over an 18-month period. The American Medical Association passed a resolution supporting the addition of adequate amounts of choline to prenatal vitamins. References Freedle RO. Correcting the SAT's ethnic and social-class bias: A method for reestimating SAT scores. Harvard Educ Rev. 2003. 73(1):1-42. Bell CC and J Aujla. Prenatal vitamins deficient in recommended choline intake for pregnant women. J Fam Med Dis Prevent. 2016. 4(2):1-3. Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders: A randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2015 Nov;102(5):1113-25. Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders(FASD) has high feasibility & tolerability. Nutr Res. 2013. Nov;33(11):897-904. Zeisel SH and KA da Costa. Choline: An essential nutrient for public health. Nutr. Res. 2009. Nov;67(11):615-23. Freedman R et al. Higher gestational choline levels in maternal infection are protective for infant brain development. J Pediatr. 2019 May. 208:198-206. Velazquez R et al. Maternal choline supplementation ameliorates Alzheimer's disease pathology by reducing brain homocysteine levels across multiple generations. Mol Psychiatry. 2019 Jan 8. doi: 10.1038/s41380-018-0322-z. Wilhoit F et al. Fetal alcohol spectrum disorders: Characteristics, complications, and treatment. Community Ment Health J. 2017 Aug;53(6):711-8. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Show Notes Last week, Igor Galynker, MD, PhD, spoke with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about how to identify suicide crisis syndrome. This week, he explores the kinds of "gut feelings" that clinicians can access to help them identify when a patient might have the syndrome. Dr. Galynker has been a guest on the Psychcast twice before, once to discuss the impact of suicide on physicians and a second time to talk about his research on the arguments for adding a suicide-specific diagnosis to the DSM-5. He is associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel in New York. In addition, Dr. Galynker is founder and director of the Richard and Cynthia Zirinsky Center for Bipolar Disorder, and professor of psychiatry at the Icahn School of Medicine, both at Mount Sinai. Later, Renee Kohanski, MD, discusses the ability of psychiatrists to help patients realize that they can choose what matters in their lives. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. The "gut feelings" -- emotional reactions to the patient in suicide risk assessment -- also will elicit behaviors from a clinician. Behavioral signs of the four emotions are pertinent for clinicians who are burned out or may have limited emotional awareness. Examples include: Anxious overinvolvement manifested as going above and beyond for a patient; doing things that are out of character, such as answering phone calls/texts on the weekend; reluctance to set boundaries. Dislike and distancing: The patient in suicide crisis syndrome will be the last one the clinician sees on the inpatient unit or the one he/she postpones or forgets to see; the clinician experiences dread tied to the prospect of seeing a patient all day, shortens sessions, or does not answer phone calls. How to combine emotional response and the suicide crisis syndrome. New research from Dr. Galynker and colleagues suggests that the predictive validity for suicide risk doubles if the patient meets criteria for suicide crisis syndrome and the clinician has an emotional response as described above. The emotional response is elicited not just from the suicide crisis syndrome but also from the suicidal narrative. The narrative of a suicidal person describes an intolerable present with no future. This type of aberrant narrative triggers an emotional response in the clinician. One could argue the electronic medical record makes it difficult to understand the patient's narrative, which can impede the clinician's ability to have an emotional response to the patient's suffering. Why has psychiatry not focused on suicide over other mental health diagnoses? As a transdiagnostic phenomenon, one could argue that suicide must be a primary focus of assessment and treatment by psychiatrists. Suicide elicits a variety of cultural responses, ranging from shame, disgust, and a sense of weakness to empathy for the pain and suffering of a suicidal person. It is difficult to connect with someone who is suffering from a desire to die, but this might be what the patient wants. Clinical excellence is the ability to connect with a variety of patients in different settings, and it's about demonstrating how one cares. References Olfson M et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-26. Galynker I et al. Prediction of suicidal behavior in high-risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb;34(2):147-58. Cohen LJ et al. The suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav. 2018 Oct;48(5):613-23. Suicide rising across U.S. Centers for Disease Control and Prevention. Vital Signs. 2018 Jun. Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: Advantages outweigh limitations. World Psychiatry. 2014 Jun;13(2):128-30. Fawcett J. "Diagnosis, traits, states and comorbidity in suicide" in The Neurobiological Basis of Suicide. Boca Raton, Fla.: Taylor & Francis, 2012. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Show Notes Igor Galynker, MD, PhD, talks with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about suicide crisis syndrome. Dr. Galynker has been a guest on the Psychcast twice before, once to discuss the impact of suicide on physicians and a second time to talk about his research on the arguments for adding a suicide-specific diagnosis to the DSM-5. He is associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel in New York. In addition, Dr. Galynker is founder and director of the Richard and Cynthia Zirinsky Center for Bipolar Disorder, and professor of psychiatry at the Icahn School of Medicine, both at Mount Sinai. Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Later, in the "Dr. RK" segment, Renee Kohanski, MD, tells the story of a patient who found a way to rediscover his value system against great odds. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Suicide crisis syndrome: A suicide-specific mental state Until recently, there was no differentiation between the mental state associated with lifelong suicide risk versus the mental state associated with imminent suicide risk. Jan Fawcett, MD, distinguished these mental states for the first time by differentiating acute risk of imminent death and lifelong risks and traits of suicidal behavior. Lifetime suicide risk factors include mental illness, history of suicide attempts, depression, and substance abuse. Imminent suicidal behavior risk factors include panic, acute anhedonia, agitation, and insomnia. Dr. Galynker and colleagues have identified a condition they call suicide crisis syndrome, which they define as a mental state that predicts imminent suicidal behavior in days to weeks. The predictive validity has been replicated across several cultures and populations. Suicide crisis syndrome: To be identified as having suicide crisis syndrome, the patient must meet both criterion A and two criteria of B. Criterion A: Frantic hopelessness or state of entrapment defined as being stuck in a life situation that is painful and intolerable, and a feeling that all routes of escape are blocked. The risk of suicide within 1 month is 13% for people who meet criteria for suicide crisis syndrome. Criterion B: Affective dyscontrol, including emotional pain or mental pain; severe panic with agitation, and dissociation; rapid mood swings that can include happiness; and acute anhedonia. Cognitive dyscontrol, which can include ruminative flooding associated with headache or head pressure; cognitive rigidity; and inability to suppress the ruminative thoughts. (For example, you might assess by asking: "Do you control the thoughts or do the thoughts control you?") Overarousal with insomnia and agitation. Social withdrawal and isolation, and evading communication. Why are suicide-specific diagnoses necessary? 75% of people who die by suicide do not report suicidal ideation to a clinician, psychiatrist, or primary care physician. Notably, suicide crisis syndrome does not include suicidal ideation in the criteria, because not all people within imminent risk feel suicidal until the moment strikes. Some patients will hide their suicidal ideation from their clinician to prevent having their plan foiled. Suicide crisis syndrome creates a fuller picture of patient risk. Assessment of the criteria help a clinician consider more risk factors for imminent risk than simply a patient's self-report about suicidal ideation. Approach suicidality with a different framework Suicide-specific diagnoses represent a profound shift in approach, because suicide is a transdiagnostic phenomenon for depression, bipolar disorder, and schizophrenia. A person can be at imminent risk for suicide without meeting criteria for other DSM diagnoses. Other suicide-specific diagnoses: Maria A. Oquendo, MD, PhD, and colleagues have put forward "suicidal behavior disorder," which is a diagnosis that captures the propensity of suicidal behavior and urges to kill oneself. Suicidal behavior disorder and suicide crisis syndrome provide clinical targets for treatment of suicide. Without a diagnosis, clinicians cannot test treatment or teach the assessments. Use emotional reactions to the patient in suicide risk assessment Clinicians can identify "gut feelings" that help hone their assessments. Galynker and colleagues have identified four emotions that can help clinicians identify suicide risk: Distress. Dislike with distancing. Anxious overinvolvement, with a paradoxical combination of hope and distress. Collusion/abandonment/rejection, which includes a type of hopelessness and calm. Clinicians can be trained to identify these emotions, which they may have been taught to suppress. Recognition of these emotions can be cultivated through

Show Notes Elspeth Cameron Ritchie, MD, MPH, talks with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about averting disruptions in psychiatric medications after short- and long-term disasters. Dr. Ritchie is a psychiatrist who works in Washington. Show Notes by Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Later, in the "Dr. RK" segment, Renee Kohanski, MD, discusses the potential impact of pharmacogenomics on the practice of psychiatry. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Dr. Ritchie and disaster psychiatry She entered disaster psychiatry through her many years as a military psychiatrist. She had to think about how to plan and treat psychiatric emergencies during deployments to an austere environment, such as Somalia and Iraq. She was on active duty during Sept. 11, 2001, and helped coordinate the disaster response during that period and then completed a fellowship in disaster psychiatry at the Uniformed Services University in Bethesda, Md. Ritchie says that the field has changed immensely, from the way in which it once handled debriefings to the current use of psychological first aid. Yet, she thinks that psychiatric medications are a neglected area of planning. Minor, major disasters can cause disruptions in psychiatric medications Access/continuity of psychiatric medications is overlooked in planning. Disruption in psychotropic medications will affect many populations, including people with serious mental illness (SMI), first responders, and patients dependent on controlled substances such as methadone, buprenorphine and naloxone, and benzodiazepines. Especially for those with SMI in a disaster that creates increased stress, the absence of medications can have longer negative consequences, such as changes in behavior as hospitalizations or that may lead to contact with the legal system. Plans need to be made in advance with patients to prevent disruption in medications. Small disasters could include a weather event, such as a snow or rainstorm. These can create barriers to medication at the basic level, such as a lack of electricity affecting computer systems, a pharmacist cannot make it to work, etc. Larger disasters, such as hurricanes, can have effects that last months to years, such as loss of psychiatrists or lack of other infrastructure related to mental health. Population-specific planning during disasters Patients with SMI: Some might be homeless and affected by weather conditions; there often may be a robust citywide response aimed at creating a safety net for these individuals. First responders: It is essential to have medications available for sleep, such as trazodone or zolpidem, to mitigate the effects of long, stressful workdays that make it hard to "turn off" and get rest. Working professionals: Many people balance busy lives on a routine basis, so it's important to help these patients maintain their medications and functioning. Psychiatrists should make sure that these patients have adequate supplies of medications, such as SSRIs. How can psychiatrists help to prepare? They can ensure that patients can have an adequate supply of medications in several locations in case of disaster or emergency. They can provide a 90-day supply of medication in the event of a large disaster with lasting effects. They can determine that patients have a printed up-to-date list of all their medications in case they need to change pharmacies or have medications refilled by another clinician, such as a primary care physician. Patients and doctors rely on the electronic health records for medication lists, which may fail during a disaster. They can identify at-risk patients, such as those on controlled substances (opiates and benzodiazepines), and refill any medications that, if missed, can result in withdrawal syndromes. Disaster planning has come a long way over the last 30 years Disaster planning often takes into consideration food supply and medications. However, psychiatric medications often are forgotten as being essential to patients. For example, the Centers for Disease Control and Prevention does not stockpile psychotropic medications, other than valium, for emergencies. Psychiatrists can advocate within their cities or states to ensure that disaster plans include a contingency for psychiatric care, such as stockpiles of psychotropic medications. Psychiatrists can help in disaster planning by consulting on formularies for disasters and suggesting versatile psychotropic medications that can be used in multiple settings or for different patient types. Examples of versatile medications include mirtazapine for sleep and depression, bupropion for depression and ADHD, medications for sleep, antipsychotics, and such key SSRIs as fluoxetine. Psychiatrists also must plan for themsel

Ep. 70 Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. In this episode, Richard Balon, MD, returns to the MDedge Psychcast to discuss benzodiazepines. This time, Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, interviewed Dr. Balon about prescribing benzodiazepines for patients with serious medical illnesses. They also examine some of the controversies around benzodiazepines and common mistakes that some clinicians make when prescribing these drugs. Dr. Balon is professor of psychiatry at Wayne State University in Detroit. And later, in the "Dr. RK" segment, Renee Kohanski, MD, explores the need for psychiatrists to challenge the distorted thinking patterns of patients, particularly in light of the growing influence of social media. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Benzodiazepines can be used for patients with serious mental illness across several areas of medical illness, including those with cardiovascular, gastrointestinal, and sleep disorders, as well as for those with generalized anxiety disorder (GAD) and panic disorder. Cardiovascular illness Patients with cardiovascular illness might have just encountered a near-death experience and present with somatic symptoms of their cardiovascular illness and anxiety. This overlap of symptoms makes cardiovascular illness a reasonable comorbidity in which to use benzodiazepines for anxiety. A naturalistic study of patients with heart failure showed patients on benzodiazepines had a small decrease in mortality. The reason is unknown, but it could be from a decrease in anxiety and stress, both of which affect the heart. Older studies show that some benzodiazepines can be used in addition to antihypertensives. Gastrointestinal illness Benzodiazepines also are useful for such gastrointestinal (GI) illnesses as peptic ulcer disease, inflammatory bowel disease, irritable bowel syndrome, etc. The symptoms of GI illness, such as constipation, diarrhea, and nausea, can complicate the use of SSRIs or tricyclic antidepressants for anxiety. Older studies suggest that adding benzodiazepines to the regimen of these patients, especially those without substance use disorder, can improve outcomes. Sleep disorders Five benzodiazepines have been approved for sleep disorders: triazolam, flurazepam, temazepam, estazolam, and quazepam. These medications are used infrequently despite having a long half-life, which is useful for sleep initiation and maintenance. Quazepam is designed specifically for insomnia and has activity at a different part of the alpha subunit on the GABA receptor. Clonazepam also is useful, especially for patients with comorbid anxiety and sleep issues, because it contributes to sedation, and as a result of its long half-life, it continues to relieve anxiety throughout the day. Generalized anxiety disorder (GAD) and panic disorder Many clinicians are leery about using alprazolam for several reasons. The medication's short half-life contributes to patients using the drug several times a day. Immediate relief of anxiety has a reinforcing effect, which in turn, increases the risk of abuse. There are no well-designed trials comparing benzodiazepines with SSRIs. Many of the recommendations about how to use benzodiazepines come from clinical experience. Some patients with GAD without substance use benefit from benzodiazepines such as clonazepam. It is possible for some patients to stay on long-term treatment with benzodiazepines and not need higher doses because of tolerance. Clarity is needed about the true impact of benzodiazepines on patients Benzodiazepines are an integral part of the psychopharmacology armamentarium yet are underused. Their use is increasingly discouraged, and trainees are not getting enough experience with prescribing benzodiazepines. Benzodiazepines are rarely abused on their own. Common mistakes in using benzodiazepines Patients who might need or benefit from treatment with benzodiazepines are not adequately assessed. Dose escalation with benzodiazepines often is avoided. When patients ask for an increase in the dose, this is not necessarily sign of abuse. A dose increase might be a sign that the patient is still anxious. Trainees are not getting proper guidance in prescribing benzodiazepines; they need to be familiar with prescribing all classes of psychotropics. References Slee A et al. Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. Lancet 2019 Feb 23;393(10173):768-77. Guina J, Merrill B. Benzodiazepines I: Upping the care on downers: The evidence of risks, benefits, and alternatives. J Clin Med. 2018 Jan 30. doi: 10.3390/jcm7020017. Salzman C. The APA task force report on benzodiazepine dependence, toxicity, and abuse. Am J Psychiatry. 1991

Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. In this episode, Lorenzo Norris, MD, host of the MDedge Psychcast, interviews Jonathan M. Meyer, MD, about prescribing clozapine and understanding barriers of use. Dr. Meyer is clinical professor of psychiatry, University of California, San Diego, and a psychopharmacology consultant with the California Department of State Hospitals. Overview of clozapine Clozapine is an effective medication for treatment-resistant schizophrenia and lethality/suicide. Clozapine is underused by clinicians for many reasons. Clinicians have less comfort with prescribing clozapine. Too few trainees are exposed during residency to prescribing clozapine. Using clozapine during training provides the knowledge and comfort necessary to prescribe it once out in practice. Fear of prescribing clozapine outweighs the benefits to patients who need it. Other barriers include monitoring burdens in confluence with systems issues. Indications for use Treatment-resistant schizophrenia is defined as an inadequate response to two antipsychotic trials, and treatment-resistant schizophrenia occurs in about 30% of patients with schizophrenia. People with treatment-resistant schizophrenia have a 5% chance of responding to other antipsychotic medications, while the response rate to clozapine is about 40%. In light of those statistics, getting patients with schizophrenia on clozapine should be a priority. Everyone benefits when a patient with treatment-resistant schizophrenia is started on clozapine. Clozapine treatment leads to decreased symptoms and suffering, improved quality of life, decreased suicidality and aggression, and lower hospitalization rates, which in turn, lead to decreased health care costs. Barriers to using clozapine Education is key to empowering physicians to start prescribing clozapine and overcoming the initial resistance to prescribing. SMI Adviser is a website sponsored by the American Psychiatric Association (APA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) that provides access to education, data, and consultations for clinicians who treat serious mental illness. SAMHSA also has sponsored "centers of excellence" in New York state and the Netherlands that provide consultation and on-demand answers to questions about prescribing. The Clozapine Handbook, written by Dr. Meyer and Stephen M. Stahl, MD, PhD, is another centralized resource for prescribers. Dr. Meyer and Dr. Stahl wrote the handbook to educate and encourage clinicians to prescribe clozapine and improve patient outcomes. Adverse events and monitoring Myocarditis: Rate of myocarditis ranges from 0.5% to 3% (most rates from Australia), an adverse event that happens primarily within the first 6 weeks of clozapine therapy. Symptoms suggesting myocarditis include fever and elevated troponin level more than twice the upper limit of normal. Clinicians can order a C-reactive protein test, which can help rule in myocarditis if troponins are elevated but not at twice the upper limit range. In the first 6 weeks of therapy, clinicians are encouraged to order a troponin test during the patients' weekly labs. Isolated fever does not mean myocarditis, because fever is a common side effect during titration, and clinicians can complete the fever work-up. Cigarette smoke can induce cytochrome P450 (CYP) enzyme, including CYP1A2. It is not necessary to have patients stop smoking when they start clozapine. Clinicians can adjust the clozapine dose based on response and clozapine level. Induction of CYP1A2 enzyme happens only when people smoke or burn the actual leaf of tobacco or marijuana. Vaping or e-cigarettes will not induce CYP1A2 and change clozapine levels. Threshold of response is 350 ng/mL, however levels that lead to response differ with each individual and will be influenced by smoking habits. Other common side effects include orthostasis, sedation, and sialorrhea. New technologies are available to reduce barriers of prescribing clozapine and to improve patient adherence to hematologic monitoring. Athelas is a company that manufactures a Food and Drug Administration–cleared point-of-care device to measure neutrophil count by way of a finger stick. Results are dispensed real time. Athelas also will take care of medication dispensing. A point-of-care device is in development for plasma clozapine levels with fingerstick, which will allow clinicians to make titration decisions in real time instead of 1 week after levels. The device already is available in Europe. Creating a system that allows for adherence Using case managers to improve clozapine adherence is cost effective when the amount saved from avoiding hospitalization is taken into account. Clozapine can lead to a functional recovery in terms of how a patient interacts with family, friends, and society at large. Clozapine has the ability to i

Show Notes In this episode, we revisit three of our best episodes on preventing suicide. In episode 46, Lorenzo Norris, MD, host of the MDedge Psychcast, interviewed Igor Galynker, MD, about how to assess suicide crisis syndrome. Dr. Norris is editor in chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Galynker is associate chairman for research in the department of psychiatry at Mount Sinai, New York. In episode 42, Dr. Norris interviewed Caroline Bonham, MD, and Avi Kreichman, MD, about addressing suicidality in rural communities and strategies for enhancing resilience. Dr. Bonham and Dr. Kreichman work together at the University of New Mexico, Albuquerque. She serves as vice chair of the department of psychiatry and behavioral sciences at the university, and he is an assistant professor there. In episode 54, Sidney Zisook, MD, who directs the residency training program at the University of California, San Diego, conducted a Masterclass on the many causes of physician suicide and how this might be prevented. And stay tuned for our Dr. RK segment, where Renee Kohanski, MD, who talks about making mistakes while caring for patients and granting ourselves full and complete forgiveness. Dr. Kohanski has a private practice in Mystic, Conn. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Headline: Update on the American Psychiatric Association – Part 2 Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Lorenzo Norris, MD, interview with Saul Levin, MD, MPA, CEO and medical director of the American Psychiatric Association (APA). Dr. Levin also is clinical professor at George Washington University. Improving access to care and impact of psychiatrists is imperative. Finding a doctor: More physicians need to be trained. Increasing the number of physicians can be accomplished through initiatives funded by the government and by private medical centers. Innovation in training at both undergraduate and graduate levels is needed to increase the number of physicians across all specialties. Debt repayment: The APA is encouraging the federal government to diversify its loan repayment options, such as by making it possible for psychiatrists to practice in more diverse but underserved places in exchange for loan repayment. Getting to a doctor: Telepsychiatry and collaborative care are means of increasing access. Collaborative/integrative care: The psychiatrist acts as an adviser to a whole team and then offers direct patient care in more complex cases. Telepsychiatry improves access by decreasing stigma and reducing commute time to and from patient visits. Both psychiatrists and patients save time and gain convenience. Using evidence-based treatments (EBT) is important in psychiatry. One goal is to advance the use of EBT to enhance the impact of psychiatric treatment, especially by using quality measures (for example, the nine-item Patient Health Questionnaire) to validate the impact of treatment. The Centers for Medicare & Medicaid Services has given grants to medical associations such as the APA to create quality measures to quantify/validate the impact of treatments in an effort to foster more EBT in psychiatry. Conclusion: Advocating on behalf of people with psychiatric disorders requires a broad approach. The APA lobbies for fairness, parity, and quality treatment. The group works to advance EBTs and new treatments. Recruitment of diverse individuals to psychiatry is important. "Moonshot" level research is integral to the advancement of psychiatry and the mental health of the patients. The APA strives to balance a mission of government advocacy and individual psychiatrist education. References APA Innovation Lab Mental health parity advocacy Advocacy and APAPAC For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Update on the American Psychiatric Association – Part 1 Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Lorenzo Norris, MD, interview with Saul Levin, MD, MPA, CEO and medical director of the American Psychiatric Association (APA). Dr. Levin also is clinical professor at George Washington University. In 2019, the American Psychiatric Association celebrated its 175th anniversary. The APA was the first medical association formed in the United States. The 2019 APA annual meeting in San Francisco attracted 13,000 psychiatrists and mental health professionals, and hosted 650 sessions covering all topics in psychiatry, including subjects related to private, community, and academic psychiatry. Highlights of the 2019 meeting included: A Gala at San Francisco City Hall, which allowed generations of psychiatrists to celebrate the progress of the APA. Sessions at the meeting, which focused on the latest basic, clinical, service, and psychopharmacology research. Additional sessions focused on minority and underrepresented populations, both within APA membership and patient populations. Major networking opportunities at the APA were available, allowing peers and experts in the field to create lifelong professional relationships. A burgeoning networking opportunity is the Psychiatry Innovation Lab, which is "an incubator at the American Psychiatric Association that aims to catalyze the formation of innovative ventures to transform mental health care." The APA's role in advocacy: The organization is not just a guild that seeks to support psychiatrists. Part of the APA's mission is to advocate for patients with mental health illness with a focus on improving treatment and outcomes. For members, the APA sponsors a National Advocacy Day on Capitol Hill and state advocacy days, in which the APA helps fund people to come talk to their elected representatives. Major areas of advocacy by the APA as a medical association are numerous. Mental health parity: Advocating for equal pay to psychiatrists for treating mental health diagnoses as well as the provision of equal coverage of psychiatric diagnoses by insurance companies. Augmentation of the workforce: Supporting measures aimed at making sure that there are enough psychiatrists to treat patients with mental illness in the United States. Examples of advocacy initiatives by the APA are numerous. The group is active in the following areas: Advocates for legislation that advances telepsychiatry by supporting laws aimed at reducing barriers to the technology. Promotes integrative mental health care models. Explains the concept of prior authorization on Capitol Hill and helps to craft sensible guidelines. Promotes evidence-based treatments for substance use disorders, especially opioid use disorders. Lobbies for appropriations for agencies such as the Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health, and the National Institute on Alcohol Abuse and Alcoholism. Helps construct smart loan repayment plans aimed at allowing psychiatrists to practice in low-resource areas. The APA recommends several research initiatives. "Moonshots" should be a goal in in psychiatry, much like those taken with illnesses such as HIV and breast cancer. Stigma must be reduced, and money must be appropriated to mental illness research in the same way it is for other medical illnesses. References APA Innovation Lab Mental health parity advocacy Advocacy and APAPAC For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Show Notes Lorenzo Norris, MD, interview with Robert McCarron, DO, at the American Psychiatric Association meeting (#APAAM19) Dr. McCarron is vice chair of education and integrated care at University of California, Irvine, department of psychiatry. He is also trained as an internist. Shortage of psychiatrists, other mental health providers About 70% of all psychiatrists are over the age of 50 years and looking toward retirement. This also pertains to other mental health providers, such as psychologists. Implications of shortage People with severe mental illnesses (SMIs) are not getting the care they need. On average, they die 10-15 years younger than people who do not have SMIs. Patients with SMIs have a higher risk of death from illnesses such as heart disease, hypertension, and osteoarthritis because they are not getting preventive/primary care. Patients with chronic pain issues are not getting care. In California, physician assistants provide care to many patients, but they get only 2 weeks of instruction in psychiatry. About 80% of all antidepressants are prescribed by nonpsychiatrists. About 60% of all mental health care is delivered in the United States by clinicians who do not specialize in mental health. This care is delivered in primary care settings. About 40%-45% of patients seen in primary care offices are treated for behavioral health issues, such as depression, anxiety, or substance use disorders. Suicides are up more than 20% over the last decade. On average, 25 veterans die by suicide each day. Training primary care colleagues in psychiatry Primary care physicians have a core baseline in biomedical sciences. Giving them a booster in behavioral health is a way to address the shortage. The Train New Trainers Primary Care Psychiatry Fellowship was launched at University of California, Davis, and the University of California, Irvine. It has 125 fellows throughout the country, and the hope is to double that number. The program lasts 1 year, including two intensive weekends. It teaches fellows how to conduct motivational interviewing; short, targeted, and brief psychotherapies that are effective and evidence based. The Fellowship includes Web-based presentations two to three times per month. It also includes small group mentorship meetings in which fellows discuss patients and learn how to navigate complex cases. A combined residency program might be another way to address the need for more training in psychiatry. References Price S. Front line: Using primary care to prevent suicide. Tex Med. 2018 Nov 1;114(11):16-21. Santiani A et al. Projected workforce of psychiatrists in the United States: A population analysis. Psychiatr Serv. 2018 Jun;69(6):710-3. Huff C. Shrinking the psychiatrist shortage. Manag Care. 2018 Jan;27(1):20-2. Wilkins KM et al. Integration of primary care and psychiatry: a new paradigm for medical student clerkships. J Gen Intern Med. 2018 Jan;33(1):120-4. McGough PM et al. Integrating behavioral health into primary care. Popul Health Manag. 2016;19(2):81-7. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Guest George T. Grossberg, MD: Samuel W. Fordyce Professor; director, geriatric psychiatry at Saint Louis University. Dr. Grossberg spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company. New developments in Alzheimer's research The Systolic Blood Pressure Intervention Trial, also known as the SPRINT MIND Study, showed that tightly controlled systolic blood pressure (SBP) of 120 mm Hg, compared with an SBP of 140 mm Hg, resulted in a 20% reduced risk of developing mild cognitive impairment. The SPRINT study was terminated early at the median follow-up of 3.26 years as its results showed that tightly controlled SBP significantly reduces the risk of stroke and heart disease. The Alzheimer's Association has agreed to fund an additional 2 years of the SPRINT MIND Study to evaluate whether tightly controlled BP is effective in reducing the risk of Alzheimer's disease. In the brain, the glymphatic system was discovered in 2012 and is similar to the lymphatic system in its role as a drainage system for removing toxins. Glial cells mediate toxin removal, and the glymphatic system removes toxins that eventually can cause cell death in the brain. Because the glymphatic system is involved in removing the beta-amyloid plaques that contribute to cell death in AD, the glymphatic system is another area of investigation in the pathogenesis of AD. Novel treatment of moderate to advanced AD involves using plasma infusion. Infusion of plasma products from healthy, nonimmunocompromised 18-year-old individuals into older patients with AD is a potential treatment for AD. Precedent for this intervention comes from animal studies investigating parabiosis, a procedure in which two animals are connected so that they share each other's blood stream. When such a circulatory exchange occurs between a younger mouse and an older mouse with AD, the older AD model mouse regains cognitive abilities and is able to complete mazes that it was unable to complete before. How can this model be adapted to humans? One possibility might involve infusing plasma from young healthy individuals into older adults with advanced AD. A safety proof-of-concept study, published recently, found that plasma products can be safely infused. The next step is an efficacy study. A relationship has been found between AD and periodontal disease. The primary bacteria related to periodontal disease, Porphyromonas gingivalis, is found in close proximity in the brain to the plaques and tangles of AD. One theory posits that the presence of this bacteria is related to inflammation that may contribute to the causality of AD. Could AD be treated with the antibiotics used to treat periodontal disease? The answers remain unclear. Aducanumab, a monoclonal antibody targeting the beta-amyloid plaques of AD, initially showed favorable changes in imaging studies of the brains of people with AD. In March 2019, the study was halted because of futility. An independent data-monitoring committee determined that the early results seen on imaging did not result in clinically meaningful changes, compared with placebo. Some AD researchers consider this drug failure the "final nail in the coffin" of the amyloid hypothesis, and the pathogenesis of AD is most likely related to tau neurofibrillary tangles and other mediators, such as the immune system and inflammation. References SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 26 Nov 2015;373:2103-16. Jessen NA et al. The glymphatic system: A beginner's guide. Neurochem Res. 2015 Dec;40(12):2583-99. Dominy SS et al. Porphyromonas gingivalis in Alzheimer's disease brains: Evidence for disease causation and treatment with small-molecule inhibitors. Science Advances. 23 Jan 2019;5(1): doi: 10.1126//sciadv.aau3333. Conese M et al. The fountain of youth: A tale of parabiosis, stem cells, and rejuvenation. Open Med (Wars). 2017;12:376-83. Phase 3 study of aducanumab in early Alzheimer's disease. ClinicalTrials.gov Identifier: NCT02477800. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Twitter: @MDedgePsych

Part I of II (episode 62) If you have lost a patient to suicide, or if you simply want to be part of the conversation, we strongly encourage you to email us at [email protected] your email will be read and discussed in a future episode. You can also tweet at us at @MDedgePsych. If you're someone struggling with suicide in need of care, the national suicide hotline is 800-237-8255.

Part I of II (episode 62) If you have lost a patient to suicide, or if you simply want to be part of the conversation, we strongly encourage you to email us at [email protected]. Your email will be read and discussed in a future episode. You can also tweet at us at @MDedgePsych. If you're someone struggling with suicide in need of care, the national suicide hotline is 800-237-8255.

In this masterclass, Charles L. Raison, MD, returns to the MDedge Psychcast to discuss the risks and benefits of antidepressants. He previously appeared on the Psychcast in episodes 15 and 16. Dr. Raison is Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families and professor, School of Human Ecology, and professor, department of psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison. Later, Renee Kohanski, MD, discusses the need for psychiatrists to take care of and nourish their communities. Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Treatment with antidepressants The STAR-D trial, a large effectiveness trial (n = 4,000), looked at the effect of SSRIs and other medications for the treatment of depression. As an effectiveness trial, STAR-D looked at "real" patients with comorbidities (as opposed to efficacy trials, which use "perfect patients" with no comorbidities to minimize confounding effects). Only 30% of patients went into complete remission with first step of treatment with an SSRI (citalopram) at the highest tolerated dose. Almost 50% experienced a response (a 50% reduction in symptoms of depression on standardized scale). Cynicism and hope for antidepressants To obtain Food and Drug Administration approval, a medication requires two positive studies (showing that the drug beats placebo), and on average, an SSRI requires five to seven studies to get the two positive studies. A meta-analysis of negative SSRI studies that were "filed away" found only a 1.8-point difference on Hamilton Depression Rating Scale score between SSRI vs placebo. The difference between SSRI and placebo in treatment disappeared among patients who were less depressed. Geddes et al., presented a more balanced view in a published meta-analysis of 522 trials that included more than 100,000 patients. Antidepressants had a modest benefit, compared with placebo. In head-to-head studies, some antidepressants were better than others, such as amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine. Predictors of response Poor response to antidepressants: Presence of comorbid anxiety disorder, failure of first or subsequent antidepressant trials. Within STAR-D, among those who failed three treatment steps, only 13% responded to the next treatment. Good response to antidepressants: An acute response to an antidepressant predicts long-term response. A 20% or greater improvement within 2 weeks of treatment resulted in a higher chance of remission, compared with those who don't initially respond, who then had a less than 5% chance of remission. Are antidepressants good for everyone? The difference between active antidepressants and placebo is small. A latent growth curve analysis of placebo vs. antidepressants for depression showed that there are two separate trajectories with antidepressants: 70% will respond and are vastly improved, while 30% actually do worse. A National Institute of Mental Health study from 1980s randomized patients to two types of psychotherapy vs. tricyclic antidepressants (TCAs) vs. waitlist control group. Treatment took place for 16 weeks, and patients were followed for 18 months. People who went into remission on TCAs were more likely to relapse than those who went into remission on psychotherapy. Epidemiological Catchment Area (ECA) trial: Prospective data of 92 people from the total 3,500 in the study. Of the 92 with a first major depressive episode, 50% had a second major depressive episode. Of those who were treated into complete remission, even after 5 years, more than 50% had a relapse of their depression. Conclusion: Relapse of depression is common when patients come off antidepressants To stay well, a patient with depression should continue to receive an antidepressant. Clinicians must ask: Do the antidepressants increase the risk of relapse of depression? Depression is a disabling disease, so treatment is necessary. But clinicians should question for whom and when antidepressants should be used. References Turner EH et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358:352-60. Cipriani A et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet. 2018 Apr 7:391(10128):1357-66. Penninx BW et al. Two-year course of depressive and anxiety disorders: Results from the Netherlands study of depression and anxiety (NESDA). J Affect Disord. 2011 Sep;133(1-2):76-85. Perlman K et al. A systematic meta-review of predictors of antidepressant treatment outcome in major depressive disorder. J Affect Disord. 2019 Jan 15;243:503-15. For more MDedge Podcasts go to mdedge.com/podcasts Email the show: [email protected] Interact with us on Tw

For more MDedge Podcasts go to mdedge.com/podcasts In part II of this Psychcast Masterclass, Patricia Westmoreland, MD, returns to discuss severe, enduring eating disorders, including management and ethical questions. In Dr. RK this week, Renee Kohanksi explores the impact of censorship and self-censorship. Email the show: [email protected] Interact with us on Twitter: @MDedgePsych Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Guest Patricia Westmoreland, MD, a forensic psychiatrist at the University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; adjunct assistant professor of psychiatry at the University of Colorado Denver. Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company. Harm reduction, palliative care, and futility Harm reduction model: A focus on returning to reasonable level of functioning without focus on full weight restoration, especially if full weight restoration has not proven sustainable with previous treatment. Harm reduction is managed an as outpatient with regular check-ups. Team collaborates for attainable, mutual treatment goals. Patients are allowed to stay at a lower body mass index (BMI) and are able to partially function and do things they enjoy, such as living with family and working part time. Patients maintain an agreed-upon weight and regularly check labs. Inpatient hospitalization is pursued only to restore weight back to previously agreed-upon goal: BMI is a marker of risk; BMI greater than 15 kg/m2 is lower risk, and BMI less than 13 kg/m2 is higher risk (lower BMI is tied to higher immunocompromised risk, more fractures, and other illnesses, as well as a greater risk of suicide, etc.) Palliative care is offered when patients have failed harm reduction and cannot sustain an acceptable body weight (not weight restored): Palliative care is NOT hospice, and therefore, there are no specific expectations. Treatment goal is comfort care, i.e., analgesics for fractures and decubitus ulcers, anxiolytics for refractory anxiety. Ethics and futility: When to say "enough is enough"? In anorexia nervosa (AN), frequently, many treatments have been implemented, and there may be no cure. Some think that anorexia should never be an end-stage diagnosis. Cynthia Geppert, MD, MPH, a health care ethicist and a professor of psychiatry and internal medicine at the University of New Mexico, Albuquerque, who wrote in the American Journal of Bioethics: "Futility and chronic anorexia nervosa: A concept whose time has not yet come," argues against futility: AN does not meet definition of a terminal illness: The patient's depleted weight renders a patient as having a life-threatening illness. Can a patient be terminal and is care futile if there is hope for long-term recovery? Legally: Cognitive distortions make up the core of AN as an illness. Do patients with AN have the capacity to decide that further treatment is futile? Cognitive impairments often normalize with treatment. Are physicians obligated to treat first in order to restore a patient's decision-making capacity before allowing them to choose palliative care? People with AN may lack capacity because they cannot appreciate the consequences of their decision, which is one of the four components of capacity. In support of futility, Cushla McKinney, PhD, of the biochemistry department at University of Otago (New Zealand), argues against the complete rejection of the concept of futility, saying it risks forcing a small and chronic group of patients into an intolerable situation. Arguments for futility: Not EVERY individual with AN lacks capacity. Some argue for futility, and allowing patients to make choices in line with what they value in life. Prognosis, even with treatment, is poor, especially for older individuals with years of failed treatments and medical comorbidities. Are we doing harm by forcing an invasive treatment that patients don't want – especially after much treatment? Illustrative case of AG, a 29-year-old female with chronic AN, who had a guardian for medical decision making: The guardian had decided in favor of tube feedings many times; AG had suffered complications such as heart failure. AG wanted to enter palliative care, arguing that she did not want to die, but if death were the result of AN, then "so be it." The judge ruled she could refuse treatment. He did not comment on capacity, but ruled she could make this decision to die on her terms. Emerging concerns: Is anorexia nervosa an end-stage illness or not? How will physician aid-in-dying overlap with AN? Do eating disorder patients have the capacity to request aid-in-dying, and what is the physician obligation? References Eddy J. Recovery from anorexia nervo

In Episode 59 Patricia Westmoreland, MD, gives a masterclass lecture on managing severe and enduring eating disorder (SEERS). Renee Kohanksi, MD, poses the question, "What do we want?" Contact us: [email protected] Twitter: @mdedgepsych Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Guest Patricia Westmoreland, MD: forensic psychiatrist at University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; and adjunct assistant professor at University of Colorado Denver in department of psychiatry. Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company. Introduction, definition, role of involuntary treatment, and novel treatment options Introduction: Prognosis: Anorexia nervosa (AN) has the highest mortality of any psychiatric disorder. Risk factors for death: Older age at first presentation, lower weight at presentation, greater duration of illness, comorbid alcohol or diuretic abuse, comorbid mood disorder, history of psychiatric hospitalization and suicide attempts, and self-harm. Less than 50% recover completely, about 30% improve somewhat but require frequent hospitalizations or treatments, and 20% develop a SEED. Eddy et al. longitudinal study of eating disorders (EDs): AN patients can recover over the long term. Overall, 31% were better at 9 years; 63% better at 22 years of follow-up. Treatment: Treat ASAP, especially if patient is seen at a young/pediatric age before symptoms are fully developed and weight loss is profound. Weight gain as the central treatment: Many patients are reluctant to get treatment that focuses only on food intake and weight gain. Predictors of improvement: Weight gain that is parallel to improvement in physical and psychological well-being, diagnosis at a younger age, and shorter duration of illness. Medications: Fluoxetine is the only Food and Drug Administration-approved treatment for EDs, including bulimia, at doses of 60 mg and above. Patients with EDs have poor response to selective serotonin reuptake inhibitors because of starvation and limited production of serotonin and serotonin receptor abnormalities. Severe and enduring eating disorders (SEED) definition: 6-12 years of an ED can qualify as chronic. Lower likelihood of recovery with symptoms substantially interfering with quality of life. Role for involuntary treatment in EDs: Few treatment centers do involuntary treatment of ED. Involuntary treatment can involve guardianship for medical decisions. Guardianship is useful for medical treatment and admission to a medical ward, for example, when a patient requires forcible tube feeding for life-threatening starvation. Commitment or certification is required for involuntary treatment in a psychiatric hospital. Commitment is sought by a psychiatrist and is a tool in cases when the patient is dangerous to self or others and is gravely disabled. It is useful to commit a patient who is refusing care and has not been sick for long. Often, commitment/certification is used as a last resort, and the patient is too sick to truly recover. Pros and cons of involuntary treatment: Pro: No difference in weight restoration in voluntary vs. involuntary treatment, and patients are often grateful after involuntary treatment. Cons: Involuntary tube feeding has unclear long-term outcomes. Some studies show poor outcomes for people who are treated involuntarily, though this is likely because of their comorbidities. Novel treatment options: Ketamine has been used in EDs. Concerns remain about the drug's addictive potential and inability to clearly change eating disorder pathology. Oxytocin: There are reduced cerebrospinal fluid levels of oxytocin in AN, and oxytocin restores during recovery. Experimentally in rats, oxytocin may reduce the fear and social phobias related to eating. Electroconvulsive therapy does not reduce ED symptoms such as restricted eating and fear of fatness, but it can improve depression. People with ED are often medically ill, so the patient must be physically able to undergo treatment. Because of medical comorbidities, AN patients are more likely to have complications like delirium. Transcranial magnetic stimulation: Dorsolateral prefrontal cortex involved in self-regulatory control, inhibitory control, and cognitive flexibility. Some studies show promising results of using this intervention with ED and mild side effects like syncope and headache. Deep brain stimulation (DBS): Treatment targets the nucleus accumbens and the subcallosal cingulate gyrus, which theoretically alter balance between reward and cognitive inhibitory and control systems that are related to pathological eating behaviors. DBS has strongest theoretical rationale in terms of neurocircuitry targe

Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Masterclass guest Richard Balon, MD: professor of psychiatry and training director at Wayne State University, Detroit. In March, Dr. Balon spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company. Physician burnout and effective interventions The scales (for example, the Maslach Burnout Inventory) do not necessarily represent the full extent of burnout: If physicians work 12 hours but find fulfillment in work, they will be tired but not necessarily burned out. However, if physicians work 12 hours a day feeling frustrated by the systemic problems, then burnout can ensue. Common contributors to provider burnout: Excessive workload: Pressures of working with an electronic medical record, extensive time spent on documentation; lack of work satisfaction and job control; lack of respect for the work; student loan burden. "Moral injury": The emotional burden, which occurs when physicians cannot deliver ideal care/treatment to patients, especially when limited by resources (such as insurance or poverty), or other systemic health care issues. Work environment and organizational culture: These factors also contribute to physician burnout. Burnout is a problem for health care organizations as a whole Two main ways to address burnout: Physician-directed interventions (focused on individuals) and organization-directed interventions. Organization-directed burnout prevention strategies include: Reducing workload; reducing time spent on documentation, such as decreasing time spent in front of EMRs; cultivating effective teamwork; fostering a sense of job control. Organizations prefer individual-focused interventions over systemic changes. Examples include mindfulness teaching, yoga, cognitive-behavioral therapy techniques, education about burnout, and education. Individual-focused interventions are great, but they are not realistic for changing the culture that contributes to burnout. Interventions for burnout In a systematic review and meta-analysis in JAMA Internal Medicine, Maria Panagioti, PhD, and colleagues found that: Burnout interventions focused on individual physicians have small, significant effect on physician burnout. Organizational-directed approaches result in greater treatment effects, especially when interventions focus on promoting healthy individual-organization relationships. The impact of individual interventions can be improved when supported by organizational interventions. Interventions targeted at more experienced physicians within primary care settings show greater treatment effect than interventions targeted at less experienced physicians within secondary treatment settings. Approaches identified by staff, as outlined in a New England Journal of Medicine article, can lead to meaningful change. A Hawaiian health care system queried individuals (physicians, mid-levels, and nursing staff) to identify parts of EMR documentation that are poorly designed and unnecessary, and lead to unintended burdens contributing to burnout. This type of survey improves efficiency of a system and shows that the health care organization cares about preventing clinician burnout. References Panagioti M et al. "Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis." JAMA Intern Med. 2017 Feb 1;777(2):195-205. Ashton M. "Getting rid of stupid stuff." N Engl J Med. 2018 Nov. 8;379(10):1789-91.

Host Lorenzo Norris, MD, returns this week for a dual-specialty episode on the opioid crisis and how it can be mitigated. He welcomes psychiatrist Martin Klapheke, MD, and family practice physician Magdelena Pasarica, MD, PhD, to talk about education, strategies, and collaboration between psychiatry and family practice medicine. In Dr. RK this week, Renee Kohanski, MD, talks about whether something is indeed better than nothing. You can contact the Psychcast by emailing us at [email protected] or you can follow us on Twitter at @MDedgePsych. Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Guests Dr. Martin M. Klapheke: psychiatry residency program director; assistant dean, medical education; and professor of psychiatry at University of Central Florida, Orlando Dr. Magdalena Pasarica: associate professor of medicine; medical director, KNIGHTS (Keeping Neighbors in Good Health Through Service) student-run free clinic; family medicine chair, Family Medicine Interest Group adviser at University of Central Florida, Orlando How to address the opioid crisis during training The opioid crisis looms large over the medical field: 130 deaths from opioid overdoses per day. 11 million people misuse opiate prescriptions and 2.1 million people have an opioid use disorder. In 2018, the Department of Health & Human Services released a 5-point strategy in response to the opioid crisis: Access: Providing better prevention, treatment, and recovery services. Data: Offering timelier, more specific public health data and reporting. Pain management: Mitigating risk while prescribing with healthy, evidence-based methods of pain management. Overdoses: Targeting overdose-reversing drugs better. Research: Doing better research on pain and addiction. Educating the next generation of medical professionals to address the opioid crisis From the family medicine and resident education point of view: Mitigate the risk when prescribing opiates. Identify opioid use disorder (OUD). Use the interdisciplinary approach to know when to refer to psychiatry and pain medicine. Primary care providers are on the front lines of the crisis, as 11% of patients report chronic pain. PCP will have to treat pain and: From the psychiatric and medical education point of view: Before opioid crisis, there was little instruction in how to treat acute or chronic pain. Medical education now teaches about pain management: Information about non-narcotic analgesics, nonmedication pain treatments, and addiction and its treatment. Medical students: Focus on working with family members of those with OUD and especially on using naloxone to reverse opioid overdose. Interprofessional approach is most effective with communication with shared priorities We can collaborate effectively by understanding our shared priorities and offering all providers the opportunity to working toward these priorities in their own ways. From Dr. Klapheke: The opioid crisis crosses all specialties of medicine, and doctors will reach the limit of their expertise. Work interprofessionally by communicating and knowing what resources are available. Communicate what each party is doing for the epidemic and for the patient. This means knowing about resources in the hospital, clinics, city, county, law enforcement, etc. From Dr. Pasarica: Again, we must acknowledge the limits of our expertise and work interdisciplinarily in a team-based approach. Each team member needs to be responsible for the follow-up, even if the patient is referred to another person such as a counselor or a psychiatrist. Each team member must share information and what has been done for the patient. How is addressing the opioid epidemic being integrated into medical student and resident education? From Dr. Klapheke: At University of Central Florida, the medical school uses vertical and horizontal integration of information into the curriculum. During the preclinical years: Write OUD and pain management into standardized patient work. Focus on the pharmacology of opiates and understanding neuroscience of addiction. During clinical rotations: Discuss OUD and the opioid epidemic during every specialty rotation and in lectures: Use simulations: For example, during the third year, treat a patient experiencing opioid overdose. Medical schools should take advantage of already created online resources to teach about substance use disorder and opioid use disorder. Educating medical students and residents to incorporate family members in treatment: Give family members information on chronic pain, addiction, and refer them to support groups. From Dr. Pasarica: There also is a focus on interdisciplinary care in clerkships and in the student-run free clinic. It is important to teach interdisciplinary care in clerkships and volunteer settings. Work with counseling students and pharmacy students to screen and manage substance use disorder. Vis

MDedge Psychiatry live Twitter chat on the aftermath of losing a patient to suicide. April 24th, 6 - 7 p.m. EST. @MDedgePsych, #MDedgeChats Episode 54 Donald Black, MD, gives a masterclass lecture on behavioral addictions and Renee Kohanski talks about what normal is. Show Notes By Jacquiline Posada, MD. Gambling disorder (previously pathological gambling) is widespread, though not commonly assessed Patients may not volunteer information related to gambling unless asked, so questions about gambling should be included in routine questioning Assessment should include questions about legal and illegal gambling Explore extent: Ask about the level of financial burden; impact on home life, such as marital problems and divorce; legal complications like bankruptcy. Finally, ask about suicide risk related to gambling Treatment: There is strong data for SSRI medications and naltrexone for urges Therapy is more efficacious, such as CBT therapy and Gamblers Anonymous In certain states, such as Iowa, a person can ask for "self-exclusion," which is essentially banning oneself from a casino or lottery. Also, participation in gambling results in arrest Behavioral addictions: Behavior that is out of control and has qualities and consequences similar to drug and alcohol addiction Examples include gambling disorder, compulsive buying, compulsive sexual behaviors (hypersexuality), and Internet addiction Gambling disorder is similar enough to substance addictions that it is included in the DSM-5 in the "substance-related and addictive disorder" Addiction neurocircuitry active in these behavioral addictions: Dopamine driven in the nucleus accumbens Compulsive shopping: primarily a female disorder, onset in late 20s, with shopping and spending that are chronic and problematic CBT programs developed to target compulsive shopping, studies about medications for this disorder are mixed Compulsive sexual behavior: Primarily a male disorder affecting 5% of the population; onset late teens, early 20s. The addiction will combine conventional sexual behaviors taken to extremes often combined with an addiction to pornography This disorder will often overlap with an Internet addiction No evidence-based treatments exist, though CBT-driven models and 12-step programs exist SSRI or TCA antidepressants may be helpful in dampening sex drive Internet addiction has developed in our technologically enabled world; most psychiatrists have encountered this addiction. Most data come from Asia, where children are exposed to technology at an even earlier age than in the U.S. China has developed residential treatment programs involving individual and group therapies. References Black DW. Can J Psychiatry. 2013 May;58(5):249-51. "Behavioral addictions as a way to classify behaviors" Dell'Osso B et al. Eur Arch Psychiatry Clin Neurosci. 2006 Dec;256(8):464-75. "Epidemiologic and clinical updates on impulse control disorders: a critical review" National Council on Problem Gambling. State by state help for problem gambling Zajac K et al. Psychol Addict Behav. 2017 Dec;31(8):979-94. "Treatments for Internet gaming disorder and Internet addiction: A systematic review"

In this episode of the MDedge Psychcast, Sidney Zisook, MD, gives a Masterclass lecture on physician suicide and Dr. RK talks about what can be spoken into existence. If you have ideas, suggestions, questions for Dr. Norris or Dr. RK, or feedback for the show, please email us at [email protected]. You can also follow us on Twitter @MDedgePsych. Show NotesBy Jacqueline Posada, MD Introduction Suicide in general population increased by 30% since 1999. The suicide rate was 14 people in every 100,000 up from 10.5 people per 100,000 in 1999. 400 physicians die per year. However, there is not great data collection about profession-specific suicide Suicide is the leading cause of death in male residents and the 2nd leading cause of death in female residents This represents a serious loss of the medical profession as well as the thousands of patients who lose their physician as well Risks factors for physician suicide Psychological: Physicians tend be contentious, perfectionistic, and compulsive. They are able to cope with delayed gratification, and this may lead to a false sense of ability to cope with all obstacles, without failures. Medicine presents physicians with many obstacles such as the deaths of our patients and human frailty. Human imperfection and physician failures are juxtaposed against these traits listed above Historical and genetic risk factors: Past suicide attempt and presence of mood disorder Untreated depression is an especially high risk for physicians as they may leave their mental illness untreated due to stigma As of 2017, 32 of 48 state licensing boards continue to question doctors about their mental health history. There is increased risk of suicide with the presence of the long arm version of the serotonin transporter gene and history of childhood trauma Workplace risk factors: Physicians identify electronic medical records (EMR) and increased documentation demands as contributing to burnout and less job satisfaction EMR means that doctors feel like they spend more time with records than face to face with patients. With EMR there is less eye contact and direct connection with patients so it's hard to foster relationships Physicians feel the stress of increased use of technology and connectivity via cell phones and the need to "keep up" Change in culture As a profession we are starting to talk about physician suicide; acknowledgment of the issue can lead to change. ACGME and other workplaces are starting to integrate physician wellness into curriculums and culture. References: NCHS Data Brief No. 330. 2018 Nov."Suicide mortality in the United States, 1999-2017" Yaghmour, NA et al. Acad Med. 2017 Jul. 92(7):976-83."Causes of death of residents in ACGME-accredited programs 2000 through 2014" Implications for the learning environment" Babbott S et al. J Am Med Inform Assoc. 2014 Feb;21(e1):e100-61. Electronic medical records and physician stress in primary care: Results from the MEMO Study" Gold KJ et al.Gen Hosp Psychiatry. 2013 Jan-Feb;35(1):45-9. "Details on suicide among U.S. physicians: Data from the National Violent Death Reporting System" ACGME Symposium on Physician Well-Being

Charles Raison, MD, returns to the Psychcast this week to give a Masterclass lecture on the bidirectional relationship between inflammation and depression. There are links to relevant research below. Dr. Raison discusses incorporating the science of inflammation into the pharmacologic treatment of depression. He addresses research suggesting that while depression as a whole isn't an inflammatory condition, inflammation may be a depressive subtype. He also covered how inflammation might affect treatment. You can listen to Dr. Raison's take-home messages by skipping to (19:45). CHARLES RASION, M.D. Dr. Raison is Mary Sue and Mike Shannon Chair for Healthy Minds, Children, & Families and Professor of Human Development and Family Studies at the School of Human Ecology as well as Professor in the Department of Psychiatry at the University of Wisconsin-Madison School of Medicine and Public Health. Dr. Raison previously appeared on Psychast in a two-part lecture on ketamine. In episode 14, Dr. Raison talked on ketamine and PTSD and in episode 15, he talked about ketamine and depression. You can find those episodes by clicking the links below: Psychcast Episode 14: Charles Raison, MD, Ketamine & PTSD. Psychcast Episode 15: Charles Raison, MD, Ketamine & depression. Relevant Research: Use these links to find more on this Masterclass. Rong, Carola, et al. Predictors of Response to Ketamine in Treatment Resistant Major Depressive Disorder and Bipolar Disorder. Int J Environ Res Public Health. 2018 Apr 17:15(4): doi: 10.3390/ijerph15040771. https://www.ncbi.nlm.nih.gov/pubmed/29673146 Savitz, JB et al. Treatment of Bipolar Depression With Minocycline and/or aspirin: an adaptive, 2x2 double-blind, randomized, placebo-controlled, phase II-A clinical trial. Transl Psychiatry. 2018 Jan 24;8(1):27. doi: 10.1038/s41398-017-0073-7. https://www.ncbi.nlm.nih.gov/pubmed/29362444 Raison, et al. A Randomized Controlled Trial of the Tumor Necrosis Factor-alpha Antagonist Infliximab in Treatment Resistant Depression: Role of Baseline Inflammatory Biomarkers. JAMA Psychiatry. 2013 Jan;70(1):31-41. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4015348/ Miller AH, Raison CL. Are Anti-inflammatory Therapies Viable Treatments for Psychiatric Disorders?: Where the Rubber Meets the Road. JAMA Psychiatry. 2015 Jun; 72(6): 527–528. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542670/ Adzic M, et al. Therapeutic Strategies for Treatment of Inflammation-related Depression. Curr Neuropharmacol. 2018 Jan 30;16(2):176-209. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883379/

Episode 52: Tardive dyskinesia masterclass II Leslie Citrome, MD, MPH, returns to the MDedge Psychcast to lecture on Tardive Dyskinesia. In episode 52, where we caught up with Dr. Citrome at the Psychopharmacology Update meeting in Cincinnati, he discusses how to evaluate treatments for TD within the context of P values and effect sizes. Dr. Citrome joined Psychcast host Lorenzo Norris, MD, in the 13th edition of the Psychcast to talk about management of TD. In episode 13, Dr. Citrome said that you can start screening your patients in the waiting room as well as when they walk to the exam room. He and Dr. Norris also discussed movement conditions and the role antipsychotics might play in patients with TD. You can listen to the conversation between Dr. Norris and Dr. Citrome from July of 2018 by clicking here. TD has been a recent topic of interest at the Psychcast. In the 45th episode Johnathan Meyer, MD, noted that TD has been the bane of the psychiatrist's existence for the better part of a half-century. You can listen to our tardive dyskinesia Masterclass I by clicking here. We would love to hear from you. Contact the show if you have feedback, questions, or ideas for segments, guests or topics. Email us at [email protected] or Tweet at us @MDedgePsych.

Contact us: [email protected] Twitter: @mdedgepsych In this In this masterclass episode, Stephen Levine, MD, stops by to talk about how a person's sexuality flows throughout their lives. And later, Dr. RK discusses bipolar in part I of her new series.

Contact us: [email protected] Twitter: @mdedgepsych Masterclass Lecture: What's New in Alzheimer's Disease. Lecturer: George T. Grossberg, MD. He is the Samuel W. Fordyce professor and Director of Geriatric Psychiatry at St. Louis University School of Medicine. You can read more from Dr. Grossberg including video and writing, by clicking here. Dr. RK: Dr. RK's topic this week is the MDQ and how she uses in her practice. Learn more about the MDQ by clicking here.

Contact us: [email protected] Twitter: @mdedgepsych In this episode, Nicolas Badre, MD, talks with Lorenzo Norris, MD, about ways to approach reducing dosages or discontinuing medications that aren't beneficial. And Renee Kohanski, MD, ponders the privilege of being part of patients' gifted moments.

Contact us: [email protected] Twitter: @mdedgepsych In this episode, Marlene Freeman, MD, discusses the latest studies on the risks of treating, and not treating, women with bipolar disorder during pregnancy. And Renee Kohanski, MD, returns with part two of her feature on eating her own words.

Contact us: [email protected]: @mdedgepsych Richard Balon, MD, is professor of clinical psychiatry and anesthesiology and associate chair of education at Wayne State University in Detroit. In this masterclass episode of psychcast, he lectures on the recent increase in the price of drugs.

Contact us: [email protected] In this episode, Igor Galynker, MD, stops by to talk about suicide with Lorenzo Norris, MD. One major topic of conversation centers around the suicide-specific diagnosis. And later, Renee Kohanski, MD, talks about the importance of communication. You can listen to Dr. Galynker's first appearance on the Psychcast here (http://bit.ly/2LGiRwn).

Contact us: [email protected] Twitter: @mdedgepsych

Contact us: [email protected] Twitter: @MDedgePsych Johnathan Meyer, MD, notes that TD has been the bane of the psychiatrist's existence for the better part of a half century. In this Mastercalss edition, Dr. Meyer talks about this disease and analyzes where the field is today.

Contact us: [email protected] Twitter: @MDedgePsych Today, Dr. Gail Erlick Robinson (http://bit.ly/2AZXZx1) joins Dr. Lorenzo Norris (http://bit.ly/2z99Yrr) from the 2018 meeting for the group for the advancement of psychiatry or GAP (http://bit.ly/2FRn9Bj) to discuss violence against women.

Contact us: [email protected] More from the MDedge Psychcast: Resilience Part 2: People and relationships http://bit.ly/2McPfs2 Suicidality and its impact on physicians http://bit.ly/2TOAA8Q Antidepressants in children: Jeffrey Strawn http://bit.ly/2srA1pR In this episode, Caroline Bonham, MD (http://bit.ly/2RMT5x8), and Avi Kriechman, MD (http://bit.ly/2FtFZPy), join Psychcast host Lorenzo Norris, MD, via phone to discuss enhancing resilience in rural communities. Overall life expectancy decreased from 78.7 years to 78.6 years from 2016 to 2017. Researchers from the CDC noted that along with drug overdose deaths, suicide also drove the average lifespan over that time (http://bit.ly/2APzJxB). While suicide is an all-encompassing issue, suicide in rural communities presents unique challenges. Dr. Bonham is Vice Chair in the Department of Psychiatry and Behavioral Sciences at the University of New Mexico School of Medicine and Dr. Kriechman is assistant professor in the same department and a child psychiatrist with an aim of youth suicide prevention.

If you would like to respond to any of Dr. Nasrallah's comments in this masterclass, email us at [email protected]. In this edition, the inaugural guest on the MDedge Psychcast, Henry Nasrallah, MD (http://bit.ly/2LZX7wC), returns to lecture on first-episode psychosis. Dr. Nasrallah is Editor-in-Chief of Current Psychiatry and is the Sydney W Souers Endowed Chair and professor and charming of the department of Neurology an Psychiatry at the University of Cincinnati College of Medicine. You can read more work from Dr. Nasrallah here: http://bit.ly/2Qx8SLP

In this masterclass edition, Joseph Goldberg, MD (http://bit.ly/2C7eWFR), gives a talk on the first episode of major depression. Dr. Goldberg is a clinical professor of psychiatry at the Ichan school of medicine at Mount Sinai in New York City.

In this episode, we revisit some of our best content on substance use disorders.

Special edition: the best of psychopharmacology. In this episode the Psychcast looks back at this year in psychopharmacology: Conversation: Anxiety + Comorbid AHDH with Jeffrey Strawn. MASTERCLASS: Ketamine by Charles Raison (07:55). MASTERCLASS: Stimulants by Michael Gitlin (16:18). Conversation: benzodiazapines Richard Balon (21:50).

In this episode, Roberto Lewis-Fernandez (http://bit.ly/2RRTpYe), MD, joins MDedge Psychiatry Editor-in-Chief, Lorenzo Norris, MD, to talk about how cultural assessments work and why they're imperative to person-centered care. More from Dr. Lewis-Fernandez, Curbside Consult: Chinese American man with high risk of psychosis (http://bit.ly/2BaCpVP).

Write to Dr. Norris and the show: [email protected] re Psychcast. In this episode, Jack Drescher, MD (http://bit.ly/2QawNWf), joins Lorenzo Norris, MD, to talk about issues surrounding sexual conversion therapy. More from this episode: Dr. Dresher bio/website http://bit.ly/2QawNWf Dr. Drescher Book: Sexual Conversion Therapy: Ethical, Clinical, and Research Perspectives https://amzn.to/2FVNDmH Dr. Drescher research paper The Growing Regulation of Conversion Therapy. J Med Regul, 2016 102(2). 7-12 http://bit.ly/2Edx0kL

From GAP 2018, Lorenzo Norris, MD (http://bit.ly/2z99Yrr), welcome Ashwin Patkar, MD (http://bit.ly/2P6jBvQ), to discuss the opioid epidemic and how North Carolina is approaching it systemically. And later, Dr. RK knows that some of your patients are blue this time of year, she joins us to talk about what that is and what you can do about it. More from Dr. Patkar:'Opioid abuse and overdose: Keep your patients safe Identify patients at risk, ensure an accurate evaluation, and treat the underlying disorder' (http://bit.ly/2P380xT)

In this episode of the MDedge Psychcast, Jack Rozel, MD, comes back to the show to discuss how things are in Pittsburgh following the shooting at the Tree of Life Synagogue.