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MDedge Psychcast

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MDedge Psychcast is a weekly podcast from MDedge Psychiatry, online home of Clinical Psychiatry News and Current Psychiatry. Hosted by Editor in Chief Lorenzo Norris, MD, Psychcast features psychiatric clinicians discussing the issues and concerns that most affect their specialty. The information in this podcast is provided for informational and educational purposes only.
101 Episodes
Charles L. Raison, MD, returns to the Psychcast to conduct a Masterclass on psychedelics for patients with major depressive disorder. Dr. Raison, professor of psychiatry at the University of Wisconsin–Madison, previously conducted a Masterclass on the risks and benefits of antidepressants. He disclosed that he is director of translational research at the Usona Institute, also in Madison. Later, Renee Kohanski, MD, raises questions about the felony child abuse case of pediatric emergency department doctor John Cox. Takeaway points Psychedelics are a range of compounds that share a common mechanism as agonists at the postsynaptic 5-HT2A serotonin receptor. Psychedelic agents have a novel therapeutic quality. Studies suggest that a few or even one exposure to a psychedelic compound, which has a short-term biological effect, leads to long-lasting therapeutic effect, such as remission of mood disorder or change in personality characteristics. The clinical outcomes are mediated by the intensity of the psychedelic experience. A psychedelic experience is characterized by profound, rapid alterations in what is seen, sensed, felt, and thought. It often leads to personal growth with experiences of transcendence. Subjects in trials often report a “mystical experience” they describe as a sense of unity with the universe and understanding of one’s deeper purpose. Psychedelic experiences also are characterized by a difficulty in describing them with words. Because psychedelics are illegal substances, the traditional route of pharmaceutical companies’ funding the research for clinical trials is not available. Organizations such as Usona Institute and MAPS (Multidisciplinary Association for Psychedelic Studies) are leading the way. The Food and Drug Administration has granted psilocybin a “breakthrough therapy designation” for the treatment of major depressive disorder. Summary Psilocybin, lysergic acid diethylamide (LSD), mescaline, ayahuasca (active ingredient: N,N-dimethyltryptamine [DMT]), and 3,4-methylendioxy-methamphetamine (MDMA) are all classified as psychedelics. Psychedelics have been used for thousands of years for spiritual ceremonies. Psychedelics came to the attention of medicine and science after 1943 when Albert Hofmann, PhD, a chemist at a Sandoz Lab in Basel, Switzerland, synthesized LSD and accidentally ingested it, serendipitously identifying its mind-altering properties.  Until 1970, psychedelics were widely used in clinical research, and more than 1,000 academic papers about their use were published. For example, psychedelics were used as a model for schizophrenia and helped identify the role of serotonin in psychosis. They also were studied to treat addiction and as a treatment for existential anxiety in cancer. In 1971, psychedelics were declared illegal under the U.N. Convention on Psychotropic Substances. Researchers returned to psychedelics in the 2000s, examining a variety of uses, including the capability to reliably induce psychedelic experience in healthy normal volunteers (no previous psychiatric diagnosis) and promote emotional well-being in healthy normal volunteers. The role of psychedelics as medicine are once again being studied in a variety of contexts, such as mood disorders, PTSD, addiction, and phase-of-life problems. Most notable from the research is the capability of psychedelic compounds to induce long-lasting effects on personality, mood disorders, and PTSD after one or a few ingestions. What is remarkable is how the therapeutic effect remains long after the biological presence of the compound is gone from the body. The clinical outcomes are mediated by the intensity of the psychedelic experience. The Usona Institute, a medical research organization, started as a nonprofit to advance the research into psychedelics needed for the FDA to approve psychedelics as a treatment. Because psychedelics are still illegal, the traditional route of pharmaceutical companies funding this type of research is not available. The FDA has granted psilocybin a “breakthrough therapy designation” for the treatment of major depressive disorder. The breakthrough therapy designation “indicates that the drug may demonstrate substantial improvement on a clinically significant endpoint(s) over available therapies.” The breakthrough therapy designation is for major depressive disorder, not for treatment-resistant depression, suggesting that the FDA recognizes the shortcomings of current treatments for depression. References Johnson MW, Griffiths RR. Potential therapeutic effects of psilocybin. Neurotherapeutics. 2017 Jul;14(3):734-40. Griffiths RR et al. Psilocybin-occasioned mystical-type experience in combination with meditation and other spiritual practices produces enduring positive changes in psychological functioning in trait measures of prosocial attitudes and behaviors. J Psychopharmacol. 2018 Jan;32(1):49-69. Johnson MW et al.  Long-term follow-up of psilocybin-facilitated smoking cessation. Am J Drug Alcohol Abuse. 2017 Jan;43(1):55-60. Griffiths RR et al. Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. J Psychopharmacol. 2016 Dec;30(12):1181-97. Rozzo M. Book review: “‘How to Change Your Mind.” Columbia Magazine. 2018 Fall. *  *  *   For more MDedge Podcasts, go to Email the show:
William Lynes, MD, joins guest host Michael F. Myers, MD, to discuss his struggles with medical and psychiatric hardships, his suicidality, and the eventual suicide attempt that changed his life. Dr. Myers is professor of clinical psychiatry, State University of New York, Brooklyn. Dr. Lynes, a retired urologist, author, and speaker/advocate on physician burnout and suicide, divides his professional life into two distinct eras: 1987-1998, during which he had a successful practice and happy life, and after 1998, when he spiraled downward medically and psychiatrically. After meeting another physician with a similar experience who had published her story of burnout and mental health struggles in 2015, Dr. Lynes decided to speak out. Eventually, he published an essay about his experience in the Annals of Internal Medicine. Take-home points Being open with close colleagues or supervisors about mental health struggles and/or burnout can provide a much-needed lifeline to struggling physicians. Addressing burnout and mental health diagnoses of physicians requires medical groups and institutions to provide access to psychiatric treatment from clinicians outside of the professional network in which the physician practices. Practicing medicine can be a 24/7 profession, and being “on” all the time can contribute to burnout. Lifestyle choices such as exercise, hobbies, family, and spirituality are all helpful outlets to address the constancy of practicing medicine. Giving in to the notion that you can treat yourself is not a good idea. Decreasing the stigma tied to mental illness can be helped by people with lived experience, such as Dr. Lynes. *  *  *   References Lynes W. The last day. Ann Intern Med. 2016 May 3;164(9):631. Myers MF and Freeland A. The mentally ill physician: Issues in assessment, treatment and advocacy. Can J Psychiatry. 2019 Dec 6;64(12):823-37. Forbes MP et al. Optimizing the treatment of doctors with mental illness. Aust NZ Psychiatry. 2019 Feb;53(2):106-9. Myers MF. “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.” 2017 Feb 14. (Self-published). Bird JL. “Using Narrative Writing to Enhance Healing.” Medical Information Science Reference, 2019. *  *  *   For more MDedge Podcasts, go to Email the show:
George T. Grossberg, MD, conducts a Masterclass on treating mood disorders in geriatric patients from the CP/AACP Psychiatry Update 2019 meeting in Las Vegas. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Grossberg is the Samuel W. Fordyce professor and director of geriatric psychiatry at St. Louis University School of Medicine in St. Louis. Later, Renee Kohanski, MD, discusses the first thing psychiatrists can do for patients. Take-home points from Dr. Grossberg: The prevalence of major depressive disorder among older adults who reside in the community is similar to that of the general population (6%). In nursing homes, the prevalence of significant clinical depression is close to 25%. Depression in older adults in long-term care facilities is underrecognized and undertreated. Risk factors for depression include advanced age (80-90 years), loneliness and lack of social support, painful conditions, frailty, and medical comorbidities. Medications that are central nervous system depressants, such as opiates and benzodiazepines, also can contribute to depression. Alcohol can also be a depressant. Depression in the face of cognitive impairment is extremely common and can even speed cognitive decline. Apathy, defined as lack of motivation, can look like depression. However, depression will have amotivation coupled with vegetative symptoms, such as disrupted sleep and loss of appetite, and mood changes, such as sadness and tearfulness. Low-dose stimulants are effective for apathy, but antidepressants are not; so, it’s important to differentiate the two. Undiagnosed and untreated depression contributes to a significant degree of morbidity because it can slow recovery in rehabilitative settings and impair adherence to essential medications. Treating depression also can improve pain control by making it more tolerable as a somatic symptom. Individuals older than 65 years account for more than 20% of all completed suicides in the United States. Psychological autopsy studies suggest that many of these individuals had undiagnosed depression. Clinicians should not shy away from treating geriatric patients for depression with medication and interventions such as cognitive-behavioral therapy. With pharmacotherapy, start low, go slow, and titrate up to a therapeutic dose. Older adults may take longer, up to 8-12 weeks, to respond to SSRIs, so it’s imperative not to give up on medications too soon. Electroconvulsive therapy is the most effective treatment for severe depression in geriatric patients. Some consider advanced age an indication for ECT; medical comorbidities are not a contraindication for ECT. It is unclear how effective ketamine is in older patients, but it deserves consideration. Prompt diagnosis and treatment of mood disorders is paramount in patients of advanced age and those living in long-term care facilities. Treating depression in the older patient also improves the quality of life for caregivers and professional staff. References Birer RB et al. Depression in later life: A diagnostic and therapeutic challenge.  Am Fam Physician. 2004 May 15;69(10):2375-82. Sjoberg L et al. Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults.  J Affect Disord. 2017 Oct 15;221:123-31. Grossberg GT et al. Rapid depression assessment in geriatric patients. Clin Geriatr Med. 2017 Aug;33(3):383-91. *** For more MDedge podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych
In this, the 100th episode of Psychcast, Nick Andrews talks with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about the January front-page article in Clinical Psychiatry News that featured Matthew E. Seaman, MD, an emergency physician with depression who took his own life. The article describes the Dr. Seaman faced. Later, Christine B.L. Adams, MD, a psychiatrist who practices in Louisville, Ky., discusses her book, “Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships” (Santa Barbara: Praeger, 2018), with Dr. Norris. Take-home points from Dr. Adams Children learn emotional patterns in families. These behaviors get reinforced. As children form dating relationships, for example, those patterns continue to be reinforced. People may go on autopilot and have knee-jerk reactions in response to people, which allows them to react emotionally without thinking about what’s necessary for each person. Long-term dynamic psychotherapy can help patients observe what they are doing in relationships and what others are doing. Ultimately, patients can be taught to look at and uncover their automatic responses. Once these patterns are uncovered and moved from the emotional realm to the intellectual realm, they can be interrupted. Genesis and development of the book’s principles Homer B. Martin, MD, a Louisville, Ky.–based adult psychiatrist who worked with Dr. Adams for 30 years, developed the original premise of the book. When he died, his wife asked Dr. Adams, who was his protégé, to finish it. The book is based on the observations made by Dr. Martin during his 40 years of conducting psychotherapy with patients. It is designed to be accessible both to psychiatric trainees as well as to general readers. Dr. Adams started teaching the concepts in the book during a 6-week university class to determine whether the ideas were digestible and useful. Mainstream movies were used to help people learn to observe and identify roles that were emotionally conditioned and to determine how a character’s change in behavior would change the other person. Movies that can be used to help people identify problematic patterns include “Ordinary People,” “Gran Torino,” “The Remains of the Day,” “The Door in the Floor,” and “When Harry Met Sally.” References Yazici E et al. Use of movies for group therapy of psychiatric inpatients: Theory and practice. Int J Group Psychother. 2014 Apr;64(2):254-70. Ross J. You and me: Investigating the role of self-evaluative emotion in preschool prosociality. J Exp Child Psychol. 2017 Mar;155:67-83. Werner AM et al. The clinical trait self-criticism and its relation to psychopathology: A systematic review – Update. J Affect Disord. 2019 Mar;246:530-47. *  *  *   For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
In episode 99 of the Psychcast, Frank Yeomans, MD, PhD, clinical associate professor of psychiatry at the Weill Medical College of Cornell University, Ithaca, N.Y., spoke with Dr. Norris at the Group for the Advancement of Psychiatry (GAP) fall 2019 meeting about treating patients with personality disorders. Characteristics of personality disorders A personality disorder affects the quality of a person’s experience and his or her ability to deal with challenges in life, including comorbid psychiatric disorders. A personality disorder is not based on symptoms alone and determines how people engage with their environment; it is a part of the biological side of psychiatry. The DSM traditionally relied on a traits-based definition of personality disorders. Yet, in the “emerging measures and models” section, the DSM-5 describes a dimensional/categorical model of personality disorders, which looks at personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. This harkens back to the concept of borderline personality organization as outlined by Otto F. Kernberg, MD. The dimensional model suggests that individuals with personality disorders benefit from behavioral therapies, such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT), to treat problematic traits. Exploratory and insight-focused psychotherapies can help individuals understand their personality organization. Ideally, the treatments for personality disorders would be sequenced, starting with CBT or DBT and transitioning into exploratory therapy. Much like borderline personality disorder, at the core of narcissistic personality disorder is a fragmented sense of self, but in the latter disorder, a self-centered narrative exists that is coherent to the person but does not support reality. If mental health is defined as the ability to adapt to the different circumstances of life, people with narcissism cannot adapt and instead, develop a grandiose narrative to soothe the fragmented self. Therapeutic interventions for narcissism focus on disrupting the narrative in a gentle way that allows patients to understand the model in which they currently experience the world and then reconstitute an adaptive narrative. An effective treatment approach is psychodynamic therapy, with a focus on a treatment contract and specific, explicitly agreed-upon goals. Try to focus more on the interaction with the patient than on the narrative content of the session. The therapy must focused on how the patient acts in therapy, and their adaptations and reactions, because these are the actions that negatively affect their relationships and daily lives. The biological part of a person is processed at the psychological level, so psychiatrists must be interested in psychological aspects of treatment. References Sharp C et al. The structure of personality pathology: Both general ('G') and specific ('S') factors? Abnorm Psychol. 2015 May;124(2):387-98. Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry. 2009 May 1;166(5):530-9. Caligor E et al. Narcissistic personality disorder: Diagnostic and clinical challenges. Am J Psychiatry. 2015 May;172(5):415-22. Morey LC et al. Personality disorders in DSM-5: Emerging research on the alternative model. Curr Psychiatry Rep. 2015 Apr;17(4):558. *  *  *  For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych    
Alberto J. Espay, MD, MSc, conducts a Masterclass lecture on treating patients with Parkinson’s-related psychosis from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Espay is professor of neurology at the University of Cincinnati. He also serves as director of the James J. and Joan A. Gardner Family Center Research Chair for Parkinson’s Disease and Movement Disorders. And later, in the “Dr. RK” segment, Renee Kohanski, MD, asks you to think about some of the complex issues tied to getting treatment for people who are both homeless and have serious mental illness.  *  *  *  Treatment of Parkinson’s-related psychosis  Psychosis related to Parkinson’s disease (PD) is a common reason for hospitalization, institutionalization, and decline of patients with PD. The diagnosis of PD is required before the development of psychosis to diagnose patients with Parkinson's-related psychosis. Parkinsonism that appears after development of psychosis is Lewy body dementia. Many factors influence the development of psychosis in PD. Extrinsic factors include medical illnesses or metabolic derangement causing delirium with psychosis; nonessential dopaminergic medications such as ropinirole and selegiline; anticholinergic medications such as benztropine, amantadine, and bladder antispasmodics; and insomnia. The last resort for treatment of psychosis is levodopa because patients will experience motoric decline and loss of functioning. There are several mechanisms for psychosis to occur via the dopaminergic, serotonergic, and glutamatergic pathways; thus, three neurotransmitters – serotonin, dopamine, and glutamate – can be manipulated to treat psychosis. Quetiapine, clozapine, and pimavanserin are the three antipsychotics safe for use in Parkinson’s disease. Clozapine is infrequently used, because of the risk of neutropenia and required blood work monitoring, but evidence shows that the benefits usually outweigh the risks of motor decline. Quetiapine is commonly used, because it has a favorable effect on sleep and psychosis, but it negatively affects the movement disorder of Parkinson's disease. Pimavanserin (Nuplazid), the only medication FDA approved for hallucinations and delusions associated with psychosis in Parkinson’s disease, is highly selective for the 5-HT2A receptor as both an inverse agonist and antagonist. Primary adverse effects are peripheral edema and confusion, but overall the adverse effects profile is similar to that of placebo. In the pimavanserin clinical trials, a subset of patients worsened and experienced more visual hallucinations. In addition, pimavanserin can prolong the QT interval, so patients taking other QT-prolonging medications or who have cardiac comorbidities should be monitored with an EKG. Post hoc data analysis from as pivotal phase 3 study suggests that patients with cognitive impairment and dementia may receive more benefit from pimavanserin.   *  *  *  References Cruz MP. Pimavanserin (Nuplazid): A treatment for hallucinations and delusions associated with Parkinson’s disease. P T. 2017 Jun;42(6):368-71. Cummings J et al. Pimavanserin: Potential treatment for dementia-related psychosis. J Prev Alzheimers Dis. 2018;5(4):253-8. Huot P. 5HT2A receptors and Parkinson’s disease psychosis: A pharmacological discussion. Neurodegenerative Disease Management. 2018 Nov 19. doi: 10.2217/nmt-2018-0039.  *  *  *  For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
Michael A. Norko, MD, professor of psychiatry at Yale University in New Haven, Conn., spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about incorporating patients’ spiritual and religious histories into psychiatric evaluations. Dr. Norko, lead author of a paper exploring whether religion is protective against suicide, sat down with Dr. Norris at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP.   Evidence, questions to consider about religion and spirituality Various spiritual and religious factors are linked to decreased rates of suicide behaviors and attempts, including weekly attendance to worship services, personal beliefs about the preciousness of life, and commitment to a faith practice. Which specific parts of religious and spirituality are protective? Are the protective factors the social connection or the spiritual connection alone? Those who attend worship services weekly are at lower risk of suicide. It’s unclear whether weekly attendance is a proxy for the social connectedness or for the level of internalization of the religious beliefs. Commitment to a faith is measured by a consistent and strong belief in the faith tradition. Just because someone says they belong to a faith tradition does not automatically mean a person is at lower risk of suicide. Strong alignment with the faith also is protective. Alignment is different from commitment, because if patients are doubting or their personal beliefs conflict with long-held religious traditions, this can increase patients’ suicide risk.  Questions to ask about spirituality and religion in clinical practice A spiritual and religious history is essential to a psychiatric evaluation, because asking about religion lets the patient know that this is a welcome topic. Examples of questions a clinician can ask include: “Is there any faith tradition that you belong to? How important is your faith or beliefs? Is there anything about your religious beliefs you think are important to your mental health treatment?”  Difficult areas to navigate with religion and spirituality Lack of expertise or personal experience with religion can be a barrier. It is important to remember that patients usually welcome curiosity about their religious beliefs and emotional lives. Clinicians need not be experts in religion, but they can be alert to the salient values and notice whether the person is struggling with certain beliefs. Clinicians also can encourage patients to talk to their clergy. When someone asks a clinician, “What is your faith practice?” this can be approached as an informed consent question. The clinician can ask how talking about their own beliefs or faith practices will deepen and help the therapeutic work of the patient. If a person is feeling let down by a certain failing of their religious community, therapy is a good place to explore what strengths and succor they had received from their religion. Therapy also can be used to guide patients toward additional places, or even substitutes, to meet their needs. Understanding patients’ faith background and beliefs can help clinicians reframe certain crises, especially if the psychiatrist and therapist have talked discussed those crises with patients over time. It’s more useful to understand patients’ faith before the crisis, because grasping for a spiritual or religious answer at the last moment can feel inauthentic.  References  Norko et al. Can religion protect against suicide? J Nerv Ment Dis. 2017. Jan;205(1):9-14. Kruizinga R et al. Toward a fully-fledged integration of spiritual care and medical care. J Pain Symptom Manage. 2018 Mar;55(3):1035-40.   Thomas LP et al. Meaning-centered psychotherapy: A form of psychotherapy for patients with cancer. Curr Psychiatry Rep. 2014 Oct;16(10):488. Lawrence RE et al. Religion and suicide risk: A systematic review. Arch Suicide Res. 2016;20(1):1-21. D’Souza R, George K. Spirituality, religion and psychiatry: its application to clinical practice. Australas Psychiatry. 2006 Dec;14(4):408-12. FICA Spiritual History Tool:, which is based on Puchalski C and Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000 Spring;3(1):129-37. George Washington University Institute for Spirituality and Health (GWISH):
Lorenzo Norris, MD, and Roger McIntyre, MD, talk about obesity, inflammation, and mental illness. The conversation, which originally dropped a few months ago, took place at the Focus on Neuropsychiatry 2019 meeting. The meeting was sponsored by Current Psychiatry and Global Academy for Medical Education. The original podcast included robust Show Notes by Jacqueline Posada, MD. Also, you can watch the conversation between Dr. Norris and Dr. McIntyre on video or on YouTube. Later, Renee Kohanski, MD, talks about different ways to think about resolutions and behavioral change. For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych
In this episode of the MDedge Psychcast, we revisit an interview that Lorenzo Norris, MD, MDedge Psychiatry editor in chief, conducted earlier this year by phone with two psychiatrists working in New Mexico. Dr. Norris spoke with Caroline Bonham, MD, and Avi Kriechman, MD, about enhancing resilience in rural communities. Dr. Bonham is vice chair in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is assistant professor in that department, and a pediatrician who works on youth suicide prevention and school mental health.   Understanding risks of suicide in rural communities Nationally, suicide rates have been going up across the United States, including in rural communities. Paucity of mental health clinicians supporting youth and their families has implications for youth suicide. Impact of structural poverty and the opioid epidemic also have implications for these rising rates.  Identifying resources within small, rural communities Communities have resources that are not tapped into enough by clinicians, such as churches, teachers, and community health workers. Recent studies show that most communities have members who know people at risk and want to help. It is important for clinicians to think outside of the box so that they help facilitate the use of natural resources/strengths that exist within small communities, such as food pantries that operate out of mental health centers, spiritual organizations, and aftercare programs in schools.  Building resilience among individuals The literature shows that engaging people in a collaborative, transparent process of care is effective. If community members who do not have problems, such as suicidality, physical ailments, or a severe mental illness, are taught to reach out, destigmatize, and facilitate treatment, the mental health outcomes of patients are better. Concrete, feasible intervention would be to work with gun store owners about the risk factors for suicide, how to encourage people to seek help. Some police departments provide education about the safe storage of firearms. References Curtin SC and Heron M. Death rates due to suicide and homicide among persons aged 10-24: United States, 2000-2017. NCHS Data Brief. 2019 Oct;(352):1-8. Altschul DB et al. State legislative approach to enumerating behavioral health workforce shortages: Lessons learned in New Mexico. Am J Prev Med. 2018 Jun;54(6 suppl 3):S220-9. Bonham C et al. Training psychiatrists for rural practice: A 20-year follow-up. Acad Psychiatry. 2014 Oct;38(5):623-6. Kriechman A et al. Expanding the vision: The strength-based, community-oriented child and adolescent psychiatrist working in schools. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):149-62. For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych
Ruta Nonacs, MD, PhD, conducts a Masterclass lecture on treating women with postpartum depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Nonacs is a staff psychiatrist with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital in Boston.  *  *  *   Help us make this podcast better! Please take this short listener survey: *  *  *   Features of postpartum depression  Postpartum depression (PPD) affects 10%-15% of women after delivery. For many women, their depression starts in the third trimester and worsens after delivery. Unique symptoms of PPD include difficulties bonding with the baby, feeling like an inadequate mother, and experiencing severe sleep disturbance with anxiety and edginess. In a common scenario, the mother will not be able to sleep at night, though her baby is sleeping well. Anxiety is a common comorbidity, especially obsessive thoughts about the baby’s safety. Treatment of PPD Treatment in this population is complicated by many demands placed on a mother as the primary caregiver of an infant. The medication chosen must target depression and anxiety, improve sleep, yet not be too sedating. The concentration of antidepressants in breast milk is low, but many women will defer treatment for their depression until they’ve stopped breastfeeding. Treatment of mild PPD includes recruiting more support to help the mother with care of the infant and psychotherapy to identify stressors and coping skills. In moderate to severe PPD, antidepressants are needed. Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are the preferred treatments, and studies support the use of sertraline, fluoxetine, paroxetine, and venlafaxine at their standard dosages. SSRIs and SNRIs are compatible with breastfeeding, because the medications are detected in the breast milk at very low levels. Brexanolone (Zulresso) is the only Food and Drug Administration–approved medication for postpartum depression. It is a neurosteroid and derivative of allopregnanolone, which is a positive allosteric modulator of the gamma-aminobutyric acid receptor. Brexanolone has low oral bioavailability and is administered only as a 60-hour infusion in a certified medical setting with continuous monitoring. The trials for brexanolone included women with moderate to severe PPD, and Hamilton Depression Rating Scale scores (HAM-D) scores ranging from 20 to 25. After the 60-hour infusion, 45% of the subjects with severe PPD in the brexanolone group achieved remission by the end of treatment, compared with 23% in the placebo group. Women retained the antidepressant effect at the 30-day follow-up. The results in the moderate PPD group were not as impressive; these women had a decrease in their depression HAM-D scores, but the antidepressant effect did not continue to the 30-day follow-up. The FDA approval came with a Risk Evaluation Mitigation Strategy in place.   Currently, approximately 100 sites are ready to administer brexanolone; however, some obstacles remain: Obstacles to using brexanolone The medication costs more than $30,000 per infusion, and it is uncertain how much insurance will cover. Since brexanolone is administered in hospital settings, women must be separated from their children for several days. Breastfeeding must be stopped while women are on the medication because of the lack of data about excretion in breast milk. Brexanolone is labeled as a Schedule IV medication because it has a similar mechanism of action to midazolam and diazepam. Likelihood of diversion is low, but some women with substance abuse histories might be concerned about this treatment.  References Leader LD et al. Brexanolone for postpartum depression: Clinical evidence and practical considerations. Pharmacotherapy. 2019 Nov;39(11):1105-12. Meltzer-Brody S et al. Brexanolone injection in postpartum depression: Two multicenter, double-blind, randomized, placebo-controlled, phase 3 trials. Lancet. 2018 Sep 22;392(10152):1058-70. Nonacs R. A Deeper Shade of Blue: A Woman’s Guide to Recognizing and Treating Depression in Her Childbearing Years. New York, NY: Simon & Schuster; 2006. Massachusetts General Hospital Center for Women’s Mental Health. National Institutes of Health. Drugs and Lactation Database (LactMed). *  *  *   For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
 Roberto Lewis-Fernández, MD, returns to the MDedge Psychcast, this time to discuss ways to approach pharmacotherapy for Latino patients with depression. Previously, on episode 36 of the Psychcast, Dr. Lewis-Fernández discussed the role of cultural assessments in providing person-centered mental health care. Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University and director of the New York state Center of Excellence for Cultural Competence and the Hispanic Treatment Program at the New York Psychiatric Institute, spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP. And later, in the “Dr. RK” segment, Renee Kohanski, MD, asks whether some euphemisms that are becoming more common in society keep us from finding real solutions to problems. *  *  *   Help us make this podcast better! Please take this short listener survey: *  *  *   How Latino patients typically think of illness and medications Commonly, patients of Latino descent seek mental health treatment after trying other interventions, such as talking with family, clergy, and primary care clinicians. Latino patients, similar to other patient populations, sometimes present with ambivalence about medications and concerns that the medications might be “fairly strong” or addictive. The need to take medications is seen as an admission of sorts that the presenting problem of depression or anxiety is serious. Specifically, Latino patients are concerned about medications and risk of physical and psychological addiction and being reliant on a crutch. For example, a Latino patient might worry that by taking an antidepressant medication, they will lose their innate ability to improve on their own. This belief plays out when Latino patients stop medication prematurely, just as it begins to be effective, in order to “poner de mi parte,” which translates to “do my share.” The Latino culture puts weight on self-reliance. Latino patients often look for flexibility in medications and express concern about their effect on the body. For example, some patients might want to take medication only on days in which they feel sick. Others might ask for days off from the medication to ensure that the body does not weaken from being dependent on medications. Natural remedies often are favored by Latino patients. In some Latino communities, there might be natural pharmacies and “botanicas,” which provide herbal and vitamin remedies. Natural medicines are viewed as “gentle” and more in line with what the body needs. Psychotherapy for the treatment of mild depression often is favored by patients who want to use therapy before medications. Latino patients usually prefer more "advice"-driven psychotherapy that focuses on problem solving. Possible structural barriers to treating Latino patients Common structural barriers to accessing care include limited time to make appointments because of work and family obligations as well as a fragmented health care system with ever changing clinicians. Stigma and concerns about “harm to the body” can prove to be barriers.  How clinicians might work with Latino patients Be open to being flexible to patients’ requests, such as the desire to perhaps skip a day each week or even stop medications. Exerting clinical authority based on biological understanding of the medication and diagnosis can backfire and can result in patients stopping the medication altogether. Understand different conceptions in the Latino community about how and when emotions should be expressed. The “ataque de nervios” (“attack of nerves”) presented in the DSM-5 as a culture-bound syndrome is indicative of the Latino attitude that emotions are meant to be expressed but also controlled. So “un ataque de nervios” represents a situation that is so overwhelming that emotions take over, such as an attack and cannot be controlled. Know that warmth is more important than expertise in the eyes of some Latino patients. References Vargas SM et al. Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy. Transcult Psychiatry. 2015 Apr;52(2):244-73. Lewis-Fernández R et al. Impact of motivational pharmacotherapy on treatment retention among depressed Latinos. Psychiatry. 2013 Fall; 76(3):210-2. Moitra E et al. Examination of ataque de nervios and ataque de nervios like events in a diverse sample of adults with anxiety disorders. Depress Anxiety. 2018 Dec;35(12):1190-7. *  *  *   For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
Martha Sajatovic, MD, conducts a Masterclass lecture on older-age bipolar disorder from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Sajatovic is professor of psychiatry and of neurology at Case Western Reserve University in Cleveland. She also directs the Neurological and Behavioral Outcomes Research Center at University Hospitals Cleveland Medical Center. *  *  *  Help us make this podcast better! Please take this short listener survey: *  *  *  Conceptualizing OABD Older–age bipolar disorder (OABD), defined as a person aged 60 years or older with bipolar disorder, makes up one-quarter of bipolar patients. It is a heterogeneous population that includes early- and late-onset disease. Late onset is diagnosed when a person has a manic or hypomanic episode at or after the age of 50 years. Bipolar depression in later life has long been seen as a “special population,” and the treatment has been extrapolated from larger clinical trials of younger patients. Late–onset bipolar disorder usually has attenuated manic episodes and depressive episodes are prolonged and severe. In OABD, the patients are more likely to have multiple morbidities, which makes medication management more complex. People with bipolar disorder lose 1-2 decades of life, compared with the general population. No medications are specifically approved by the Food and Drug Administration for bipolar disorder or bipolar depression in older adults. However, the treatment follows general geriatric psychiatry principles: Start low and go slow.  International guidelines on treating bipolar disorder Starting low means using half or even less of the recommended dose that a clinician would use in mixed-aged populations. Titrate slowly to allow the person time to acclimate to side effects that usually resolve. Bipolar disorder is a chronic disease, so medication adherence is paramount. Adherence can be jeopardized when a person experiences excessive side effects from the beginning of treatment. First-line treatment for bipolar depression in OABD include lurasidone (Latuda) or quetiapine (Seroquel) with low dosing and slow titration. This recommendation is supported by data from a post hoc analysis of the clinical trial data of lurasidone for bipolar depression. Lithium is also recommended and underused. The level should be lower for OABD; an appropriate target for older adults with bipolar disorder is 0.4-0.8 mEq/L, especially in people who are older and frailer. Lamotrigine (Lamictal) also is helpful and fairly well tolerated. Clinicians need to be attentive to a patient’s medical comorbidities and psychosocial support to enhance adherence and improve outcomes. This approach would entail working closely with primary care clinicians and using an integrative approach as the medical comorbidities will influence the success of bipolar treatment.  References Sajatovic M and Chen P. Geriatric bipolar disorder. Psychiatr Clin North Am. 2011 Jun 3;34(2):319-33. Eyler LT et al. Understanding aging in bipolar disorder by integrating archival clinical research datasets. Am J Geriatric Psychiatry. 2019 Oct;27(10):1122-34. Shulman Kl et al. Delphi survey about using lithium in OABD. Bipolar Disord. 2019 Mar;21(2):117-23. Forester BP. Safety and effectiveness of long-term treatment with lurasidone in older adults with bipolar depression: Post hoc analysis of a 6-month, open-label study. Am J Geriatr Psychiatry. 2018 Feb;26(2):150-9. *  *  *  For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych    
This week, we are replaying five interviews that MDedge Psychiatry editor in chief Lorenzo Norris, MD, conducted at the 2019 American Psychiatric Association annual meeting. Dr. Norris spoke with Igor Galynker, MD, (Mount Sinai Beth Israel, N.Y.) about identifying suicide crisis syndrome; Jonathan M. Meyer, MD, (University of California, San Diego) about prescribing clozapine for treatment refractory schizophrenia; Robert M. McCarron, DO, (University of California, Irvine) about psychiatry and primary care; Cam Ritchie, MD, MPH, about preparing patients for disruptions in psychiatric medications; and Richard Balon, MD, (Wayne State University, Detroit) about overcoming resistance to prescribing benzodiazepines for patients with serious mental illnesses. *  *  *   Help us make this podcast better! Please take this short listener survey: *  *  *     For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
Jack Drescher, MD, returns to the MDedge Psychcast, this time to discuss ethical issues raised by the treatment of gender-variant prepubescent children with MDedge Psychiatry editor in chief Lorenzo Norris, MD. The two spoke at the 2019 Group for Advancement in Psychiatry (GAP) meeting in White Plains, N.Y. Dr. Drescher is a Distinguished Life Fellow of the American Psychiatric Association, past president of GAP, and a past president of the APA’s New York County Psychiatric Society. He has a private practice in New York. And later, in the “Dr. RK” segment, Renee Kohanski, MD, says artificial intelligence is much more powerful than we imagined. *  *  *   Help us make this podcast better! Please take this short listener survey: *  *  *   Three approaches used to address gender-variant children Despite the acceptance of gender dysphoria as a diagnosis with standardized treatments, the treatment of gender-variant prepubescent children remains a controversial area. There are several treatment approaches regarding how and when a child should have a social transition to their desired gender.  The oldest treatment approach is based on research that shows that most children will grow out of their gender dysphoria when the therapies applied help the children get used to living in the body of their assigned gender. Essentially, this approach discourages public or private social transition.  The Dutch Protocol is based on research that shows the difficulty in predicting which children will continue to have gender dysphoria and which will not. Some children will have persistent gender dysphoria and become transgender; some may become homosexual; and others may identify with their own biological sex. The Dutch approach encourages children to have cross-gender interests and to privately identify with their desired gender, but there is not a public social transition. Families and clinicians use watchful waiting to see whether the gender dysphoria persists. It’s based on the idea that one cannot predict the future and so parents accept the child wherever they are.  The final approach focuses on social transition without a medical or surgical treatment. Therefore, if the child’s gender dysphoria desists, they can “detransition,” since there was no medical intervention. The gender-affirmative approach, mostly found in the United States, presupposes that it is possible to identify which children will persist in their transgender presentations and encourages a public, social transition to living as their identified gender. In case the child “makes a mistake,” they can transition back to their biological sex. A social transition occurs when a child, with the help of clinicians, explains to the family that they believe the gender dysphoria is going to last and that the child should be allowed to present publicly as their desired gender. This includes communicating with the school, family, and friends to help the child to be treated respectfully in the gender they desire.  Treatments for gender-variant children Puberty suppression is a medical treatment used by physicians in all three approaches. These medications block sex hormone action and are used to delay puberty and prevent the development of undesired secondary sex characteristics of the biologic sex. Adolescents frequently experience anxiety, depression, even suicidal ideation during this period because they feel pressured to choose their gender and avoid developing the secondary sexual characteristics of their biological sex.  Social changes are outpacing the science. More frequently, children show up at gender clinics already socially transitioned by their parents; these children outnumber the subjects in the persist and desist literature. Regardless of the approach used, parents and clinicians should try to act on the exigent circumstances to relieve the distress of the child.  Patients who are transitioning should be referred to a specialist, because this is a sensitive topic and treatment requires expertise.  References  Shumer DE et al. Advances in the care of transgender children and adolescents. Adv Pediatr. 2016 Aug;63(1):79-102. Reed GM et al. Disorders related to sexuality and gender identity in the ICD-11: Revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21. Zraick K. Texas father says 7-year-old isn’t transgender, igniting a political outcry. New York Times. 2019 Oct 28. *  *  *   For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych
Michelle Magid, MD, conducts a Masterclass lecture on botulinum toxin for depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Magid is associate professor University of Texas in Austin, and associate professor of Texas A&M University in College Station. She disclosed serving as a speaker for Ipsen, maker of Dysport (abobotulinumtoxinA, or ABO), and as a consultant for Allergan, maker of Botox (onabotulinumtoxinA). *  *  *   Help us make this podcast better! Please take this short listener survey:  *  *  *   This week in psychiatry: Conduct disorder in girls gets overdue research attention by Bruce Jancin The physiological and emotion-procession abnormalities that underpin conduct disorder in teen girls are essentially the same as in teen boys. however, the clinical presentation of conduct disorder in the two groups is often different.  What we know about botulinum toxin Botulinum toxin is the product of Clostridium botulinum. The neurotoxin inhibits the release of acetylcholine, resulting in flaccid muscle relaxation. Its clinical use started in 1989 to treat strabismus (crossed eyes) and blepharospasm, a dystonic reaction in the eyes. Currently, botulinum is a Food and Drug Administration–approved treatment of chronic migraine in adults. For use in depression, 30-40 units of botulinum toxin is injected into the glabellar region of the face (the forehead). A purported mechanism of action of botulism for depression includes the “facial feedback hypothesis,” in which the activation of muscles of facial expression, consciously or unconsciously, influences emotions. Botulinum toxin for depression is an off-label treatment with four case series, five randomized, controlled studies, and a phase 2 trial by supported by Allergan. New findings on use of botulinum toxin for depression  Magid and colleagues completed a pooled analysis of three randomized, controlled trials totaling 134 patients. Fifty-nine people were included in the botulinum toxin intervention group with a Beck Depression Inventory (BDI) score of 29, and 75 individuals in the placebo group with BDI of 26. In each group, 64% of patients were continued on other medications for depression, and the groups had similar histories of long-standing depression. In the botulinum toxin group, 52% had a response to the intervention, with an at least 50% reduction in their baseline depression scores, compared with a limited response in the placebo group. In the pooled analysis, Dr. Magid’s group analyzed whether the cosmetic effect of botulinum toxin could be a confounding factor. The investigators ruled out that effect by using a subanalysis to evaluate whether the decrease in wrinkles correlated with decrease in depression, and it did not. Allergan moved forward with a phase 2 proof-of-concept trial; the results were mixed. The endpoint was response rate in Montgomery-Åsberg Depression Rating Scale (MADRS) at week 6. With a 30-unit Botox dose, there was a statistically significant decrease in MADRS at week 9, but not at week 6. There was no statistically significant divergence in data between the placebo and intervention group with the 50-unit dose. Given the response rate at week 9, Allergan is proceeding with a phase 3 trial. The cost is about $400 per treatment, and the treatment is given three to four times a year, which makes the cost comparable to that of other psychopharmacologic treatments. Adverse events are mild and include headache and local site irritation. In the current studies, botulinum treatment has been used as both monotherapy and augmentation; however, there are not enough data to know whether one is more effective than the other. In conclusion, burgeoning psychopharmacology research on treatments such as botulinum toxin for depression and novel medications, such as esketamine and brexanolone, broaden our understanding of the etiology of depression. This research is generating novel modes of treatment that will help more patients with refractory illness. References Magid M et al. Treating depression with botulinum toxin: A pooled analysis of randomized controlled trials. Psychopharmacology. 2015 Sep;48(6):205-10. Magid M et al. Treatment of major depressive disorder using botulinum toxin: A 24-week randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2014 Aug;75(8):837-44.  *  *  *   For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
Andrew Penn, MS, NP, conducts a Masterclass lecture on psychedelic-assisted psychotherapy from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Mr. Penn, a psychiatric nurse practitioner, is associate clinical professor of community health systems in the School of Nursing at the University of California, San Francisco. Later, Dr. Renee Kohanski is back – this time to discuss the need to call out the truth when we see it. *  *  * Help us make this podcast better! Please take this short listener survey: *  *  * Reemergence of MDMA for PTSD and psilocybin for MDD Psychedelic-assisted psychotherapy is currently being investigated with 3,4-methylenedioxy-methamphetamine (MDMA) for treatment-resistant post-traumatic stress disorder (PTSD) and psilocybin for the treatment of major depressive disorder (MDD). The use of these compounds would be highly regulated. These are not medications that would be dispensed for a patient to take home. Both would be given in the clinical setting of one or more psychotherapy sessions with two therapists who would continue to work with the patient over time. MDMA was first patented by Merck in 1912, synthesized again in the 1970s, and used by psychotherapists to assist treatment. However, its recreational use spread, leading to its classification as a Schedule I controlled substance, thus prohibiting research or use in a medical setting. Lobbying through the Multidisciplinary Association for Psychedelic Studies, also known as MAPS, managed to bring MDMA into phase 3 clinical trials, and in 2017 the Food and Drug Administration granted breakthrough therapy designation for its use with psychotherapy for PTSD. MDMA is a potent releaser of serotonin, oxytocin, and prolactin, which in combination, allow the patient to feel less fear, trust the psychotherapist more, and overcome the defenses blocking them from talking about traumatic experiences. MDMA permits patients to stay in the optimal arousal zone to discuss the traumatic event. After the psychedelic-assisted session, patients continue to process memories and sequelae of the event and integrate changes into their lives to overcome trauma. If MDMA is approved by the FDA, it would be available only under a REMS, or Risk Evaluation and Mitigation Strategy, or  drug safety program. Psilocybin is a partial agonist on 5-HT2A serotonin receptors. The brain of a severely depressed person is extremely rigid with limitations on the usual predictive capacity of the human brain. Psilocybin facilitates plasticity to “reset” and see a situation as it truly is, rather than through the rigid cognitive distortions of depression. Although MDMA and psilocybin are controlled substances, we can think of these medications like anesthetics, which are drugs that can be prescribed in clinical settings under supervision only. These are old compounds used in a novel manner that can reduce suffering for patients who have not responded to the current modes of therapy for PTSD and MDD. References Mithoefer MC et al. MDMA-assisted psychotherapy for treatment of PTSD: Study design and rationale for phase 3 trials based on pooled analysis of six phase 3 randomized trials. Psychopharm (Berl). 2019 Sep;236(9):2735-45. Carhart-Harris RL et al. Psilocybin with psychological support for treatment-resistant depression: An open-label feasibility study. Lancet. 2016 Jul 1:3(7):619-21. Pollan M. The Trip Treatment. New Yorker. 2015 Feb 9. Cooper A. Psilocybin sessions: Psychedelics could help people with addiction and anxiety. 60 Minutes. 2019 Oct 13. Sessa B. “The Psychedelic Renaissance: Reassessing the Role of Psychedelic Drugs in 21st Century Psychiatry and Society.” London: Muswell Hill Press, 2012. Usona Institute: News on Psychedelics   For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
  Mark S. Gold, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to discuss the intersection between the rise in suicide and the opioid crisis in the United States. Dr. Gold is adjunct professor of psychiatry at Washington University in St. Louis. He also serves on the editorial advisory board of MDedge Psychiatry. Previously, Dr. Gold served as distinguished professor and chairman of the psychiatry department at the University of Florida, Gainesville. * * *  Help us make this podcast better! Please take this short listener survey: * * * Timestamps: This week in Psychiatry (01:11) Interview with Dr. Gold (03:40) This week in Psychiatry Demeaning patient behavior takes an emotional toll on physicians by Steve Cimino Suicide and the opioid crisis In 2017, more than 70,000 people died from overdose, and 47,600 of those deaths involved prescription or illicit opioids. Most coroners list the deaths as “accidental” unless there is a suicide note or the deceased spoke about an intent to die. Chronic opioid self-administration changes the brain. The person becomes less high and more depressed over time. The prevalence of depression is at least 50% in those with opioid use disorder. Some experts estimate that up to 30% of opioid overdoses are intentional and count as suicide. A person with opioid use disorder has 13 times the risk of attempting and completing suicide, compared with the general population. Until recently, psychiatric evaluations and suicide assessments were not routine in the chain of events from opioid use to overdose to transition to medication-assisted treatment (MAT). People whose overdoses are reversed by naloxone are prime candidates to ask whether an overdose was accidental. In an emergency department in Flint, Mich., 30% of overdose patients rescued with naloxone described their overdose as a suicide attempt. Although some people revived with naloxone are angry, it is important to consider irritability and anhedonia that come from giving an opioid antagonist during a high. Future of treatments in the opioid crisis Much is still unknown. For example, there are no MAT options for either stimulant or cannabis use disorders, which are implicated in the morbidity and mortality of the overdose crisis. More research is needed to determine how long patients should be on MAT and when their brains “reset” after addiction. Also, in the pipeline is advanced imaging showing how drug use changes a person’s neurocircuitry and genetics. The OPRM1 gene, for example, is a polymorphism whose presence predicts whether a person is more likely to become addicted after their first use of opiates and determines treatment resistance to recovery. In the next year, efforts aimed at preventing overdoses and investigating the risk and rates of suicide are likely to continue. If every patient with a high-dose opioid prescription were offered naloxone, nearly 9 million more naloxone prescriptions could have been dispensed in 2018. So, we might see state-level policies that seek to increase naloxone prescriptions to patients based on morphine equivalents. Looking beyond overdoses and relapse prevention, the National Institute on Drug Abuse (NIDA) has identified novel targets focused on regenerating the reward system in order to return the brains of people with addictions to premorbid function after years of abuse.   References Volkow N and Gordon J. Suicide deaths are a major component of the opioid crisis. NIDA. 2019 Sep 19. Oquendo MA and Volkow ND. Suicide: A silent contributor to opioid-overdose deaths. New Engl J Med. 2018;378:1567-9. 5-point strategy to combat the opioid crisis. U.S. Department of Health & Human Services. Still not enough naloxone where it’s most needed. Centers for Disease Control and Prevention. 2019 Aug 6.   For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
  Dinah Miller, MD, returns to the MDedge Psychcast, this time to do a Masterclass lecture on involuntary commitment. Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care.” She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. In addition, Dr. Miller is a columnist for Clinical Psychiatry News and serves on the editorial advisory boards of CPN and MDedge Psychiatry. Timestamps: This week in Psychiatry (00:37) Masterclass lecture (02:00) Dr. RK (40:50) This week in Psychiatry: Duloxetine 'sprinkle' launches for patients with difficulty swallowing by Christopher Palmer Drizalma Sprinkle (duloxetine delayed-release capsule) has launched for the treatment of various neuropsychiatric and pain disorders in patients with difficulty swallowing. Overview of the involuntary commitment debate Four main controversies surround involuntary treatment First, standards for involuntary commitment vary by state; most states require that a person be diagnosed with a mental illness and is imminently dangerous to self or others. Some states extend their parameters to include those who are “gravely disabled” or need of psychiatric treatment. Second, as involuntary beds decrease, there is no place for involuntary treatment. Third, involuntary treatment includes outpatient civil commitment (OCC), and policy groups differ in their opinions of involuntary inpatient and outpatient treatments. Laws defining the need and amount of mandated outpatient services vary, based on geographical area. Also, outpatient commitment is difficult to enforce. The final controversy addresses a patient’s right to refuse treatment with medication. Groups hold wide-ranging positions along policy spectrum The Treatment Advocacy Center is a strong proponent of involuntary hospitalization. The group advocates for more state hospital beds in the United States, monitors the number of state hospital beds, proposes an involuntary standard of based on need for treatment, and argues that anosognosia justifies involuntary hospitalization. The National Alliance on Mental Illness (NAMI) is a grassroots organization founded by parents of individuals with serious mental illness (SMI) and initially represented a view in favor of involuntary hospitalization based on protecting those with SMI. However, as NAMI has grown to represent a broad swath of people with mental illness, the organization has struggled with whether it represents the interests of people with SMI only or a broader group of people with any mental illness. The American Psychiatric Association holds the middle ground, identifying dangerousness as the standard of involuntary care. In 2015, the APA released a carefully worded stance in support of outpatient commitment on a limited basis. Organizations strongly against involuntary treatment include the Bazelon Center for Mental Health Law, whose mission is to protect and advance the rights of adults and children with mental illness. The Bazelon Center opposes anything that restricts the rights of people with mental illness. The recovery movement, which developed as a backlash against the perceived paternalism of psychiatry, prioritizes the mental health consumer’s autonomy with an emphasis on peer support and being proactive in health care choices. On the antipsychiatry spectrum are the groups MindFreedom International and the Citizens Commission on Human Rights. Both of those groups oppose involuntary treatment. Violence and mental illness In the community, psychiatric illness is thought to be responsible for 4% of total violence and 7%-10% of murders. The MacArthur Foundation investigated rates of violence in people with mental illness 10 weeks after an inpatient hospitalization. It found that, compared with community samples, people with mental illness following hospitalization have higher rates of violence. The rate of violence was 8% for people with schizophrenia, 15% for bipolar disorder, 18% for depression, and 23% for personality disorder. Twenty weeks after discharge, patients with more treatment contacts were less likely to be violent. Mental illness does not belong in conversations about violence prevention because violence is more strongly correlated with substance use, anger, and early exposure to violence. Thus, mass murder cannot be prevented with forced care or institutionalization. The case is less clear for involuntary treatment for suicide prevention. For example, we know that two-thirds of gun deaths are suicides; however, we do not have statistics to elucidate whether involuntary hospitalization would prevent suicides. Final thoughts Involuntary hospitalization should be the treatment choice of last resort. A psychiatrist should pursue careful assessment with as many sources as possible and strongly suggest alternatives, such as voluntary hospitalization. Involuntary hospitalization could be less traumatizing by implementing steps such as reducing forced treatments, minimizing seclusion and restraints, asking patients for feedback at the end of their stays, and acknowledging that involuntary treatment is difficult. Involuntary care would be less necessary if voluntary care were easier to access earlier in an illness to avoid crisis and hospitalization.   References Miller D and Hanson A. “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). Torrey EF et al. The MacArthur Violence Risk Study revisited: Two views ten years after its initial publication. Psychiatr Serv. 2008 Feb 1;59(2):147-52. Testa M and West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010 Oct;7(10):30-40. For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych  
Kent A. Kiehl, PhD, joins host Lorenzo Norris, MD on the MDedge Psychcast to discuss the use of MRI scans to provide information about the brains of people who exhibit antisocial behaviors. The goals are to use the information to treat patients and prevent violent crimes.  Timestamps: This week in Psychiatry (00:33) Meet the guest (03:35) Interview (04:25) Credits (54:10) Dr. Kiehl is professor of psychology, neuroscience, and law at the University of New Mexico, Albuquerque. He also codirects a nonprofit mental health research institute called the Mind Research Network, also in Albuquerque. He also helps run a for-profit consulting firm that helps attorneys do better science, called MINDSET. This week in Psychiatry: Suicide attempts up in black U.S. teens by Randy Dotinga Overall rates of suicide dipped from 1991 to 2017, according to research published in Pediatrics. However, the rate of suicide attempts grew slightly in black adolescents during that time.  SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI: 10.1542/peds.2019-1187.   Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Brain imaging can support diagnoses Dr. Kiehl works with cutting-edge technology using noninvasive structural and functional brain imaging; machine learning, such as artificial intelligence; and algorithms to evaluate forensic patients and understand psychopathology, predict outcomes, and measure the impact of interventions. Dr. Kiehl and his team travel to prisons across the country with two mobile MRI units imaging incarcerated individuals and forensic patients. More and more, brain imaging is considered in capital cases, because MRI provides valuable information for defense attorneys and prosecutors. For example, a man was charged with murder and his MRI supported a diagnosis of frontotemporal dementia with a behavioral variant, so he was able to plead not criminally responsible based on his illness – and was sent to a state mental hospital rather than to death row. The case of John W. Hinckley Jr., who shot former President Ronald Reagan and his press secretary, James Brady in 1981, was an initial case in which neuroscience and imaging influenced the verdict. The shooter’s brain imaging showed enlarged ventricles and cortical atrophy, which supported a diagnosis of schizophrenia – particularly when compared with the imaging of age-matched controls. Structural and functional MRI is an adjunct to neuropsychological tests. Neuroscientists are elucidating patterns through artificial intelligence and algorithms that can be useful to civil and criminal cases. For example, age is considered a strong predictor of antisocial behaviors. To enhance accuracy, Dr. Kiehl’s team has developed a neuroprediction model in which MRI quantifies brain age, which correlates closely with cognitive testing scores. So, brain age might be more useful for predicting behavior than chronological age. This study used more than 1,000 imaging studies of inmates. The data were analyzed using an algorithm called independent component analysis, which evaluates distinct neural circuits to identify components that predict age. In the next step of analysis, the algorithm identifies patterns associated with reoffending. Younger brain age in the anterior temporal lobe and orbitofrontal cortex – brain areas associated with decision making – accurately estimates the risk of reoffending better than just chronological age. Based on an understanding of brain plasticity, dogma suggesting that people who commit violent crimes cannot be changed should be challenged. A group at the University of Wisconsin, Madison, was asked to create an evidence-based, multimodal treatment program for the hardest-to-treat violent juvenile offenders. The program, which includes interventions such as multisystemic family therapy and positive reinforcement contingency treatment, resulted in a decrease in reoffending and violent crimes in participants who received 10 months of treatment. Dr. Kiehl’s group followed up with those juvenile boys using MRI to evaluate what had changed in their brains, how much treatment is required, and how or whether those brain changes can be reinforced. Reduction in incarceration costs is a return on investment for the states that fund those types of programs. Take-home points If scientists can identify useful interventions and identify brain changes though imaging, perhaps science can affect outcomes such as societal violence and incarceration rates. Implementation is the primary short-term obstacle. This type of research needs more funding and institutional change to identify programs that work. The brain has an incredible amount of plasticity, which translates into opportunities for change.   References  The Mind Research Network Kiehl KA. The Psychopath Whisperer: The Science of Those Without Conscience. Random House, 2014. Kiehl KA et al. Age of gray matters: Neuroprediction of recidivism. Neuroimage Clin. 2018;19:813-23. Steele VR et al. Machine learning of structural magnetic resonance imaging predicts psychopathic traits in adolescent offenders. Neuroimage. 2017 Jan 15;145(Pt B);265-73.   For more MDedge Podcasts, go to Email the show: Interact with us on Twitter: @MDedgePsych        
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 Email the show: Interact with us on Twitter: @MDedgePsych  
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