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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.
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MDedge Psychcast host Lorenzo Norris, MD, interviews Steven Wengel, MD, about the challenges of loneliness in geriatric populations in nursing homes, especially during the current COVID-19 pandemic. Dr. Norris also discusses potential interventions with Dr. Wengel, who is a geriatric psychiatrist at the University of Nebraska Medical Center in Omaha. And later, in the “Dr. RK” segment, Renee Kohanski, MD, talks about how, in the midst of the pandemic, we are slowing down while we’re speeding up … and are learning how to use – and not abuse – technology. Take-home points Loneliness has been defined as a form of social pain; it is more than sadness or a “state of mind.” Loneliness and being alone are separate issues suggesting that loneliness is more of an emotional state and being alone is often a choice. Loneliness can be characterized as deficits in authentic interactions and connection because you can be surrounded by people and still feel lonely. Loneliness has been studied as a predictor of health problems and is identified as a risk factor for early mortality and dementia and as a predictor of chronic illnesses such as depression. When it comes to treating loneliness in the geriatric population, favor any type of intervention over none and avoid chalking up symptoms as “just loneliness.” Basic interventions include providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive type symptoms with an SSRI. Summary In a study of nursing-home patients, 9% report loneliness often or always and 25% report loneliness sometimes; older adults are more susceptible to loneliness secondary to frailty and limited transport options. Loneliness is an independent risk factor for early mortality and a predictor for other chronic diseases including dementia, hypertension, depression, and overall poor health. During the COVID-19 pandemic, most nursing homes are under lockdown, and all visitors are barred to minimize the introduction of COVID-19 to the facilities. This means residents are unable to see family and loved ones. This necessary intervention brings up the question of quality of life over quantity of life for older individuals. Isolation and social distancing have also taken away group activities like communal meals and games with socializing. Children of institutionalized patients might also feel a sense of loss and guilt as they are not allowed to see their loved ones. Particular to geriatrics, physical touch is essential to healing emotional pain, for example, a gentle touch or massage to relieve anxiety or physical redirection to ease agitation secondary to dementia. Two primary means of addressing loneliness for the geriatric population include providing structure and finding opportunities for volunteerism such as helping other residents or completing simple tasks within the institution. Loneliness and major depressive disorder are difficult to differentiate in the older population. Dr. Wengel recommends favoring intervention over none. This means using basic interventions like providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive symptoms with an SSRI. References Jansson AH et al. Loneliness in nursing homes and assisted living facilities: Prevalence, associated factors and prognosis. Jour Nursing Home Res. 2017;3:43-9. Social isolation, loneliness in older people pose health risks. National Institute on Aging. https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks. Cacioppo JT. Loneliness: Human Nature and the Need for Social Connection. New York: W.W. Norton and Company, 2008. *  *  *   Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
MDedge Psychcast host Lorenzo Norris, MD, interviews Sy Atezaz Saeed, MD, MS, about his annual analysis of the key studies that could change day-to-day psychiatric practice. Dr. Norris’s conversation with Dr. Saeed is based on a two-part evidence-based review that identified the top 12 research findings for clinical practice from July 2018 to June 2019. Part 1, which Dr. Saeed wrote with Jennifer B. Stanley, MD, and Part 2 were published in Current Psychiatry. Take-home points Each year, Dr. Saeed identifies 10-20 high-quality journal articles with direct impact on clinical practice that, if used appropriately, can generate better outcomes for psychiatric patients. The goal of the list is to close the gap between cutting-edge science and clinical practice. Secondary literature (for example, Cochrane Reviews, NEJM Journal Watch, and so on) is used to differentiate the clinically relevant “signal” from the noise of all the research produced. Knowledge changes over time, so it’s important to be up to date but flexible in how the knowledge is applied. Summary The methodology used to generate the list is aimed at identifying 10-20 useful articles. Dr. Saeed took a three-pronged approach that reviewed research findings suggesting readiness for clinical utilization published between July 1, 2018, and June 30, 2019; asked several professional organizations and colleagues: “Among the papers published from July 1, 2018, to June 30, 2019, which ones in your opinion have (or are likely to have or should have) impacted/changed the clinical practice of psychiatry?”; and looked for appraisals in postpublication reviews such as NEJM Journal Watch, F1000 Prime, Evidence-Based Mental Health; commentaries in peer-reviewed journals; and other sources that suggest an article is of high quality and clinically useful. This approach generated a solid list of articles to consider presenting at journal clubs or a topic to present at grand rounds. Studies on this list also might overlap with research covered in popular media, so the list is a tool that clinicians can use to answer questions patients raise. The secondary literature is used to differentiate the clinically relevant “signal” from the noise of all the research produced. Those secondary sources include Cochrane Reviews, BMJ Best Practice, NEJM Journal Watch, Evidence-Based Mental Health, and commentaries in peer-reviewed journals to help distill the clinically useful articles for a busy clinician. Four of the 12 articles that affected Dr. Saeed’s practice covered the risk of death associated with antipsychotic medication usage in children, the role of antipsychotic polypharmacy in schizophrenia to decrease inpatient hospitalizations, the outcomes associated with prescribing different adjunctive medications in combination with antipsychotics, and the use of prazosin for nightmares in PTSD. References Saeed SA et al. Top research findings of 2018-2019 for clinical practice. Part 1. Current Psychiatry. 2020 January;19(1):12-8. Saeed SA. Top research findings of 2018-2019 for clinical practice. Part 2. Current Psychiatry. 2020 February;19(2):22-8. Ray WA et al. Association of antipsychotic treatment with risk of unexpected death among children and youths. JAMA Psychiatry. 2019;76(2):162-71. Tijhonen J et al. Association of antipsychotic polypharmacy vs. monotherapy with psychiatric rehospitalization among adults with schizophrenia. JAMA Psychiatry. 2019;76(5):499-507. Stroup TS et al. Comparative effectiveness of adjunctive psychotropic medications in patients with schizophrenia. JAMA Psychiatry. 2019;76(5):508-15. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507-17. Show notes by Jacqueline Posada, MD, associate producer of the MDedge Psychcast. Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, conducts a Masterclass on what psychiatrists and other mental health clinicians can do to mitigate the impact of COVID-19. Dr. Ritchie is writing additional commentaries on this topic for MDedge Psychiatry. And later, in the “Dr. RK” segment, Renee Kohanski, MD, says that, with simple tools or guidelines, humans have the ability to withstand adversity that is stronger than we will ever know. Take-home points Epidemics and pandemics are characterized by fear and anxiety. Quarantine will be a challenge for patients with addictions and vulnerable populations such as individuals who are homeless. Psychiatrists can aid with social distancing by providing patients refills for psychotropic medications without requiring an in-person visit and switching to telepsychiatry where possible. The Coronavirus Preparedness and Response Supplemental Appropriations Act waives Medicare telehealth reimbursement restrictions for mental health services during certain emergency periods. Inpatient psychiatric units must take special precautions to prevent spread of COVID-19, such as improving procedures for sanitizing communal areas and items, limiting visitation, screening patients for symptoms, and arranging transfer when appropriate. COVID-19 infection can spread on units to patients and staff and may compromise clinicians’ ability to provide care safely. Psychiatrists also play a role in helping address the shortage of personal protective equipment (PPE) by talking to patients about the appropriate use of PPE and sanitizer. Summary Emotional response to pandemics: Epidemics and pandemics are characterized by fear and anxiety as people worry about their risk of exposure, infection, and spreading the pathogen. Clinics can alleviate the anxiety by transitioning to telehealth when possible, discouraging handshakes, keeping a distance from patients, and rearranging waiting rooms and other spaces to provide more room between chairs and tables. Psychiatrists can encourage patients and fellow clinicians to engage in activities that normally reduce anxiety, such as exercising, setting aside time for relaxation at home, and taking regularly prescribed or over-the-counter medications. Quarantine considerations: Quarantine and isolation will be difficult for most people, and especially so for patients with psychiatric disorders, including substance use disorders. Psychiatrists can prepare themselves and patients for quarantine by refilling medications for more than 30 days. The Centers for Disease Control and Prevention recommends clinicians refill nonurgent medications without an in-person visit. Patients who are addicted to alcohol or other substances may be tempted to leave the house to acquire those substances. It may be a physician’s responsibility to either suggest to patients that they have enough of their substance at home or give them something to treat withdrawal or cravings. Considerations for inpatient psychiatric units: Psychiatric units are built for socialization and communal treatment; thus, psychiatric units will have to change policies, including limiting visitors; decreasing occupancy on the units; and ensuring that communal items such as phones, chairs, and books are properly sanitized. Long-term psychological impact of a pandemic: The negative economic impact of the pandemic, such as unemployment in the tourism and service industries, may have consequences including rising rates of depression and anxiety, suicides, and increases in domestic violence and substance abuse.  Psychiatrists can help address the shortage of PPE by talking to patients about the appropriate use of PPE and sanitizer. It is wise to have a stock of food, medications, and supplies for 14-21 days of quarantine, but in a public health emergency we can urge patients and ourselves to be mindful of the needs of others and avoid hoarding. We need to remind ourselves, our patients, and our colleagues to stay healthy by getting enough sleep, taking on the appropriate level of readiness, and remaining flexible as our daily lives are changed by the pandemic. References Centers for Disease Control and Prevention. Interim guidelines for healthcare facilities: Preparing for community transmission of COVID-19 in the United States. H.R. 6074: Coronavirus Preparedness and Response Supplemental Appropriations Act. Passed Congress 2020 Mar 6. Brooks SK et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet. 2020 Mar 14;395(10227):912-20. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Lorenzo Norris, MD, interviews Nina J. Gutin, PhD, a psychologist with a private practice in Pasadena, Calif., about losing patients and loved ones to suicide. Dr. Gutin wrote two evidence-based reviews on the topic late last year. The reviews were published in Current Psychiatry. *  *  *   Take-home points When mental health clinicians lose a patient to suicide, the sequelae can include stigma, potential legal consequences, impact on future clinical work, and restraints on processing the loss because of confidentiality concerns. The American Association of Suicidology founded the Clinician Survivor Task Force (CSTF), which provides consultation, support, and education to mental health professionals to help them respond to the personal/professional loss from the suicide of a patient or loved one. Mental health institutions can benefit from protocols on how to respond to a potential completed suicide, so clinicians and families are not left in a vacuum of uncertainty and blame. After a patient suicide, clinicians need an anonymous or safe space to talk about the patient and the suicide without breaking confidentiality. This can be an online forum, such as the one sponsored by the CSTF, or an institution can identify a supportive colleague who has suffered a similar loss. The CSTF forum allows clinicians to remain anonymous. Summary  Several domains require attention after the loss of a patient from suicide: Confidentiality restrains the ability to talk about the details of the loss, which stymies grief and learning from the event. Restraints of confidentiality pertain to individual clinicians and clinical teams. On a team, it might feel as if the clinicians are unable to process the loss as a group and talk about important details. Legally, clinicians worry about potential lawsuits, and “psychological autopsies” can lead to retraumatization. Clinicians might struggle with how – or whether – to talk to a patient’s family after suicide. Some lawyers advise compassion over caution. In collaboration with lawyers who advise what can be disclosed, a clinician can speak with a family, and this compassion toward families might decrease the risk of a lawsuit. Clinicians should be prepared for a patient suicide to affect their clinical work. A clinician might become hypervigilant about suicide risk and overreact, or they might experience denial about the risk and avoid asking questions about suicide. Ethically, suicide is an “occupational hazard” of working in the mental health field. Blaming clinicians for patient suicide hampers the depth of working with people with mental illness by causing some clinicians to avoid “high-risk” patients. The stigma around death by suicide extends to the survivors of the loss. When clinicians express vulnerability about loss, it can be interpreted as guilt. Clinicians are expected to keep going no matter what, which is unrealistic. Grief over a patient’s death should be neither pathologized nor shamed. Guilt and blame are the flip sides of each other; both express the complexity and ambiguity of these kinds of losses. Institutions should have “postvention” protocols in place to respond to the likely event of a completed suicide. Guidelines can address what needs to be covered in a review of the case while also supporting clinicians, so they don’t feel like it’s a tribunal. Clinicians should be warned of the normal sequelae of a client suicide, and institutions can make accommodations based on the expected impact of suicide on a clinician’s work. Institutions can provide support by connecting clinicians who have also lost clients to suicide to dispel the belief that they are alone in their loss and to mitigate self-blame. The CSTF provides support through in-person and online support groups, and postvention protocols for institutions. It also and maintains a bibliography of research on clinician survivorship. References Gutin NJ. “Losing a patient to suicide: What we know.” Current Psychiatry. 2019 Oct 18(10):14-6,19-22,30-2. Gutin NJ. Losing a patient to suicide: Navigating the aftermath. Current Psychiatry. 2019 Nov 18(11):17-18,20,22-4. American Association of Suicidiology. Clinicians as Survivors: After a Suicide Loss. Owen JR et al. Suicide symposium: A multidisciplinary approach to risk assessment and the emotional aftermath of patient suicide. MedEdPORTAL. 2018 Nov 28;14:10776. Myers MF and Fine C. Touched by suicide: Bridging the perspectives of survivors and clinicians. Suicide Life Threat Behav. 2007 Apr;37(2):119-26. *  *  *   Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com  
Jonathan Meyer, MD, returns to the Psychcast, this time to conduct a Masterclass lecture on treating patients with lumateperone. Dr. Meyer, of the University of California, San Diego, disclosed receiving either speaking honoraria or advising fees from several companies, including Intra-Cellular Therapies, which developed lumateperone (Caplyta). Later, Renee Kohanski, MD, discusses tailored interventions psychiatrists can incorporate into their practices to address overweight and obesity resulting from medications tied to weight gain. Take-home points Lumateperone, an atypical antipsychotic, was approved by the Food and Drug Administration for the treatment of adults with schizophrenia on Dec. 20, 2019. It has only one approved effective dose of 42 mg given with food. Further studies might define doses higher or lower, but those data are not available yet. The only adverse effect found with lumateperone was somnolence or sedation. Lumateperone was 24%; placebo was 10%. The medication has a low affinity and occupancy of the dopamine D2 receptors. This pharmacodynamic trait is reflected by the relatively low rates of extrapyramidal side effects in the clinical trial data. For now, the short-term studies of lumateperone suggest limited metabolic and endocrine effects, compared with other atypical antipsychotics. The primary indication for using lumateperone may be its tolerability profile, because nonadherence contributes to the morbidity of schizophrenia. Lumateperone is not a drug that should be used for treatment-resistant schizophrenia. The only drug that should be used for refractory patients with schizophrenia is clozapine (Clozaril). Summary Lumateperone has a unique pharmacologic profile. It has a low affinity for muscarinic, histaminergic, and alpha-adrenergic receptors. In the clinical trials, the primary side effect reported was somnolence and/or sedation. The medication also has a lower affinity for dopamine D2 receptors and occupies less than 40% of these receptors even at peak-dose timing. Conventional treatment of psychosis suggests that antipsychotic properties of D2 antagonist medications occur when 60%-80% of D2 receptors are occupied. Yet, there may be other properties of atypical antipsychotics that can increase the efficacy with lower levels of D2 blockade. Knowledge of alternative mechanisms comes from studying other antipsychotics. For example, pimavanserin (Nuplazid), an antipsychotic medication for treatment of psychosis in Parkinson’s disease, has no affinity for any dopamine receptors. Instead, it has a high affinity for serotonin 5-HT2A receptors as an inverse agonist and antagonist likely in cortical circuits with downstream glutamate signaling to dopamine circuits in the ventral tegmental area, which then decreases the amount of dopamine released in the mesolimbic pathway. Pimavanserin does not have any activity on the presynaptic D2 autoreceptors. Though counterintuitive, other atypical antipsychotics block the D2 presynaptic autoreceptor, which increases dopamine release. This mechanism is possibly why other antipsychotics require a 60%-80% D2 blockade to be effective in treating psychosis. In vitro studies suggest that lumateperone does not have presynaptic autoreceptor antagonism, which could be another reason why it doesn’t need as much D2 antagonism to be an effective antipsychotic agent. Lumateperone also is a weak inhibitor of serotonin reuptake occupying 30% of the serotonin receptors. Given its diverse pharmacologic mechanisms, lumateperone may confer antidepressant properties, and clinical trials are in the process to evaluate the use of lumateperone in bipolar depression. The drug is expected to be available at the end of March 2020. References Meltzer HY et al. Pimavanserin, a selective serotonin (5-HT)2A-inverse agonist, enhances the efficacy and safety of risperidone, 2 mg/day, but does not enhance efficacy of haloperidol, 2 mg/day: comparison with reference dose risperidone, 6 mg/day. Schizophr Res. 2012;141(2-3):144-52. Correll CU et al. Efficacy and safety of lumateperone for treatment of schizophrenia: A randomized clinical trial. JAMA Psychiatry. 2020 Jan 8. doi: 10.1001/jamapsychiatry.2019.4379. Corponi F et al. Novel antipsychotics specificity profile: A clinically oriented review of lurasidone, brexpiprazole, cariprazine, and lumateperone. Eur Neuropsychopharmacol. 2019;29(9):971-85. U.S. National Library of Medicine. Lumateperone drug label *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Patricia Westmoreland, MD, returns to the Psychcast to conduct a Masterclass on treating bulimia. Dr. Westmoreland, an attending psychiatrist at the Eating Recovery Center in Denver, previously discussed eating disorders. She is an adjunct assistant professor in the department of psychiatry at the University of Colorado at Denver, Aurora, and has a private forensic psychiatry practice in Denver. Takeaway points Anorexia nervosa and bulimia nervosa can have life-threatening medical complications. All medical complications can resolve with consistent nutrition and full weight restoration. Eating disorders must be treated and associated behaviors stopped to prevent complications from returning. Anorexia-related medical complications usually are attributable to weight loss and malnutrition. Bulimia-related medical complications can occur at any weight, and are related to the mode and frequency of purging. Complications include metabolic abnormalities, such as electrolyte and acid-base disturbances, volume depletion, and damage to the colon. Patients with bulimia have a lower mortality rate than do those with anorexia. However, the mortality of patients with bulimia is two times higher than that of age-matched healthy controls because of acid-base disturbances and severe electrolyte abnormalities. The weight of the patients with bulimia does not matter. Acid-based disturbances and severe electrolyte abnormalities can kill patients at any time without warning and at any weight. Summary About 90% of purging behaviors consists of self-induced vomiting and/or laxative abuse. Self-induced vomiting can cause local complications such as gastric reflux, which can lead to dysphagia and dyspepsia; hematemesis from Mallory-Weiss tears in the esophagus; nosebleeds and subconjunctival hemorrhages; and parotid gland enlargement, known as sialadenosis, which is a chronic, noninflammatory cause of swelling of the major salivary glands. Systemic complications of self-induced vomiting include metabolic derangements, such as hypokalemia, metabolic alkalosis, and volume depletion, which can lead to pseudo-Bartter syndrome from chronic aldosterone secretion as the body attempts to maintain blood pressure; the syndrome is characterized by hyperaldosteronism, metabolic alkalosis, hypokalemia, and normal blood pressure. Treatment of local complications: Gastric reflux can be treated with proton pump inhibitors, and the patient should be screened for Barrett’s esophagus with esophagogastroduodenoscopy. Dental complications such as erosion of the enamel should be addressed with fluoride-based mouthwashes and toothpastes, and gentle toothbrushing. Parotid gland enlargement is treated by sucking on sour candies, applying hot packs, and using anti-inflammatory medications. Treatment of systemic complications: Hypokalemia, which is diagnosed on a basic metabolic panel, needs immediate repletion orally or intravenously. Depending on the severity of the hypokalemia, the patient may need cardiac monitoring in the hospital or ICU to prevent mortality from a lethal arrhythmia. In pseudo-Bartter syndrome, the elevated aldosterone does not normalize until a few weeks after purging stops, so individuals can develop edema and the other electrolyte abnormalities. Treatment is spironolactone, 25-200 mg/day. Complications from laxative abuse occur primarily from stimulant laxatives, which stimulate the myenteric plexus, the nerves of the intestines, and increase intestinal secretions and motility. Cathartic colon syndrome occurs from continued use of stimulant laxatives, which damage the nerves of the colon by rendering it incapable of peristalsis without continued use of laxatives. Individuals who abuse laxatives more than three times per week for at least 1 year are at risk of cathartic colon syndrome and need to stop laxatives immediately. References Westmoreland P et al. Medical complications of anorexia nervosa and bulimia. Am J Med. 2016;129(1):30-7. Mehler PS, Walsh K. Electrolyte and acid-base abnormalities associated with purging behaviors. Int J Eat Disord. 2016 Mar;49(3):311-8. Gibson D et al. Medical complications of anorexia nervosa and bulimia nervosa. Psychiatr Clin North Am. 2019 Jun;42:263-74. Sato Y, Fukado S. Gastrointestinal symptoms and disorders in patients with eating disorders. Clin J Gastroenterol. 2015 Oct;8(5):255-63. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
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 mdedge.com/podcasts Email the show: podcasts@mdedge.com
William Lynes, MD, joins guest host Michael F. Myers, MD, to discuss his struggles with medical and psychiatric hardships, his suicidality, and the eventual suicide attempt that changed his life. Dr. Myers is professor of clinical psychiatry, State University of New York, Brooklyn. Dr. Lynes, a retired urologist, author, and speaker/advocate on physician burnout and suicide, divides his professional life into two distinct eras: 1987-1998, during which he had a successful practice and happy life, and after 1998, when he spiraled downward medically and psychiatrically. After meeting another physician with a similar experience who had published her story of burnout and mental health struggles in 2015, Dr. Lynes decided to speak out. Eventually, he published an essay about his experience in the Annals of Internal Medicine. Take-home points Being open with close colleagues or supervisors about mental health struggles and/or burnout can provide a much-needed lifeline to struggling physicians. Addressing burnout and mental health diagnoses of physicians requires medical groups and institutions to provide access to psychiatric treatment from clinicians outside of the professional network in which the physician practices. Practicing medicine can be a 24/7 profession, and being “on” all the time can contribute to burnout. Lifestyle choices such as exercise, hobbies, family, and spirituality are all helpful outlets to address the constancy of practicing medicine. Giving in to the notion that you can treat yourself is not a good idea. Decreasing the stigma tied to mental illness can be helped by people with lived experience, such as Dr. Lynes. *  *  *   References Lynes W. The last day. Ann Intern Med. 2016 May 3;164(9):631. Myers MF and Freeland A. The mentally ill physician: Issues in assessment, treatment and advocacy. Can J Psychiatry. 2019 Dec 6;64(12):823-37. Forbes MP et al. Optimizing the treatment of doctors with mental illness. Aust NZ Psychiatry. 2019 Feb;53(2):106-9. Myers MF. “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.” 2017 Feb 14. (Self-published). Bird JL. “Using Narrative Writing to Enhance Healing.” Medical Information Science Reference, 2019. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
George T. Grossberg, MD, conducts a Masterclass on treating mood disorders in geriatric patients from the CP/AACP Psychiatry Update 2019 meeting in Las Vegas. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Grossberg is the Samuel W. Fordyce professor and director of geriatric psychiatry at St. Louis University School of Medicine in St. Louis. Later, Renee Kohanski, MD, discusses the first thing psychiatrists can do for patients. Take-home points from Dr. Grossberg: The prevalence of major depressive disorder among older adults who reside in the community is similar to that of the general population (6%). In nursing homes, the prevalence of significant clinical depression is close to 25%. Depression in older adults in long-term care facilities is underrecognized and undertreated. Risk factors for depression include advanced age (80-90 years), loneliness and lack of social support, painful conditions, frailty, and medical comorbidities. Medications that are central nervous system depressants, such as opiates and benzodiazepines, also can contribute to depression. Alcohol can also be a depressant. Depression in the face of cognitive impairment is extremely common and can even speed cognitive decline. Apathy, defined as lack of motivation, can look like depression. However, depression will have amotivation coupled with vegetative symptoms, such as disrupted sleep and loss of appetite, and mood changes, such as sadness and tearfulness. Low-dose stimulants are effective for apathy, but antidepressants are not; so, it’s important to differentiate the two. Undiagnosed and untreated depression contributes to a significant degree of morbidity because it can slow recovery in rehabilitative settings and impair adherence to essential medications. Treating depression also can improve pain control by making it more tolerable as a somatic symptom. Individuals older than 65 years account for more than 20% of all completed suicides in the United States. Psychological autopsy studies suggest that many of these individuals had undiagnosed depression. Clinicians should not shy away from treating geriatric patients for depression with medication and interventions such as cognitive-behavioral therapy. With pharmacotherapy, start low, go slow, and titrate up to a therapeutic dose. Older adults may take longer, up to 8-12 weeks, to respond to SSRIs, so it’s imperative not to give up on medications too soon. Electroconvulsive therapy is the most effective treatment for severe depression in geriatric patients. Some consider advanced age an indication for ECT; medical comorbidities are not a contraindication for ECT. It is unclear how effective ketamine is in older patients, but it deserves consideration. Prompt diagnosis and treatment of mood disorders is paramount in patients of advanced age and those living in long-term care facilities. Treating depression in the older patient also improves the quality of life for caregivers and professional staff. References Birer RB et al. Depression in later life: A diagnostic and therapeutic challenge.  Am Fam Physician. 2004 May 15;69(10):2375-82. Sjoberg L et al. Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults.  J Affect Disord. 2017 Oct 15;221:123-31. Grossberg GT et al. Rapid depression assessment in geriatric patients. Clin Geriatr Med. 2017 Aug;33(3):383-91. *** For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych
In this, the 100th episode of Psychcast, Nick Andrews talks with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about the January front-page article in Clinical Psychiatry News that featured Matthew E. Seaman, MD, an emergency physician with depression who took his own life. The article describes the Dr. Seaman faced. Later, Christine B.L. Adams, MD, a psychiatrist who practices in Louisville, Ky., discusses her book, “Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships” (Santa Barbara: Praeger, 2018), with Dr. Norris. Take-home points from Dr. Adams Children learn emotional patterns in families. These behaviors get reinforced. As children form dating relationships, for example, those patterns continue to be reinforced. People may go on autopilot and have knee-jerk reactions in response to people, which allows them to react emotionally without thinking about what’s necessary for each person. Long-term dynamic psychotherapy can help patients observe what they are doing in relationships and what others are doing. Ultimately, patients can be taught to look at and uncover their automatic responses. Once these patterns are uncovered and moved from the emotional realm to the intellectual realm, they can be interrupted. Genesis and development of the book’s principles Homer B. Martin, MD, a Louisville, Ky.–based adult psychiatrist who worked with Dr. Adams for 30 years, developed the original premise of the book. When he died, his wife asked Dr. Adams, who was his protégé, to finish it. The book is based on the observations made by Dr. Martin during his 40 years of conducting psychotherapy with patients. It is designed to be accessible both to psychiatric trainees as well as to general readers. Dr. Adams started teaching the concepts in the book during a 6-week university class to determine whether the ideas were digestible and useful. Mainstream movies were used to help people learn to observe and identify roles that were emotionally conditioned and to determine how a character’s change in behavior would change the other person. Movies that can be used to help people identify problematic patterns include “Ordinary People,” “Gran Torino,” “The Remains of the Day,” “The Door in the Floor,” and “When Harry Met Sally.” References Yazici E et al. Use of movies for group therapy of psychiatric inpatients: Theory and practice. Int J Group Psychother. 2014 Apr;64(2):254-70. Ross J. You and me: Investigating the role of self-evaluative emotion in preschool prosociality. J Exp Child Psychol. 2017 Mar;155:67-83. Werner AM et al. The clinical trait self-criticism and its relation to psychopathology: A systematic review – Update. J Affect Disord. 2019 Mar;246:530-47. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  
In episode 99 of the Psychcast, Frank Yeomans, MD, PhD, clinical associate professor of psychiatry at the Weill Medical College of Cornell University, Ithaca, N.Y., spoke with Dr. Norris at the Group for the Advancement of Psychiatry (GAP) fall 2019 meeting about treating patients with personality disorders. Characteristics of personality disorders A personality disorder affects the quality of a person’s experience and his or her ability to deal with challenges in life, including comorbid psychiatric disorders. A personality disorder is not based on symptoms alone and determines how people engage with their environment; it is a part of the biological side of psychiatry. The DSM traditionally relied on a traits-based definition of personality disorders. Yet, in the “emerging measures and models” section, the DSM-5 describes a dimensional/categorical model of personality disorders, which looks at personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. This harkens back to the concept of borderline personality organization as outlined by Otto F. Kernberg, MD. The dimensional model suggests that individuals with personality disorders benefit from behavioral therapies, such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT), to treat problematic traits. Exploratory and insight-focused psychotherapies can help individuals understand their personality organization. Ideally, the treatments for personality disorders would be sequenced, starting with CBT or DBT and transitioning into exploratory therapy. Much like borderline personality disorder, at the core of narcissistic personality disorder is a fragmented sense of self, but in the latter disorder, a self-centered narrative exists that is coherent to the person but does not support reality. If mental health is defined as the ability to adapt to the different circumstances of life, people with narcissism cannot adapt and instead, develop a grandiose narrative to soothe the fragmented self. Therapeutic interventions for narcissism focus on disrupting the narrative in a gentle way that allows patients to understand the model in which they currently experience the world and then reconstitute an adaptive narrative. An effective treatment approach is psychodynamic therapy, with a focus on a treatment contract and specific, explicitly agreed-upon goals. Try to focus more on the interaction with the patient than on the narrative content of the session. The therapy must focused on how the patient acts in therapy, and their adaptations and reactions, because these are the actions that negatively affect their relationships and daily lives. The biological part of a person is processed at the psychological level, so psychiatrists must be interested in psychological aspects of treatment. References Sharp C et al. The structure of personality pathology: Both general ('G') and specific ('S') factors? Abnorm Psychol. 2015 May;124(2):387-98. Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry. 2009 May 1;166(5):530-9. Caligor E et al. Narcissistic personality disorder: Diagnostic and clinical challenges. Am J Psychiatry. 2015 May;172(5):415-22. Morey LC et al. Personality disorders in DSM-5: Emerging research on the alternative model. Curr Psychiatry Rep. 2015 Apr;17(4):558. *  *  *  For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych    
Alberto J. Espay, MD, MSc, conducts a Masterclass lecture on treating patients with Parkinson’s-related psychosis from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Espay is professor of neurology at the University of Cincinnati. He also serves as director of the James J. and Joan A. Gardner Family Center Research Chair for Parkinson’s Disease and Movement Disorders. And later, in the “Dr. RK” segment, Renee Kohanski, MD, asks you to think about some of the complex issues tied to getting treatment for people who are both homeless and have serious mental illness.  *  *  *  Treatment of Parkinson’s-related psychosis  Psychosis related to Parkinson’s disease (PD) is a common reason for hospitalization, institutionalization, and decline of patients with PD. The diagnosis of PD is required before the development of psychosis to diagnose patients with Parkinson's-related psychosis. Parkinsonism that appears after development of psychosis is Lewy body dementia. Many factors influence the development of psychosis in PD. Extrinsic factors include medical illnesses or metabolic derangement causing delirium with psychosis; nonessential dopaminergic medications such as ropinirole and selegiline; anticholinergic medications such as benztropine, amantadine, and bladder antispasmodics; and insomnia. The last resort for treatment of psychosis is levodopa because patients will experience motoric decline and loss of functioning. There are several mechanisms for psychosis to occur via the dopaminergic, serotonergic, and glutamatergic pathways; thus, three neurotransmitters – serotonin, dopamine, and glutamate – can be manipulated to treat psychosis. Quetiapine, clozapine, and pimavanserin are the three antipsychotics safe for use in Parkinson’s disease. Clozapine is infrequently used, because of the risk of neutropenia and required blood work monitoring, but evidence shows that the benefits usually outweigh the risks of motor decline. Quetiapine is commonly used, because it has a favorable effect on sleep and psychosis, but it negatively affects the movement disorder of Parkinson's disease. Pimavanserin (Nuplazid), the only medication FDA approved for hallucinations and delusions associated with psychosis in Parkinson’s disease, is highly selective for the 5-HT2A receptor as both an inverse agonist and antagonist. Primary adverse effects are peripheral edema and confusion, but overall the adverse effects profile is similar to that of placebo. In the pimavanserin clinical trials, a subset of patients worsened and experienced more visual hallucinations. In addition, pimavanserin can prolong the QT interval, so patients taking other QT-prolonging medications or who have cardiac comorbidities should be monitored with an EKG. Post hoc data analysis from as pivotal phase 3 study suggests that patients with cognitive impairment and dementia may receive more benefit from pimavanserin.   *  *  *  References Cruz MP. Pimavanserin (Nuplazid): A treatment for hallucinations and delusions associated with Parkinson’s disease. P T. 2017 Jun;42(6):368-71. Cummings J et al. Pimavanserin: Potential treatment for dementia-related psychosis. J Prev Alzheimers Dis. 2018;5(4):253-8. Huot P. 5HT2A receptors and Parkinson’s disease psychosis: A pharmacological discussion. Neurodegenerative Disease Management. 2018 Nov 19. doi: 10.2217/nmt-2018-0039.  *  *  *  For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  
Michael A. Norko, MD, professor of psychiatry at Yale University in New Haven, Conn., spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about incorporating patients’ spiritual and religious histories into psychiatric evaluations. Dr. Norko, lead author of a paper exploring whether religion is protective against suicide, sat down with Dr. Norris at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP.   Evidence, questions to consider about religion and spirituality Various spiritual and religious factors are linked to decreased rates of suicide behaviors and attempts, including weekly attendance to worship services, personal beliefs about the preciousness of life, and commitment to a faith practice. Which specific parts of religious and spirituality are protective? Are the protective factors the social connection or the spiritual connection alone? Those who attend worship services weekly are at lower risk of suicide. It’s unclear whether weekly attendance is a proxy for the social connectedness or for the level of internalization of the religious beliefs. Commitment to a faith is measured by a consistent and strong belief in the faith tradition. Just because someone says they belong to a faith tradition does not automatically mean a person is at lower risk of suicide. Strong alignment with the faith also is protective. Alignment is different from commitment, because if patients are doubting or their personal beliefs conflict with long-held religious traditions, this can increase patients’ suicide risk.  Questions to ask about spirituality and religion in clinical practice A spiritual and religious history is essential to a psychiatric evaluation, because asking about religion lets the patient know that this is a welcome topic. Examples of questions a clinician can ask include: “Is there any faith tradition that you belong to? How important is your faith or beliefs? Is there anything about your religious beliefs you think are important to your mental health treatment?”  Difficult areas to navigate with religion and spirituality Lack of expertise or personal experience with religion can be a barrier. It is important to remember that patients usually welcome curiosity about their religious beliefs and emotional lives. Clinicians need not be experts in religion, but they can be alert to the salient values and notice whether the person is struggling with certain beliefs. Clinicians also can encourage patients to talk to their clergy. When someone asks a clinician, “What is your faith practice?” this can be approached as an informed consent question. The clinician can ask how talking about their own beliefs or faith practices will deepen and help the therapeutic work of the patient. If a person is feeling let down by a certain failing of their religious community, therapy is a good place to explore what strengths and succor they had received from their religion. Therapy also can be used to guide patients toward additional places, or even substitutes, to meet their needs. Understanding patients’ faith background and beliefs can help clinicians reframe certain crises, especially if the psychiatrist and therapist have talked discussed those crises with patients over time. It’s more useful to understand patients’ faith before the crisis, because grasping for a spiritual or religious answer at the last moment can feel inauthentic.  References  Norko et al. Can religion protect against suicide? J Nerv Ment Dis. 2017. Jan;205(1):9-14. Kruizinga R et al. Toward a fully-fledged integration of spiritual care and medical care. J Pain Symptom Manage. 2018 Mar;55(3):1035-40.   Thomas LP et al. Meaning-centered psychotherapy: A form of psychotherapy for patients with cancer. Curr Psychiatry Rep. 2014 Oct;16(10):488. Lawrence RE et al. Religion and suicide risk: A systematic review. Arch Suicide Res. 2016;20(1):1-21. D’Souza R, George K. Spirituality, religion and psychiatry: its application to clinical practice. Australas Psychiatry. 2006 Dec;14(4):408-12. FICA Spiritual History Tool: https://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool, which is based on Puchalski C and Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000 Spring;3(1):129-37. George Washington University Institute for Spirituality and Health (GWISH): https://smhs.gwu.edu/gwish/
Lorenzo Norris, MD, and Roger McIntyre, MD, talk about obesity, inflammation, and mental illness. The conversation, which originally dropped a few months ago, took place at the Focus on Neuropsychiatry 2019 meeting. The meeting was sponsored by Current Psychiatry and Global Academy for Medical Education. The original podcast included robust Show Notes by Jacqueline Posada, MD. Also, you can watch the conversation between Dr. Norris and Dr. McIntyre on video or on YouTube. Later, Renee Kohanski, MD, talks about different ways to think about resolutions and behavioral change. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych
In this episode of the MDedge Psychcast, we revisit an interview that Lorenzo Norris, MD, MDedge Psychiatry editor in chief, conducted earlier this year by phone with two psychiatrists working in New Mexico. Dr. Norris spoke with Caroline Bonham, MD, and Avi Kriechman, MD, about enhancing resilience in rural communities. Dr. Bonham is vice chair in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is assistant professor in that department, and a pediatrician who works on youth suicide prevention and school mental health.   Understanding risks of suicide in rural communities Nationally, suicide rates have been going up across the United States, including in rural communities. Paucity of mental health clinicians supporting youth and their families has implications for youth suicide. Impact of structural poverty and the opioid epidemic also have implications for these rising rates.  Identifying resources within small, rural communities Communities have resources that are not tapped into enough by clinicians, such as churches, teachers, and community health workers. Recent studies show that most communities have members who know people at risk and want to help. It is important for clinicians to think outside of the box so that they help facilitate the use of natural resources/strengths that exist within small communities, such as food pantries that operate out of mental health centers, spiritual organizations, and aftercare programs in schools.  Building resilience among individuals The literature shows that engaging people in a collaborative, transparent process of care is effective. If community members who do not have problems, such as suicidality, physical ailments, or a severe mental illness, are taught to reach out, destigmatize, and facilitate treatment, the mental health outcomes of patients are better. Concrete, feasible intervention would be to work with gun store owners about the risk factors for suicide, how to encourage people to seek help. Some police departments provide education about the safe storage of firearms. References Curtin SC and Heron M. Death rates due to suicide and homicide among persons aged 10-24: United States, 2000-2017. NCHS Data Brief. 2019 Oct;(352):1-8. Altschul DB et al. State legislative approach to enumerating behavioral health workforce shortages: Lessons learned in New Mexico. Am J Prev Med. 2018 Jun;54(6 suppl 3):S220-9. Bonham C et al. Training psychiatrists for rural practice: A 20-year follow-up. Acad Psychiatry. 2014 Oct;38(5):623-6. Kriechman A et al. Expanding the vision: The strength-based, community-oriented child and adolescent psychiatrist working in schools. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):149-62. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych
Ruta Nonacs, MD, PhD, conducts a Masterclass lecture on treating women with postpartum depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Nonacs is a staff psychiatrist with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital in Boston.  *  *  *   Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *   Features of postpartum depression  Postpartum depression (PPD) affects 10%-15% of women after delivery. For many women, their depression starts in the third trimester and worsens after delivery. Unique symptoms of PPD include difficulties bonding with the baby, feeling like an inadequate mother, and experiencing severe sleep disturbance with anxiety and edginess. In a common scenario, the mother will not be able to sleep at night, though her baby is sleeping well. Anxiety is a common comorbidity, especially obsessive thoughts about the baby’s safety. Treatment of PPD Treatment in this population is complicated by many demands placed on a mother as the primary caregiver of an infant. The medication chosen must target depression and anxiety, improve sleep, yet not be too sedating. The concentration of antidepressants in breast milk is low, but many women will defer treatment for their depression until they’ve stopped breastfeeding. Treatment of mild PPD includes recruiting more support to help the mother with care of the infant and psychotherapy to identify stressors and coping skills. In moderate to severe PPD, antidepressants are needed. Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are the preferred treatments, and studies support the use of sertraline, fluoxetine, paroxetine, and venlafaxine at their standard dosages. SSRIs and SNRIs are compatible with breastfeeding, because the medications are detected in the breast milk at very low levels. Brexanolone (Zulresso) is the only Food and Drug Administration–approved medication for postpartum depression. It is a neurosteroid and derivative of allopregnanolone, which is a positive allosteric modulator of the gamma-aminobutyric acid receptor. Brexanolone has low oral bioavailability and is administered only as a 60-hour infusion in a certified medical setting with continuous monitoring. The trials for brexanolone included women with moderate to severe PPD, and Hamilton Depression Rating Scale scores (HAM-D) scores ranging from 20 to 25. After the 60-hour infusion, 45% of the subjects with severe PPD in the brexanolone group achieved remission by the end of treatment, compared with 23% in the placebo group. Women retained the antidepressant effect at the 30-day follow-up. The results in the moderate PPD group were not as impressive; these women had a decrease in their depression HAM-D scores, but the antidepressant effect did not continue to the 30-day follow-up. The FDA approval came with a Risk Evaluation Mitigation Strategy in place.   Currently, approximately 100 sites are ready to administer brexanolone; however, some obstacles remain: Obstacles to using brexanolone The medication costs more than $30,000 per infusion, and it is uncertain how much insurance will cover. Since brexanolone is administered in hospital settings, women must be separated from their children for several days. Breastfeeding must be stopped while women are on the medication because of the lack of data about excretion in breast milk. Brexanolone is labeled as a Schedule IV medication because it has a similar mechanism of action to midazolam and diazepam. Likelihood of diversion is low, but some women with substance abuse histories might be concerned about this treatment.  References Leader LD et al. Brexanolone for postpartum depression: Clinical evidence and practical considerations. Pharmacotherapy. 2019 Nov;39(11):1105-12. Meltzer-Brody S et al. Brexanolone injection in postpartum depression: Two multicenter, double-blind, randomized, placebo-controlled, phase 3 trials. Lancet. 2018 Sep 22;392(10152):1058-70. Nonacs R. A Deeper Shade of Blue: A Woman’s Guide to Recognizing and Treating Depression in Her Childbearing Years. New York, NY: Simon & Schuster; 2006. Massachusetts General Hospital Center for Women’s Mental Health. womensmentalhealth.org National Institutes of Health. Drugs and Lactation Database (LactMed). *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  
 Roberto Lewis-Fernández, MD, returns to the MDedge Psychcast, this time to discuss ways to approach pharmacotherapy for Latino patients with depression. Previously, on episode 36 of the Psychcast, Dr. Lewis-Fernández discussed the role of cultural assessments in providing person-centered mental health care. Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University and director of the New York state Center of Excellence for Cultural Competence and the Hispanic Treatment Program at the New York Psychiatric Institute, spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP. And later, in the “Dr. RK” segment, Renee Kohanski, MD, asks whether some euphemisms that are becoming more common in society keep us from finding real solutions to problems. *  *  *   Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *   How Latino patients typically think of illness and medications Commonly, patients of Latino descent seek mental health treatment after trying other interventions, such as talking with family, clergy, and primary care clinicians. Latino patients, similar to other patient populations, sometimes present with ambivalence about medications and concerns that the medications might be “fairly strong” or addictive. The need to take medications is seen as an admission of sorts that the presenting problem of depression or anxiety is serious. Specifically, Latino patients are concerned about medications and risk of physical and psychological addiction and being reliant on a crutch. For example, a Latino patient might worry that by taking an antidepressant medication, they will lose their innate ability to improve on their own. This belief plays out when Latino patients stop medication prematurely, just as it begins to be effective, in order to “poner de mi parte,” which translates to “do my share.” The Latino culture puts weight on self-reliance. Latino patients often look for flexibility in medications and express concern about their effect on the body. For example, some patients might want to take medication only on days in which they feel sick. Others might ask for days off from the medication to ensure that the body does not weaken from being dependent on medications. Natural remedies often are favored by Latino patients. In some Latino communities, there might be natural pharmacies and “botanicas,” which provide herbal and vitamin remedies. Natural medicines are viewed as “gentle” and more in line with what the body needs. Psychotherapy for the treatment of mild depression often is favored by patients who want to use therapy before medications. Latino patients usually prefer more "advice"-driven psychotherapy that focuses on problem solving. Possible structural barriers to treating Latino patients Common structural barriers to accessing care include limited time to make appointments because of work and family obligations as well as a fragmented health care system with ever changing clinicians. Stigma and concerns about “harm to the body” can prove to be barriers.  How clinicians might work with Latino patients Be open to being flexible to patients’ requests, such as the desire to perhaps skip a day each week or even stop medications. Exerting clinical authority based on biological understanding of the medication and diagnosis can backfire and can result in patients stopping the medication altogether. Understand different conceptions in the Latino community about how and when emotions should be expressed. The “ataque de nervios” (“attack of nerves”) presented in the DSM-5 as a culture-bound syndrome is indicative of the Latino attitude that emotions are meant to be expressed but also controlled. So “un ataque de nervios” represents a situation that is so overwhelming that emotions take over, such as an attack and cannot be controlled. Know that warmth is more important than expertise in the eyes of some Latino patients. References Vargas SM et al. Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy. Transcult Psychiatry. 2015 Apr;52(2):244-73. Lewis-Fernández R et al. Impact of motivational pharmacotherapy on treatment retention among depressed Latinos. Psychiatry. 2013 Fall; 76(3):210-2. Moitra E et al. Examination of ataque de nervios and ataque de nervios like events in a diverse sample of adults with anxiety disorders. Depress Anxiety. 2018 Dec;35(12):1190-7. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  
Martha Sajatovic, MD, conducts a Masterclass lecture on older-age bipolar disorder from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Sajatovic is professor of psychiatry and of neurology at Case Western Reserve University in Cleveland. She also directs the Neurological and Behavioral Outcomes Research Center at University Hospitals Cleveland Medical Center. *  *  *  Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  Conceptualizing OABD Older–age bipolar disorder (OABD), defined as a person aged 60 years or older with bipolar disorder, makes up one-quarter of bipolar patients. It is a heterogeneous population that includes early- and late-onset disease. Late onset is diagnosed when a person has a manic or hypomanic episode at or after the age of 50 years. Bipolar depression in later life has long been seen as a “special population,” and the treatment has been extrapolated from larger clinical trials of younger patients. Late–onset bipolar disorder usually has attenuated manic episodes and depressive episodes are prolonged and severe. In OABD, the patients are more likely to have multiple morbidities, which makes medication management more complex. People with bipolar disorder lose 1-2 decades of life, compared with the general population. No medications are specifically approved by the Food and Drug Administration for bipolar disorder or bipolar depression in older adults. However, the treatment follows general geriatric psychiatry principles: Start low and go slow.  International guidelines on treating bipolar disorder Starting low means using half or even less of the recommended dose that a clinician would use in mixed-aged populations. Titrate slowly to allow the person time to acclimate to side effects that usually resolve. Bipolar disorder is a chronic disease, so medication adherence is paramount. Adherence can be jeopardized when a person experiences excessive side effects from the beginning of treatment. First-line treatment for bipolar depression in OABD include lurasidone (Latuda) or quetiapine (Seroquel) with low dosing and slow titration. This recommendation is supported by data from a post hoc analysis of the clinical trial data of lurasidone for bipolar depression. Lithium is also recommended and underused. The level should be lower for OABD; an appropriate target for older adults with bipolar disorder is 0.4-0.8 mEq/L, especially in people who are older and frailer. Lamotrigine (Lamictal) also is helpful and fairly well tolerated. Clinicians need to be attentive to a patient’s medical comorbidities and psychosocial support to enhance adherence and improve outcomes. This approach would entail working closely with primary care clinicians and using an integrative approach as the medical comorbidities will influence the success of bipolar treatment.  References Sajatovic M and Chen P. Geriatric bipolar disorder. Psychiatr Clin North Am. 2011 Jun 3;34(2):319-33. Eyler LT et al. Understanding aging in bipolar disorder by integrating archival clinical research datasets. Am J Geriatric Psychiatry. 2019 Oct;27(10):1122-34. Shulman Kl et al. Delphi survey about using lithium in OABD. Bipolar Disord. 2019 Mar;21(2):117-23. Forester BP. Safety and effectiveness of long-term treatment with lurasidone in older adults with bipolar depression: Post hoc analysis of a 6-month, open-label study. Am J Geriatr Psychiatry. 2018 Feb;26(2):150-9. *  *  *  For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych    
This week, we are replaying five interviews that MDedge Psychiatry editor in chief Lorenzo Norris, MD, conducted at the 2019 American Psychiatric Association annual meeting. Dr. Norris spoke with Igor Galynker, MD, (Mount Sinai Beth Israel, N.Y.) about identifying suicide crisis syndrome; Jonathan M. Meyer, MD, (University of California, San Diego) about prescribing clozapine for treatment refractory schizophrenia; Robert M. McCarron, DO, (University of California, Irvine) about psychiatry and primary care; Cam Ritchie, MD, MPH, about preparing patients for disruptions in psychiatric medications; and Richard Balon, MD, (Wayne State University, Detroit) about overcoming resistance to prescribing benzodiazepines for patients with serious mental illnesses. *  *  *   Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *     For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  
Jack Drescher, MD, returns to the MDedge Psychcast, this time to discuss ethical issues raised by the treatment of gender-variant prepubescent children with MDedge Psychiatry editor in chief Lorenzo Norris, MD. The two spoke at the 2019 Group for Advancement in Psychiatry (GAP) meeting in White Plains, N.Y. Dr. Drescher is a Distinguished Life Fellow of the American Psychiatric Association, past president of GAP, and a past president of the APA’s New York County Psychiatric Society. He has a private practice in New York. And later, in the “Dr. RK” segment, Renee Kohanski, MD, says artificial intelligence is much more powerful than we imagined. *  *  *   Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *   Three approaches used to address gender-variant children Despite the acceptance of gender dysphoria as a diagnosis with standardized treatments, the treatment of gender-variant prepubescent children remains a controversial area. There are several treatment approaches regarding how and when a child should have a social transition to their desired gender.  The oldest treatment approach is based on research that shows that most children will grow out of their gender dysphoria when the therapies applied help the children get used to living in the body of their assigned gender. Essentially, this approach discourages public or private social transition.  The Dutch Protocol is based on research that shows the difficulty in predicting which children will continue to have gender dysphoria and which will not. Some children will have persistent gender dysphoria and become transgender; some may become homosexual; and others may identify with their own biological sex. The Dutch approach encourages children to have cross-gender interests and to privately identify with their desired gender, but there is not a public social transition. Families and clinicians use watchful waiting to see whether the gender dysphoria persists. It’s based on the idea that one cannot predict the future and so parents accept the child wherever they are.  The final approach focuses on social transition without a medical or surgical treatment. Therefore, if the child’s gender dysphoria desists, they can “detransition,” since there was no medical intervention. The gender-affirmative approach, mostly found in the United States, presupposes that it is possible to identify which children will persist in their transgender presentations and encourages a public, social transition to living as their identified gender. In case the child “makes a mistake,” they can transition back to their biological sex. A social transition occurs when a child, with the help of clinicians, explains to the family that they believe the gender dysphoria is going to last and that the child should be allowed to present publicly as their desired gender. This includes communicating with the school, family, and friends to help the child to be treated respectfully in the gender they desire.  Treatments for gender-variant children Puberty suppression is a medical treatment used by physicians in all three approaches. These medications block sex hormone action and are used to delay puberty and prevent the development of undesired secondary sex characteristics of the biologic sex. Adolescents frequently experience anxiety, depression, even suicidal ideation during this period because they feel pressured to choose their gender and avoid developing the secondary sexual characteristics of their biological sex.  Social changes are outpacing the science. More frequently, children show up at gender clinics already socially transitioned by their parents; these children outnumber the subjects in the persist and desist literature. Regardless of the approach used, parents and clinicians should try to act on the exigent circumstances to relieve the distress of the child.  Patients who are transitioning should be referred to a specialist, because this is a sensitive topic and treatment requires expertise.  References  Shumer DE et al. Advances in the care of transgender children and adolescents. Adv Pediatr. 2016 Aug;63(1):79-102. Reed GM et al. Disorders related to sexuality and gender identity in the ICD-11: Revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21. Zraick K. Texas father says 7-year-old isn’t transgender, igniting a political outcry. New York Times. 2019 Oct 28. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych
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