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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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Candrice R. Heath, MD, and Nicole B. Washington, DO, MPH, spoke with Psychcast host Lorenzo Norris, MD, about physician mental health. Dr. Heath is affiliated with Temple University Hospital, Philadelphia. She has no disclosures. Dr. Washington disclosed serving as chief medical officer and founder of Elocin Psychiatric Services, a telemedicine company that provides care to physicians. Dr. Norris is a consultation-liaison psychiatrist and medical school dean affiliated with George Washington University, Washington. He has no disclosures. And stick around for Renee Kohanski, MD, who talks about expectations. Take-home points Physicians often delay seeking mental health treatment. Compared with the general population, the risk of suicide is 2.27 times higher in female physicians and 1.4 times higher in male physicians. The COVID-19 pandemic has created additional risk factors for all physicians, including those on the front lines and others whose clinical practices and home lives have changed because of the pandemic. Prevention and mitigation of mental illness start with understanding your own risk factors and stressors and trying to address them before they become overwhelming. Summary During the best of times, physicians are at risk for anxiety, depression, and substance use disorders. The syndromes of demoralization and burnout should be seen as prodromes to clinical diagnoses, such as major depressive disorder. An estimated 300-400 physicians die from suicide each year. Prevention of mental illness starts with identifying one’s stressors, such as balancing personal and professional demands on time; knowing one’s risk factors, such as a history of substance use and previous episodes of distress or psychiatric diagnoses; and thinking about the phases of disaster response. When it comes to the COVID-19 pandemic, are you surging with adrenaline, hitting a plateau, or experiencing a decline? Dr. Washington suggests that her patients focus on what they can control in their lives, because uncertainty and loss of control of our usual routines contribute to stress, anxiety, and fatigue. It is also helpful to reflect on past periods of hardship and resilience to identify strengths and previous strategies used to overcome challenges. Physicians who are not on the front lines are experiencing different forms of hardship, such as financial stress from furloughs and loss of patient volume. There may also be guilt about not addressing the pandemic in the same way as frontline physicians. Even without direct patient care of COVID-19, it must be acknowledged that the impact of the pandemic is everywhere. Most physicians delay seeking mental health treatment. This may particularly occur for physicians with better “lifestyles,” such as dermatologists, who some may view as suffering less. This pandemic is a reminder that all physicians need to take care of themselves, regardless of specialty. We are all adjusting to the “new normal,” so in times like this, it is helpful to seek practices such as mindfulness and “radical acceptance,” the latter of which is part of dialectical behavior therapy. Accepting reality with judging and setting expectations at a realistic level can help prevent suffering. References Phases of disaster timeline: https://www.samhsa.gov/dtac/recovering-disasters/phases-disaster American Psychiatric Association Well-being Toolkit: https://www.psychiatry.org/psychiatrists/practice/well-being-and-burnout/well-being-resources Radical acceptance by Tara Brach, PhD: https://www.youtube.com/watch?v=_K35O3G82L4 Facts about physician suicide: https://www.acgme.org/Portals/0/PDFs/ten%20facts%20about%20physician%20suicide.pdf *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Bill Scheidler, MD, is assistant clinical professor of psychiatry at the University of North Carolina, Chapel Hill. He also is associate training director for the consultation-liaison fellowship at UNC and is a lead consultant at UNC Hospitals Hillsborough. Dr. Scheidler spoke with host Lorenzo Norris, MD, about how to think through patients’ decision-making capacity in medical (rather than psychiatric) hospitals. Neither Dr. Scheidler nor Dr. Norris have disclosures. Take-home points Decision-making capacity (DMC) is essential to informed consent, which is providing patients with the information necessary to make an informed decision about medical or surgical care. Standards differ, depending on the U.S. state. DMC has four components, as defined by Paul Appelbaum, MD, and colleagues: The ability to make and communicate a consistent choice The ability to understand the information provided about medical conditions and decisions The ability to appreciate the consequences of a choice The ability to reason through the decision In the sliding-scale model of DMC, not all decisions carry the same weight. The assessment evaluates the risk-benefit ratio of a particular decision, and the bar for capacity depends on the ratio. When a patient lacks capacity and treatment over objection is pursued, the outcome is highly dependent on the hospital and state laws. Clinicians should confer with their risk management and legal team. Summary A capacity assessment usually is implicit in the process of informed consent because clinicians usually are assessing whether the patient truly understands what they are consenting to. In the legal literature, “capacity” and “competency” are used interchangeably, but in the medical field they are different. It is easier to refer to adjudicated competency in which a judge legally determines a person’s ability to make decisions. Usually, a person lacking adjudicated competency has a guardian to guide their decisions. In contrast, DMC is time and decision specific. A DMC assessment includes evaluation of the four components of capacity, including making a consistent choice, understanding the medical condition and decision, appreciating the risks, and using intact reasoning. It is a low bar of DMC for a decision that has a high benefit and low risk (e.g., a blood draw or an x-ray). An intervention that is high risk and low benefit, such as an experimental treatment, would require the highest bar of capacity for consent. The lowest bar for DMC is when the patient decides who should make medical decisions for them. In capacity assessments, clinicians must remember that a patient’s desire for a certain outcome does not translate into DMC. In these impassioned cases, clinicians need to stick to the four components of capacity in their assessment. The presence of mental illness does not preclude DMC. It is helpful to consider whether the person’s psychosis or symptoms of their disorder are influencing the decision. If a patient lacks capacity, a surrogate decision maker should be identified. With a surrogate decision maker, it’s more likely the patient’s wishes will be honored. The surrogate decision maker hierarchy differs state by state. Implicit in most DMC assessments are several questions, including: What do we do next if the person lacks capacity? Treatment over objection and the outcome are highly dependent on the hospital and state laws, so clinicians need to confer with their risk management and legal team. Usually, there are specific legal statutes to guide how to proceed if a patient's incapacity puts them at danger of harm. When treatment over objection is the only option, teams must consider whether treatment can be delayed, and what the alternative treatments should be. The mechanisms for keeping people in the hospital are usually are coercive. References Appelbaum PS. N Engl J Med. 2007;357(18):1834-40. Appelbaum PS, Grisso T. N Engl J Med. 1988;319(25):1635‐8. Wynn S. Decisions by surrogates: An overview of surrogate consent laws in the United States. American Bar Association. 2014 Oct 1. Centers for Disease Control and Prevention. Legal authorities for quarantine and isolation.  National Conference on State Legislatures. State quarantine and isolation statutes. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Renae Beaumont, PhD, assistant professor of clinical psychology at New York–Presbyterian/Weill Cornell Medical Center, spoke with host Lorenzo Norris, MD, about the Secret Agent Society. The Secret Agent Society is a video gaming–based therapy program aimed at helping children with a range of social and emotional challenges learn the social skills required to make and keep friends. The program also helps children feel happier, calmer, and braver. Dr. Beaumont disclosed her role as creator of the Secret Agent Society program. Dr. Norris has no disclosures. Take-home points The Secret Agent Society is a video gaming–based program that helps children detect how another person is feeling through the interpretation of facial expressions, body language, and vocal tone; use skills to socially engage; and to internally detect their own emotions. Secret Agent Society is meant to engage children. It can be used during clinical/therapy sessions to stimulate discussion as well as at home with parents. The indicated age range is 8-12 years, and it is useful for children with autism and with average intellectual functioning. Summary The Secret Agent Society video game has four levels. Level one is about detecting emotions from facial expressions, vocal recognition, and body language. Level two is about detecting personal emotions and using scales to identify the components and range of emotions. Levels three and four are about navigating common social challenges in real time, from losing in a game to collaborating in a group project and learning calming techniques for themselves. To encourage practical application, there is a secret agent journal section where participants can chronicle how they used their skills. Beaumont initially developed the game to help children who are on the autism spectrum. For many children on the spectrum, social skills are not innate, but can be taught and developed into life skills to help children meet their potential. Parents might be conflicted about encouraging their children to play video games. It’s important to consider the evidence behind the game and the age and skills of the research participants. In general, parents should favor video games that teach skills, have educational context, and allow parental involvement. Now that much of social interaction is over the virtual sphere and social media, games and exercises that teach social skills over these mediums help build skills early. The Secret Agent Society is meant to engage children. It can be used during a clinical/therapy to stimulate discussion and at home with parents. The game is also a helpful adjunct for psychological services offered online. The indicated age range is 8-12 years, as well as for children with autism and within average age intellectual functioning. New research is showing that the game may also be effective for children with social anxiety and ADHD. Gameplay can be integrated into what a clinician is already doing, or the Social Skills Training Institute offers online training for clinicians that would be helpful when using the game to treat patients with multiple comorbidities. Therapeutic gaming is useful during social distancing because it builds coping skills and helps children feel more in control of their emotions and actions. References Einfeld SL et al. J Intel Dev Disabil. 2018;43(1):29-39. Sofronoff K et al. Develop Disabil. 2015 Apr 28. doi: 10.1177/1088357615583467. Beaumont R, Sofronoff K. J Child Psychol Psychiatry. 2008 Jul;49(7):743-53.  Dr. Renae Beaumont’s TEDx Talk: https://www.youtube.com/watch?v=KQVv2hKipYQ Secret Agent Society/Social Skills Training Institute: https://www.sst-institute.net/ Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Frederick S. Barrett, PhD, is affiliated with the Center for Psychedelic & Consciousness Research (@JHPsychedelics) at Johns Hopkins University, Baltimore (@Hopkins Medicine). Dr. Barrett spoke with Nick Andrews (@Nick_Andrews_) at @TEDMED 2020, about the research that has been conducted by the Center for Psychedelic & Consciousness Research on the impact of psychedelics, or hallucinogens, on psychiatric disorders. He has no disclosures. Take-home points Dr. Barrett transitioned into neuroscience research through his interest in the effect of music on human emotions and the brain. Until 1970, psychedelics such as psilocybin were widely used in clinical research, with more than 1,000 academic papers published about their use. For example, psychedelics were used as a model for schizophrenia and helped identify the role of serotonin in psychosis. They were also studied to treat addiction and as a treatment for existential anxiety in cancer. In 1970, psychedelics were deemed illegal by the Controlled Substances Act which brought the United States in compliance with the 1971 Convention on Psychotropic Substances. Roland R. Griffiths, PhD, and a group at Johns Hopkins have led the way in reestablishing clinical research using psychedelics. Enthusiasm at the lab is borne out by the potential that this research might help many people. Institutional concerns also are at work because of the “rich and sordid history” of these compounds. In the next 10 years, Dr. Barrett would like to have a clear understanding of the effect size of psychedelics on mood and substance use disorders. Psychedelic agents have a novel therapeutic quality: Studies support that a few or even one exposure to a psychedelic compound has a short-term biological effect and can lead to a long-lasting therapeutic effect, such as remission of mood disorder or change in personality characteristics. The clinical outcomes are mediated by the intensity of the psychedelic experience. Summary The Center for Psychedelic & Consciousness Research is working to discern which medical indications have the most promise for being treated with psychedelics. Its goal is a balanced and rational approach to psychedelic research and subsequent treatment considering the societal and political contexts around these drugs. Dr. Barrett trained in music education and psychology and has been a musician all this life. He moved into neuroscience during graduate school and used music as a tool to study emotions and the brain. Music, meditation, and psychedelics have the similar flow component that inspires converging research questions and a desire to analyze the brain and understand this experience that is central to consciousness. Music is fundamental to the human experience, and it is exciting to try to describe the neural circuitry of how music affects the brain and emotions. Music is useful in therapy because it can regulate emotions. There has long been an overlap of the use of psychedelics and music in therapy. A prime example of this is guided imagery and music (GIM), which is a specialized form of therapy that arose out of work done by Helen Bonny, PhD, a nurse, music therapist, and concert violinist. Bonny developed a protocol for using music to regulate emotions during psychedelic experiences. In the next 10 years, Dr. Barrett would like to have a clear understanding of the effect size of psychedelics on mood and substance use disorders. It will be interesting to see whether and how psychedelics are efficacious in treating an array of substance use disorders. If effective, they would be a single-use treatment for addiction to substances that interact with diverse neural circuits. References Barrett FS et al. Sci Rep. 2020 Feb 10. doi: 10.1038/S41598-020-59282-y. Barrett FS, Griffiths RR. Curr Top Behav Neurosci. 2018;36:393-430. Barrett FS et al. Int Rev Psychiatry. 2018;30(4):350‐62. Griffiths RR et al. J Psychopharmacol. 2018 Jan;32(1):49-69. Barrett FS, Janata P. Neuropsychologia. 2016 Oct;91;234-46. Johnson MW et al. Am J Drug Alcohol Abuse. 2017 Jan;43(1):55-60. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Anne Marie Albano, PhD, professor of medical psychology and psychiatry at Columbia University, New York, and director of the Youth Anxiety Center at New York–Presbyterian Hospital, discusses strategies for treating childhood, youth, and young adult anxiety with Nick Andrews. Dr. Albano (@AnneMarieAlbano), who also is director of Modern Minds, an anxiety and depression program in Charleston, S.C., spoke with Nick (@Nick_Andrews_) at @TEDMed 2020. Dr. Albano has no conflicts of interest. Take-home points Early identification of activity avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance. Parents should validate that facing anxiety is difficult and that the child might be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears rather than to accommodating and enabling. In 2008, Dr. Albano and colleagues published a randomized, controlled trial in the New England Journal of Medicine showing that sertraline, cognitive-behavioral therapy, or a combination of both are all more effective treatments for anxiety than placebo. The treatment effect degrades over time as the developmental challenges change, so children will need booster sessions or must return to treatment. Young adults sometimes misinterpret “normal” emotions of apprehension with overwhelming anxiety that disincentivizes them to engage in activities. Therapy teaches children to “ride the wave” of anxiety and continue to move toward new experiences. Dr. Albano is currently developing a program that uses virtual reality to role-play difficult developmental experiences that cause anxiety and help young adults learn how to advocate for themselves and problem-solve through anxiety. Summary Dr. Albano noticed that, when parents do not push children to participate or let them get out of activities, this can exacerbate the child’s anxiety. Early identification of avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance. As a strategy, parents can offer children a choice of activities and push for the child to choose one of them. Parents should validate that facing anxiety is difficult and the child may be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears instead of accommodating and enabling. The psychotherapy treatments focus on “riding the wave” of emotions that come with new or intimidating experiences and pushing toward exposures. Young adults sometimes misinterpret “normal” emotions of apprehension with overwhelming anxiety, and this confusion disincentivizes engaging in activities. Dr. Albano has always integrated parents into treatment. Working with parents means finding the balance between the parents swooping in to help or rescue the child with coaching, setting limits, and pushing children toward experiences that will be exposures to anxiety. The biggest challenge is the extent to which technology tethers parents to children and builds dependency. More research needs to be done on what types of children progress with specific types of treatment, how long to stay in treatment, how to transition out of treatment, and when to offer booster sessions. Dr. Albano wants to expand treatment out of clinics and to the places in the community where anxiety happens and is at risk of hindering child development. References Walkup JT et al. N Engl J Med. 2008 Dec 25;359(26):2753-66. Kagan ER et al. Child Psychiatry Hum Dev. 2020 Apr 6. doi: 10.1007/s10578-020-009883-w. Hoffman LJet al. Current Psychiatry Rep. 2018 Mar 27. doi: 10.1007/s11920-018-0888-R. Chen A. For kids with anxiety, parents learn to let them face their fears. NPR. Morning Edition. 2019 Apr 15. McGuire JF et al. Depress Anxiety. 2019 Aug;36(8):744-52. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Cheryl A. King, PhD, clinical psychologist and professor in the department of psychiatry at Michigan Medicine, the academic health system at the University of Michigan, Ann Arbor, joined Nick Andrews at TEDMED2020. Dr. King spoke with Nick (@Nick_Andrews_) at @TEDMed about a suicide risk screen for teens that is based on computerized algorithm. Take-home points Dr. King is a longtime researcher in teen suicide, and her current project is creating a personalized adaptive suicide risk screen for teens called CASSY (Computerized Adaptive Screen for Suicidal Youth). In an adaptive algorithm, subsequent questions will change based on the previous answer. The aim is to create a profile of risk factors and warning signs to generate a risk level that will guide the type of mental health interventions required in the ED and beyond. CASSY also is being developed as a universal screen for those who might come to the ED without a mental health history. Many teens who die by suicide do not have previous contact with mental health professionals. More research is being done to create and validate treatment interventions for at-risk teens so the risk levels generated in the ED can be met with evidence-based interventions for preventing suicide. With the scarce mental health resources in some areas, Dr. King and associates have created an intervention that trains youth-nominated adults from within families to intervene in times of crisis. Summary The CASSY is based on computerized algorithms from data collected by the Pediatric Emergency Care Applied Research Network (PECARN). Within this network, thousands of teens in mental health crisis, after suicide attempt or not, have completed a suicide risk survey aimed at modeling specific warning signs and risk factors for predicting suicide attempts in the next 3 months. In an adaptive algorithm, subsequent questions will change based on the previous answer. The risk factors for teen suicide are well established, but teens who attempt are a heterogeneous group. The key to predicting an imminent risk of suicide depends on developing profiles of risk based on how the risk factors and warning signs group together. The result of the CASSY is a level of risk. Individual institutions can set their risk levels. CASSY is being developed as a universal screen for those who might come to the ED without a mental health history. Many teens who die by suicide do not have previous contact with mental health professionals. The goal is for CASSY to be integrated into a medical system’s EHR in order to make it easier to use on a broad population. The most common intervention in an ED for suicide risk is creating a safety plan that involves identifying warnings signs for decompensated mood, brainstorming coping skills, and delineating emergency contacts and a plan of action for suicidal emergency. Dr. King and associates developed the Youth-Nominated Support Team intervention, which harnesses the strength of the adults in the family to bolster treatment as usual. The teens nominate “caring adults” who they want to support them after hospitalization, and the adults are provided psychoeducation and training to more effectively support the teens. Dr. King is also working on a National Institute of Mental Health–supported study to identify the 24-hour warning signs for suicide attempts. Dr. King thinks there is more work to be done combining the screening tools with interventions in the ED and beyond. References King CA. J Am Acad Child Adolesc Psychiatry. 2019 Oct;58(10):S305. King CA et al. J Clin Psychol Med Settings. 2017 Mar;24(1):8-20. King CA et al. JAMA Psychiatry. 2019 Feb 6;76(5):492-8. King CA et al. J Am Acad Child Adolesc Psychiatry. 2019 Dec 9. doi: 10.1016/j.jaac.2019.10.015. ASQ toolkit for suicide screening: https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Lorenzo Norris, MD, touches base with Nick Andrews to discuss COVID-19 and to welcome Jacqueline Posada, MD, as an occasional cohost of the MDedge Psychcast. Dr. Posada, associate producer, interviews Lynne S. Gots, PhD, about treating anxiety, obsessive-compulsive disorder, and other disorders in the midst of the COVID-19 pandemic. Dr. Gots is an assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington. She has a private psychotherapy practice and has no financial relationships to disclosure.   Take-home points Anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. Anxiety is an adaptive response to a threat, and COVID-19 and its repercussions makes this a threatening time. In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety. Consider the following suggestions for working with anxious patients and clinicians: Acknowledge that social media has the potential for shaming and worsening social anxiety. Limit exposure to news and social media as much as possible. Monitor patients for excessive reassurance-seeking behaviors, and enact ERP plans. Establish a regular but flexible routine with boundaries between work, home, and rest. Practice self-compassion by lowering expectations and even using formal self-compassion practices. Summary Cognitive-behavioral therapy is an evidence-based therapy for obsessive-compulsive disorder (OCD) and many forms of anxiety and depression. Acceptance and commitment therapy (ACT) is considered a third-wave modality of CBT. The acceptance component is based on mindfulness and acceptance of “what is.” The commitment component involves identifying core values and actions so that a person can use his/her values as a guide to behaviors. The goal is not to eliminate anxious or obsessional thoughts but to accept they are there and work alongside them. Clinicians should be aware that anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. For example, a person’s OCD rituals may not be worsened, but an underlying tendency for perfectionism could be triggered as he/she tries to practice “the perfect quarantine.” Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety. Clinicians can look for reassurance-seeking behaviors that have cropped up with increased anxiety. For example, for a person with contamination anxiety, it might be tempting to wash for longer than 20 seconds or to wipe things down compulsively. Advise patients to pick a routine, such as washing for 20 seconds and no more. Individuals can choose a reputable source and follow its guidelines. The key is to avoid falling into the trap that more reassurance-seeking behaviors will alleviate anxiety. Using excessive reassurance-seeking behaviors can lead to increased anxiety through the conditional learning mechanism of negative reinforcement.   Other helpful suggestions Social media contains a potential for shaming based on comparing oneself and behaviors to others, so individuals should limit exposure to it. News intake should be limited to 1 hour a day, and only reputable sources should be used. Video calls also can trigger social anxiety because individuals literally have to see themselves more often than usual. Ways to minimize this anxiety include minimizing your personal image or covering the image with a Post-it note. For people who are at home all day, establish a routine with a regular wake and sleep time and scheduled breaks. Some type of boundary between home and work life should be created. Self-compassion should be practiced. The first step is to lower expectations and live according to your values and what is realistically possible given the extensive changes in the past month. Professionals need to seek support from other professionals going through the same thing, so connect with a colleague who can relate to your situation. Remember that, as mental health professionals, we are a repository for everyone else’s anxiety and suffering, so we need to be kind to ourselves. Consider using a self-compassion practice. Recognize that you are suffering. Connect with the community: Everyone is suffering. Hold that suffering and offer yourself words of compassion and loving kindness. References and resources Dr. Gots’s website: https://cognitivebehavioralstrategies.com/ Blog post by Dr. Gots that summarizes her clinical advice: https://www.nami.org/Blogs/NAMI-Blog/March-2020/How-to-Protect-Your-Mental-Health-during-the-Coronavirus-Outbreak Suggestions for when and how to decontaminate groceries: https://www.seriouseats.com/2020/03/food-safety-and-coronavirus-a-comprehensive-guide.html Self-compassion practice suggestion: https://self-compassion.org/exercise-2-self-compassion-break/ Supportive touch practice for times of stress and vulnerability: https://self-compassion.org/exercise-4-supportive-touch/ Self-compassion evidence-based resources: https://self-compassion.org/the-research/ International OCD Foundation: https://iocdf.org/ *  *  *   Show notes by Dr. Posada, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com  
Lorenzo Norris, MD, interviews Mary D. Moller, DNP, MSN, about taking advantage of the polyvagal theory of anxiety and social engagement during psychotherapy. Dr. Moller is associate professor of nursing at Pacific Lutheran University in Tacoma, Wash., where she coordinates the psychiatric mental health nurse practitioner doctorate nursing practice program. She also is in practice at Northwest Integrated Health. Dr. Moller has no conflicts of interest. Later, Renee Kohanski, MD, discusses the sacred relationship that exists between doctors and patients. Take-home points The polyvagal (PV) theory relates autonomic nervous system functions to human behavior and response to trauma. The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which together regulate the autonomic state in response to the environment and influence behavior. The unmyelinated dorsal vagus nerve controls the “freeze response,” while the myelinated ventral vagus nerve modulates social communication and can inhibit the arousal state. This theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagus nerve. It’s easier to apply the insights of polyvagal theory in person, but Dr. Moller suggests specific techniques during teletherapy. She prioritizes eye contact, which has to be done by looking at the camera; modulating your tone of voice to be more soothing; and having the patient use biofeedback techniques, such as taking their pulse during a session to make note of their physical response to anxiety. Summary The association between the sympathetic nervous system and “fight or flight” is well known. The polyvagal theory relates autonomic nervous system functions to behavior and response to trauma. The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which regulate the autonomic state in response to the environment and influence behavior. The unmyelinated dorsal vagus nerve innervates from the diaphragm down, controlling the “freeze” response. When the dorsal vagus nerve is activated, physical signs can include bradycardia or tachycardia, shallow breathing, and a “pit in the stomach” feeling from slowing down the GI tract. The myelinated ventral vagus nerve innervates from the diaphragm up, and modulates social communication and engagement, which can inhibit the arousal state. Social engagement is attunement to the subtle cues occurring during engagement with another person. The PV theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagal nerve. In the PV theory, the concept of “neuroception” is likened to an unconscious threat detector sensed by the vagus nerve before the threat is registered by the brain. Coregulation is using the environment, most commonly the physical and emotional response of another person, for emotional regulation. This occurs in the therapeutic dyad when the therapist is attuned by and not enmeshed with the patient. Think of coregulation as akin to attachment theory; when the parent is attuned and present, the child feels safer and is able to relax. Dissociation is the “freeze” mechanism of reacting to traumatic events in the moment, and again when the memories are triggered by stimulus in the environment. One way to treat dissociation is through engaging the ventral vagus nerve using social connection, such as gentle voice, gentle touch, and deep breathing or other grounding exercises. The PV theory connects the physical and emotional responses to trauma. It is impossible to physically connect through telehealth, so Dr. Moller prioritizes eye contact by looking at the camera, though this means taking one’s eyes off the patient, as well as having the patient take their own pulse to reinforce the use of biofeedback, and “breathing together” over the video treatment. References Dana DA, Porges SW. The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation (New York: W.W. Norton & Co., 2018).   Porges SW. The polyvagal perspective. Biol Psychol. 2007;74(2):116-43. Beauchaine TP et al. Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biol Psychol. 2007 Feb;74(2):174-84. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
Jay H. Shore, MD, MPH, returns to the Psychcast, this time to conduct a Masterclass lecture on using telepsychiatry in a regulatory environment that is quickly changing because of the physical distancing forced by the COVID-19 pandemic. Dr. Shore is director of telemedicine at the Helen and Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also directs telemedicine programming at the medical center’s department of psychiatry. He disclosed serving as chief medical officer of AccessCare Services and receiving royalties from American Psychiatric Association Publishing and Springer. Take-home points Practicing telepsychiatry has administrative, technological, and clinical considerations. Administrative concerns include licensure, prescribing, billing, and establishing a procedure and protocol, especially about emergencies. Technological considerations include choosing software, understanding HIPAA compliance during the current COVID-19 crisis (and afterward), and incorporating a virtual clinic workflow, such as scheduling and billing. Clinical considerations include understanding how to manage a hybrid relationship with patients and tailoring your clinical style to teleconferencing, such as reading body language through video and directing the environment as the clinician. Basic dos and don’ts: The clinical space for teleconferencing of both clinician and patient must be private and secure. Every person in each room must be introduced. The webcam should be placed on top of the computer screen that so eye contact is maintained, and the clinician’s head should take up two-thirds of the screen. Administrative considerations To practice telepsychiatry, typically psychiatrists must be licensed in the state in which the patient is located, with some exemptions within federal systems. During the COVID-19 pandemic, however, many states have waived this requirement. Inform your malpractice company that you are now participating in telepsychiatry to ensure that you are covered. During the COVID-19 crisis, the federal government has waived the Ryan Haight Act to allow the prescription of controlled substances without an initial in-person visit. Tips for dealing with an emergency: The psychiatrist should establish the physical location of the patient at the start of every appointment and document how to get a hold of them if the connection is lost. It’s helpful to know how and when to contact local emergency services; 911 is often a local call based on the GPS of the cell phone. American Telemedicine Association and American Psychiatric Association guidelines suggest using a patient support person. That person would either be a family member or close friend who is onsite during the event with whom you have preconsent to contact the clinicians if an emergency occurs. Technological considerations Telepsychiatry services should have a procedures and protocol document to outline scheduling, billing, documentation, and how to address psychiatric emergencies. For telemedicine, the videoconferencing software must be HIPAA compliant. During the COVID-19 emergency declaration, the Department of Health & Human Services’ Office for Civil Rights will exercise “enforcement discretion” and, in most cases, waive penalties of HIPAA enforcement for clinicians who are serving their patients in good faith. Use only technologies such as FaceTime or Skype if you are unable to make adequate connection with HIPAA-compliant technology. Take your in-person operational workflow and try to replicate it virtually. Make sure that people’s responsibilities are clearly delineated. Clinical considerations “Hybrid relationships” are increasingly more common with in-person and virtual interactions from videoconferencing, patient portals, email, etc. In hybrid relationships, there are both physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. The virtual space often is convenient and provides a sense of physical and emotional space between clinician and patient, with advantages and disadvantages. The virtual space means rendering care to the patient in their home and gives insight into their environment. The virtual space can also decrease stigma because the patient does not have to seek care in a physical clinic. Sometimes, more small talk than usual about the environment is helpful to bridge that virtual gap. Use more active inquiry into emotions or body language if these are not clearly communicated over videoconference. Dos and don’ts: Make sure that the lighting is good. Use the picture setting, so you can monitor your body language during the session. Make sure you are not too passive during the session. Be proactive. Animate yourself a little more than you would in person. Ask patients questions about their environment. Have a lower threshold for asking how patients are doing. More active inquiry can prove helpful. References American Psychiatric Association Telepsychiatry Toolkit: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit American Telemedicine Association: https://www.americantelemed.org/ Joint guideline on telepsychiatry from APA and ATA: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-and-ata-release-new-telemental-health-guide State licensure exemptions: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf HHS HIPAA information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html Ryan Haight Act information: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/ryan-haight-act Yellowlees P and Shore JH. Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals. Arlington, Va.: American Psychiatric Association Publishing, 2018. 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. She has no disclosures. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com
As the nation’s health care system braces for COVID-19 cases, physicians who’ve faced the pandemic first have critical lessons for everyone. In this bonus episode, two Seattle-area critical care leaders explain how their medical centers are preparing for and responding to their region’s early outbreaks. And they share some creative approaches that are uniting Seattle’s critical care departments.
MDedge Psychcast host Lorenzo Norris, MD, interviews Steven Wengel, MD, about the challenges of loneliness in geriatric populations in nursing homes, especially during the current COVID-19 pandemic. Dr. Norris also discusses potential interventions with Dr. Wengel, who is a geriatric psychiatrist at the University of Nebraska Medical Center in Omaha. And later, in the “Dr. RK” segment, Renee Kohanski, MD, talks about how, in the midst of the pandemic, we are slowing down while we’re speeding up … and are learning how to use – and not abuse – technology. Take-home points Loneliness has been defined as a form of social pain; it is more than sadness or a “state of mind.” Loneliness and being alone are separate issues suggesting that loneliness is more of an emotional state and being alone is often a choice. Loneliness can be characterized as deficits in authentic interactions and connection because you can be surrounded by people and still feel lonely. Loneliness has been studied as a predictor of health problems and is identified as a risk factor for early mortality and dementia and as a predictor of chronic illnesses such as depression. When it comes to treating loneliness in the geriatric population, favor any type of intervention over none and avoid chalking up symptoms as “just loneliness.” Basic interventions include providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive type symptoms with an SSRI. Summary In a study of nursing-home patients, 9% report loneliness often or always and 25% report loneliness sometimes; older adults are more susceptible to loneliness secondary to frailty and limited transport options. Loneliness is an independent risk factor for early mortality and a predictor for other chronic diseases including dementia, hypertension, depression, and overall poor health. During the COVID-19 pandemic, most nursing homes are under lockdown, and all visitors are barred to minimize the introduction of COVID-19 to the facilities. This means residents are unable to see family and loved ones. This necessary intervention brings up the question of quality of life over quantity of life for older individuals. Isolation and social distancing have also taken away group activities like communal meals and games with socializing. Children of institutionalized patients might also feel a sense of loss and guilt as they are not allowed to see their loved ones. Particular to geriatrics, physical touch is essential to healing emotional pain, for example, a gentle touch or massage to relieve anxiety or physical redirection to ease agitation secondary to dementia. Two primary means of addressing loneliness for the geriatric population include providing structure and finding opportunities for volunteerism such as helping other residents or completing simple tasks within the institution. Loneliness and major depressive disorder are difficult to differentiate in the older population. Dr. Wengel recommends favoring intervention over none. This means using basic interventions like providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive symptoms with an SSRI. References Jansson AH et al. Loneliness in nursing homes and assisted living facilities: Prevalence, associated factors and prognosis. Jour Nursing Home Res. 2017;3:43-9. Social isolation, loneliness in older people pose health risks. National Institute on Aging. https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks. Cacioppo JT. Loneliness: Human Nature and the Need for Social Connection. New York: W.W. Norton and Company, 2008. *  *  *   Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: 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  
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