Psychcast

In this segment of Clinical Correlation, Dr. Renee Kohanski completes part 2 of her review of the most effective treatments for patients with severe anxiety. She also announces that, after almost 200 episodes, the Psychcast is taking an indefinite pause. To reach Dr. Kohanski, email her at DocReneePodcast@gmail.com. To reach Dr. Lorenzo Norris, host of the Psychcast, email him at lnorris@mfa.gwu.edu. Clinical Correlation was published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Craig Chepke, MD, speaks with Lorenzo Norris, MD, about changes he made to his practice during the COVID-19 pandemic, and plans to make some of those changes permanent. Dr. Chepke is a psychiatrist in Huntersville, N.C., and adjunct associate professor at Atrium Health and adjunct assistant professor at the University of North Carolina at Chapel Hill. He disclosed serving as a consultant and speaker for Otsuka and Janssen, and as a speaker for Alkermes. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Chepke discussed his strategies for adapting his practice to the restrictions of the pandemic. He engaged in shared decision-making with patients when modifying his practice, including starting a drive-through pharmacotherapy clinic. To ensure that patients continued to have access to treatments such as long-acting injectable antipsychotics and esketamine, Dr. Chepke created a system in which patients could drive up to his clinic to have the medication administered. Because esketamine requires a 2-hour monitoring period after administration, he adapted the safety protocol. After patients received their intranasal spray dosage, they would complete the monitoring period in their car in the parking lot outside of his office, which was close enough to the clinic for Dr. Chepke to physically observe the patient, and to monitor vital signs wirelessly via a Bluetooth-enabled blood pressure cuff. Throughout the pandemic, Dr. Chepke found ways to care for his patients’ physical and mental health. He also adopted technologies that help him monitor his patients' vital signs and glucose levels. Especially while focusing on treatment-resistant psychiatric illness, Dr. Chepke invites family members to participate in evaluation and treatment. He uses this approach because he realizes that effective treatment must involve the system in which the individual exists. Dr. Chepke and Dr. Norris discussed ways in which clinicians can extend hope to their patients through flexibility and innovation, especially throughout the pandemic. Providing hope to patients demonstrates belief in a better future. Reference Chepke C. Current Psychiatry. 2020 May;19(5):29-30. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com  

John “Jack” Rozel, MD, MSL, returns to the Psychcast to talk with Lorenzo Norris, MD, about American gun violence and steps clinicians can take to disrupt it. Dr. Rozel is medical director of the resolve Crisis Network. He also serves as associate professor of psychiatry and adjunct professor of law at the University of Pittsburgh. Dr. Rozel is also past president of the American Association for Emergency Psychiatry. He has no disclosures. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Mass violence with guns is occurring with greater frequency and severity in the United States, compared with other countries. Mass shootings have been on the rise. In 2020 there were nearly 200 more mass shootings, compared with 2019. The United States has a broad swath of firearm violence: Deaths by suicide account 60% of gun deaths, and the remaining 40% are deaths by homicide. Only 1%-2% of firearm homicides are completed in mass shootings – which are defined as an event in which four or more people are shot in an indiscriminate manner. It is also a distinctly American problem that we have so many guns in our country. The United States has more civilian-held firearms (393 million) than the next 39 countries combined. Being an adult in the United States means being 25 times more likely to be the victim of a firearm homicide, compared with adults in any other country. Dr. Norris and Dr. Rozel conclude that violence assessments must always cover suicide and homicide risk because they are related types of violence, especially when it comes to guns. Summary Suicide risk is increased by 100-fold when a new gun enters the home, and the risk peaks in the first days to weeks of ownership and then trails off. However, there is a measurable difference in risk of suicide in the 5 years after the purchase. Dr. Rozel emphasizes that it is essential to ask patients about acquisition of new guns, because as circumstances change as with the pandemic, people may feel the need to buy a gun. Dr. Rozel presented a model for possibly reducing gun violence: Grievance: All violence starts with feeling like a victim; some people feel aggrieved after a disagreement or even a threat. The Pivot: This is a transition from simply having a grievance to violent ideation and wanting vengeance through violence. Perpetrators of violence shift from fantasy into research about planning and preparing to attack. Preparation: This stage includes acquiring weapons and, in some cases, tactical clothing. It also could include probing into their targets’ vulnerabilities, a “test attack,” and eventually the final attack. Breach: This entails a change in the safety of the potential victim.  Attack: This stage encompasses perpetrating the attack. Identifying a person at the grievance stage is the most effective place to intervene and potentially diffuse a violent situation by using motivational interviewing to enhance protective factors. Psychiatry’s greatest strength is meeting the aggressor where they are and hearing out the grievance. References Victor D and Taylor DB. A partial list of mass shootings in the United States in 2021. New York Times. 2021 Apr 16. Kim NY. Gun violence spiked during pandemic, even as the deadliest mass shootings waned. Poynter.org. 2021 Mar 25. Rozel JS and Mulvey EP. Annu Rev Clin Psychol. 2017 May 8;13:445-69. Metzl JM et al. Har Rev Psychiatry. 2021 Jan-Feb 01;29(1):81-9. Firearm access is a risk factor for suicide. Harvard School of Public Health. National Council for Behavioral Health. Mass Violence in America: Causes, impacts, and solutions. 2019 Aug. Gun Violence Archive *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

In the first part of a two-part series on anxiety disorder, Dr. Kohanski shares what may be some surprising facts information about prescribing of the tried-and-true agents of anxiety, along with some clinical pearls. Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Omar Sultan Haque, MD, PhD, talks with Lorenzo Norris, MD, about the need for medical schools to become responsive to physicians, medical students, and residents with mental disabilities. Dr. Haque is a physician, social scientist, and philosopher who is affiliated with the department of global health and social medicine at Harvard Medical School, Boston. He disclosed founding Dignity Brain Health, a clinic that seeks to provide clinical care for patients struggling with major depressive disorder. Dr. Haque also serves as medical director of Dignity Brain Health. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Haque and colleagues recently published a perspective piece in the New England Journal of Medicine about the “double stigma” against mental disabilities, which the authors define as “psychiatric, psychological, learning, and developmental disorders that impair functioning,” including common diagnoses, such as attention deficit disorder and major depressive disorder. Physicians and physicians-in-training, such as students and residents, face major challenges in disclosing mental disabilities, from fear of discrimination during the admissions process to stigma throughout training and licensure. Medical leave is often the only suggested solution to an exacerbation of a disability, and this response is likely to instill fear in trainees, because taking leave will require future disclosure and worsen the double stigma. Reasonable accommodations could improve functioning and allow trainees to remain enrolled and on their desired academic path. Dr. Haque recommends that medical schools and training programs have trained disability service providers (DSP) with specialized understanding of medical education and curricula who do not have conflicts of interest – as sometimes happens when they participate in other roles, such as serving as deans or professors within a medical school. A continued challenge to disability disclosures are questions on medical licensing applications and renewals about past or current diagnoses or treatment for mental disabilities. Dr. Haque reminds listeners that, according to the American Disabilities Act, these questions about past and current diagnoses are illegal if the answers to those questions do not affect physicians’ current functioning. Summary   Dr. Haque’s article offers several recommendations for medical schools, training programs, and licensing boards aimed at addressing the burden of the double stigma against mental disabilities within the culture of medical training and practice. Medical schools should clearly communicate that applicants with disabilities are welcome as part of a larger commitment to diversity, and individuals with mental disabilities should be admitted and allowed to complete training. Universities should hire medical school–specific disability service providers who understand medical education and are committed to parity for individuals with physical and mental disabilities. Policies related to mental disabilities should be clearly publicized so that students and trainees know what to expect if they disclose a disability, and should create reasonable accommodations for those with mental disabilities instead of promoting medical leave as the only option. Faculty members and administrators could publicly describe their own protected time for therapy and highlight the professional successes of people who were able to disclose their condition and get reasonable accommodations. The Federation of State Medical Boards should enforce the ADA-based legal standard that questions about mental disabilities should be asked and answered only if they address current functional impairments that affect a physician’s ability to practice medicine safely. References Haque OS et al. N Engl J Med. 2021 Mar 11;384:888-9. Wimsatt LA et al. Am J Prevent Med. 2015 Nov. 49(5):703-14. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Géraldine Fauville, PhD, joins Lorenzo Norris, MD, to discuss some of the causes of Zoom fatigue and strategies that can make videoconferences productive. Dr. Fauville is the lead researcher on the Zoom Exhaustion & Fatigue Scale project. She also is assistant professor in the department of education, communication, and learning at the University of Gothenburg (Sweden). Dr. Fauville has no disclosures. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Fauville started her research on Zoom fatigue in the Virtual Human Interaction Lab at Stanford (Calif.) University, founded by Jeremy N. Bailenson, PhD. The lab has pioneered research on the common but poorly understood phenomenon of Zoom fatigue.  Videoconferencing, often through Zoom, has allowed people to connect throughout the pandemic, but there are features of this modality that can contribute to stress, and for many, social anxiety. Dr. Fauville and Dr. Norris discuss Zoom fatigue and which dynamics of videoconferencing contribute to a sense of anxiety, fatigue, and affect our general wellness in a society that has come to rely on videoconferencing as a primary form of communication and central to parts of our economy during the pandemic.  Dr. Fauville discusses how the size of faces on the screen and feeling observed activate anxiety and stress. Constant mirroring from seeing yourself reflected from the camera onto a screen can lead to self-judgment and negative emotions. Loss of traditional nonverbal communication and being forced to pay attention to verbal cues or exaggerate gestures can increase the cognitive load associated with conversations that occur via videoconference. Videoconferencing also restricts mobility, because people feel tethered to a small area within their camera’s view where they can be seen.  Summary During an in-person meeting, people will stare at you while you’re speaking, but on videoconferencing it can feel as if all eyes are on you the whole time, which contributes to stress and social anxiety.  Dr. Fauville discusses the “large face” dynamic; if these conferences were real-life interactions, it would be like having a very large face just a few inches from ours,  which can feel like an invasion of privacy. For the brain, having a face in close proximity to yours signals either a desire for intimacy or conflict.  Recommendation: Minimize the videoconferencing application as much as possible and keep the size of the faces smaller.  Zoom and other platforms lead to “constant mirroring.” Seeing our own image can result in persistent self-evaluation and judgment, which can contribute to anxiety and negative emotions.  Recommendation: Keep your camera on but hide self-view; doing so can combat this constant mirroring. Videoconferencing has severely limited mobility during meetings, which make people feel trapped in the view of the camera.  Recommendation: Using a standing desk allows for more freedom from the view of the camera. You can stretch your legs, walk around in the view of the camera, and create distance, especially if you have an external keyboard.  Nonverbal communication and behaviors are essential cues between humans. Videoconferencing that focuses on head and shoulders diminishes a large portion of body language. Videoconferences are more taxing for the brain than audio-only communication because people have to be even more in tune to the cues in speakers' verbal tones, and some nonverbal cues, such as nodding, become exaggerated.  Recommendation: Organizations should create guidelines aimed at mitigating Zoom fatigue. Suggestions include allowing people to turn off their cameras for portions of meetings or didactics, having a mix of audio/telephone and video meetings, and assessing whether the information from some meetings can included in email messages or shared documents.  Dr. Fauville and colleagues created the Zoom Exhaustion & Fatigue Scale (ZEF Scale) to quantify the phenomenon. Fifteen items on the scale focus on five dimensions of Zoom fatigue, such as general, visual, emotional, social, and motivational fatigue.  Part of the evaluation of Zoom fatigue should include examining how many videoconferences you have per day, the amount of time between each, and how long the conferences last.  References Ramachandran V. Stanford researchers identify four causes for ‘Zoom fatigue’ and their simple fixes. Stanford News. 2020 Feb 23. Fauville G et al. Zoom Exhaustion & Fatigue Scale. SSRN.com. 2021 Feb 23. Bailenson JN. Nonverbal overload: A theoretical argument for the causes of Zoom fatigue. Technology, Mind & Behavior. 2021 Feb 23;2(1). doi: 10.1037/tmb0000030. Zoom Exhaustion & Fatigue Scale survey: https://vhil.stanford.edu/zef/ *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

In this week's installment of Clinical Correlation, Renee Kohanski, MD, unpacks the new Open Notes mandate. Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Guest host Vicki L. Ellingrod, PharmD, talks with Kristen M. Ward, PharmD, and Amy Pasternak, PharmD, about integrating pharmacogenomic testing into psychiatric practice. Dr. Ellingrod is senior associate dean at the University of Michigan College of Pharmacy, Ann Arbor, and professor of psychiatry in the medical school. She is also section editor of the savvy psychopharmacology department in Current Psychiatry. Dr. Ellingrod has no relevant financial relationships to disclose. Dr. Ward and Dr. Pasternak are clinical assistant professors of pharmacy at the University of Michigan.  Dr. Ward and Dr. Pasternak report no relevant disclosures. Dr. Ward and Dr. Pasternak are team leads in the University of Michigan’s Precision Health Implementation Workgroup. Take-home points Pharmacogenomics is defined as the study of the relationship between genetic variations and how our body responds to medications. Two common reasons for ordering pharmacogenomic testing are that a patient or clinician wants testing completed before starting the trial of a psychotropic medication and that there are concerns about nonresponse or loss of response to medications. Common insurance criteria used to justify such testing include at least one failed medical trial; future use of a medication likely to be affected by genetic variants, such as metabolism through CYP2D6 or CYP2C19; or identification of human leukocyte antigen (HLA) variants before starting carbamazepine or oxcarbazepine. Quality improvement and usability campaigns around pharmacogenomic testing include ensuring that testing results are readily available in the medical record. Results should be searchable. Alerts can be created for prescribers when they order a medication for which a patient has a relevant genetic variant. After ordering testing, clinicians should document the patient’s medication response genotype and phenotype in the medical record so the information can be used for medications other than psychotropics. Summary Pharmacogenomic testing may be ordered for several reasons, including cases in which a patient or clinician wants information before switching to another medication or there are questions about failed medication trials. For approximately 50% of individuals who undergo pharmacogenomic testing, there may not be a change in treatment plans, or the results might not be conclusive enough to affect treatment. However, pharmacogenomic testing is useful in reassuring and improving adherence in patients who experience somatic adverse effects to psychotropic medications and want to know whether those effects are related to their metabolism. Getting insurance companies to cover pharmacogenetic testing can be tricky, and clinicians should be familiar with the criteria requested by insurers before ordering the tests. Many of the genetic-testing companies include a patient-assistance program to cover payment when insurance companies do not. In the medical record, it’s important to document the patient's genotype and phenotype. The patient’s genotype affects their metabolism of medications beyond psychotropics. Pharmacogenomic testing results can prevent serious adverse drug reactions. If testing comments on a patient’s carrier status for specific HLA subtypes implicated in drug metabolism, carbamazepine or other related medications should be added to the patient’s drug allergy list. States requirements about informed consent for genetic testing vary, so any clinicians who order such tests should be informed about their local laws. References Ellingrod VL. Current Psychiatry. 2019 Apr;18(4):29-33. Deardorff OG et al. Current Psychiatry. 2018 Jul;17(7):41-5. Ellingrod VL and Ward KM. Current Psychiatry. 2018 Jan;17(1):43-6. Bishop JR. Current Psychiatry. 2010 Sep;9(9):32-5. Maruf AA et al. Can J Psychiatry. 2020 Aug;65(8):521-30. National Institutes of Health. National Human Genome Research Institute. Genome Statute and Legislative Database. Clinical Pharmacogenetics Implementation Consortium. CPIC guidelines.. Pharmacogenetics Knowledge Base. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. 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, speaks with Tonya Cross Hansel, PhD, about processing incidents such as the Jan. 6, 2021, siege on the Capitol, and determining how to foster recovery. Dr. Hansel is an associate professor with the Tulane University School of Social Work in New Orleans. She has no conflicts of interest. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Hansel’s research focuses on measuring traumatic experiences and implementing systematic recovery initiatives that address negative symptoms by emphasizing individual and community strengths. The tendency to come together in times of vulnerability is a human instinct. The Jan. 6 Capitol siege was a traumatic and polarizing event; in a Pew survey 1 week later, 37% of respondents expressed a strong negative emotion in response to the riot. The unpreparedness of the U.S. Capitol Police and other law enforcement agencies led to fear and shock as much of the nation watched the breach unfold in real time on television. A variety of groups attended the protest. Some groups were involved in domestic terrorism, and others were part of political groups who came protest their grievances against the government. Those who attended the event with the intent of engaging in violence and instilling fear are considered domestic terrorists. Dr. Hansel said an event such as the insurrection wears on society by causing chronic stress, and one-time events such as the insurrection can lead to a prolonged state of anxiety. Terrorism and violence are sometimes triggered by disenfranchisement when violence seems like the only way to make one’s voice heard. Disasters with an economic fallout, such as natural disasters or the ongoing COVID-19 pandemic, can result in greater disenfranchisement. Prevention of future attacks and domestic terrorism must balance people’s ability to speak out and protest with an effort to avoid disenfranchisement. The way forward must also include addressing chronic fear. Dr. Hansel suggests that building community over shared values is a powerful way to foster resilience after disaster. In the pandemic, we have all experienced sacrifice and hardship. When society moves beyond survival mode, efforts must be made to connect over our shared sense of loss. References Hartig H. In their own words: How Americans reacted to the rioting at the U.S. Capitol. Pew Research Center. 2021 Jan 15. Pape RA and Ruby K. The Capitol rioters aren’t like other extremists. The Atlantic. 2021 Feb 2. Ellis BH et al. Studies in Conflict & Terrorism. 2019 May 31. doi: 10.1080/1057610X.2019.1616929. Hansel T et al. Traumatology. 2020;26(3):278-84. Saltzman LY et al. Curr Psychiatry Rep. 2017 Jun 19. doi: 10.1007/s/1920-017-0786-6. Hall BJ et al. PLoS One. 2015 Apr 24. doi 10.1371/journal.pone.0124782. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

One wouldn't think autism spectrum disorder belonged in the same universe as narcissistic personality disorder. Yet sometimes emotional disconnection and seeming lack of empathy leads to miscommunication. There is one key difference, however. Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Brian Holoyda, MD, MPH, MBA, conducts a Masterclass on the history of psychedelic research and how the renaissance of this drug class could affect psychiatric patients. Dr. Holoyda, a forensic psychiatrist, practices in the San Francisco Bay Area. He also provides psychiatric consultations across the country. Dr. Holoyda has no disclosures. Take-home points The effects of psychedelics are dose dependent and difficult to predict. The impact of psychedelic treatment on violent behaviors was studied since the 1960s with varying results. More recent studies suggest that psychedelic use (excluding phencyclidine, or PCP) is associated with less violent crime. Dr. Holoyda recommends that, before psychiatrists treat patients with psychedelic-assisted psychotherapy, patients should be screened for history of violence or aggression while using psychedelics (and in general) and a history of serious mental illness. Patients require informed consent about the risk of violence and interventions used to control aggressive behaviors. Summary In 1960, the Harvard Psilocybin Project included a study in the Concord (Mass.) Prison in which researchers hypothesized that using psychedelic-assisted psychotherapy in prisoners would reduce risk of violent recidivism. The original authors, including Timothy Leary, PhD, published varying results of the study – including that psychedelic use reduced recidivism. However, some argue the overly positive results from the first analysis were attributable to a halo effect. A recent reanalysis showed that the base rate for recidivism in the intervention group was 34%, and not significantly different from that of the control group. Psychiatrists have continued to use psychedelic-assisted therapy for patients with psychopathology and treatment-resistant sexual offenders to investigate whether the transcendent experiences can change their personalities, including the development of insight and empathy. Dr. Holoyda published a review of all published cases in medical literature discussing psychedelic use and violent behavior. Most of the cases were published in the 1960s-1970s, when psychedelics were viewed negatively as a product of the counterculture era. More recent observational studies identified that psychedelics use is associated with a greater likelihood of carrying a firearm as well as intimate partner violence, but these newer studies are fraught, because PCP is sometimes classified as a psychedelic. Other epidemiological studies have identified reductions in violent behaviors associated with psychedelics use, compared with other illicit substances. Those reductions in violent behaviors include a lower probability of supervision failure, and a lower risk of intimate partner violence and drug distribution. Peter S. Hendricks, PhD, and associates analyzed data from 225 million individuals who took the National Survey on Drug Use and Health from 2002 to 2014 with a focus on psychedelics use, excluding PCP. They found that a lifetime history of psychedelic use decreased the odds of theft, assault, and arrest for property and violent crime. Studies such as this suggest that individuals who favor psychedelics may be less prone to violent crime rather than a direct effect of psychedelics on decreasing violent crime. As psychedelics enter the clinical sphere, clinicians must keep in mind that experiences on these agents are unpredictable. In a study of unmonitored psychedelic use, individuals report putting themselves or others at risk. Others reported behaving aggressively or violently, and others sought help at a hospital. Before using psychedelics in a therapeutic environment, clinicians should assess patients’ past use and experience on psychedelics. They also should screen for history of “bad trips,” leading to aggression, agitation, paranoia, and risky behaviors. In clinical trials with psychedelics, individuals with history of bipolar and psychotic disorders have been excluded to reduce the risk of triggering an episode. For medicolegal protection, psychiatrists should engage in a thorough informed consent process before using psychedelic-assisted therapy. References Holoyda B. Psychiatric Serv. 2020;71(12): 1297-99. Holoyda B. J Am Acad Psychiatry Law. 2020 Mar;48(1):87-97. Hendricks PS et al. J Psychopharmacol. 2017 Oct 17. doi: 10.1177/0269881117735685. Carbonaro TM et al.  J Psychopharmacol. 2016;30(12):1268-78. Metzner R. Reflections on the Concord prison project and the follow-up study. Bulletin of the Multidisciplinary Association for Psychedelic Studies/MAPS. Winter 1999/2000. 9(4). Arendsen-Hein GW. LSD in the treatment of criminal psychopaths, in "Hallucinogenic Drugs and Their Psychotherapeutic Use." (London: H. K. Lewis & Co, 1963). Leary T. Psyched Rev. 1969; 10:20-44. Leary T and Metzner R. Brit J Soc Psychiatry. 1968;2:27-51. Leary T et al.  Psychother. 1965;2:61-72. Doblin R. J Psychoactive Drugs. 1998; 30:419-26. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Dost Öngür, MD, PhD, joins host Lorenzo Norris, MD, to discuss the emerging mental health effects of the pandemic. Dr. Öngür is chief of the Center of Excellence in Psychotic Disorders at McLean Hospital in Belmont, Mass. He also serves as the William P. and Henry B. Test Professor of Psychiatry at Harvard Medical School, Boston. Dr. Öngür has no disclosures. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.  Take-home points Without a doubt, the COVID-19 pandemic will have a lasting mental health impact on society. Öngür discusses the role of trauma, grief, mourning, and social isolation during the pandemic. Summary One emerging mental health effect of the pandemic is lasting psychiatric symptoms after infection and inflammatory response, including anxiety, depression, insomnia, and fatigue. Many individuals have lost loved ones or witnessed someone close to them experience severe illness and prolonged hospitalizations. Early in the pandemic, in a 2020 Centers for Disease Control and Prevention representative survey, 30% of Americans reported symptoms of depression and anxiety, 13% reported increased substance use, and 11% thought about suicide. Individuals report greater distress, substance use, and suicidal ideation in the United States, but deaths from suicide did not increase dramatically, compared with 2019. A recent study in JAMA Psychiatry noted, however, that emergency department visits for social and mental health emergencies such as suicide attempts, overdoses, and intimate partner violence were higher in mid-March through October 2020 during the COVID-19 pandemic, compared with the same period a year earlier. One possible resilience factor for individuals with mental illness may be the protective nature of family ties. Though the shutdown led to social isolation and detachment from some networks, certain individuals came to rely more on nuclear relationships, such as family. With the pandemic, mental illness and mental health treatment have entered the public consciousness and conversation more than ever before. After the pandemic, more people will need mental health services as the social effects continue to ripple for years to come.  References Czeisler ME et al. Mental health, substance use, suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1049-1057. Faust JS et al. Suicide deaths during the COVID-19 stay-at-home advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021 Jan 21;4(1):e2034273. John A et al. Trends in suicide during the COVID-19 pandemic. BMJ. 2020;371:m452. Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. Nat Hum Behav. 2021 Jan 15;5:229-38. Holland KM et al. Trends in U.S. emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. 2020 Feb 3. doi: 10.1001/jamapsychiatry.2020.4402. *** Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.   For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com      

In this week's installment of Clinical Correlation, Renee Kohanski, MD, offers some of her treasured nonpharmacologic pearls and discusses the power in practicing what we preach while forgiving our own human foibles. Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Pete Simi, PhD, joins host Lorenzo Norris, MD, to discuss some of the factors that lead people to join hate groups, and strategies that have enabled some to leave the life of extremism behind. Dr. Simi, associate professor of sociology at Chapman University in Orange, Calif., has studied extremist groups and violence for more than 20 years. His research has received external funding from the National Institute of Justice, the Department of Homeland Security, the Department of Defense, the National Science Foundation, and the Harry F. Guggenheim Foundation. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. Dr. Norris has no disclosures. Take-home points Dr. Simi discusses how many of the White supremacists he studied live mundane, ordinary lives organized around extremist, violent beliefs. These individuals may be socialized in early life through exposure to beliefs consistent with White supremacy, such as racist ideas, slurs, and jokes, but they are not usually raised within a White supremacist family. The biggest challenge of leaving White supremacy is finding a new overarching identity, which ultimately requires redefining one’s emotional habits when it comes to engaging with society. White supremacist programming not only includes hateful beliefs but an emotional orientation that influences how an individual interprets the world around them. White supremacist violence and terrorism have long been a U.S. problem, and Dr. Simi said his awareness of the problem grew after the Oklahoma City bombing in 1995. Dr. Simi hopes that, through research and initiatives, the United States will address the root causes of White supremacist beliefs rather than focus on specific groups. Summary Dr. Simi first started studying White supremacists by evaluating their engagement on early Internet forums. Eventually, he made contact with a group that allowed him to observe their daily lives, including staying in their homes and attending collective events, such as music festivals. More recently, he has been evaluating and researching individuals who leave the White supremacist movement. As with many individuals who find solace in extremist groups, the childhood and adolescence of those who become White supremacists usually contain adverse childhood experiences and instability, such as physical and emotional abuse, and substance use in the home. These events cultivate vulnerability to White supremacy, because these adolescents and young adults are searching for a stabilizing force. In the Internet age, it’s much easier for vulnerable individuals to have chance encounters with extremist groups and beliefs, and even brief exposures are an opportunity for some to be recruited into White supremacist groups. A selling point of White supremacy is the sense of “fellowship” and “family,” which is attractive for individuals who feel disillusioned and isolated from society at large. In Dr. Simi’s research, half of his sample participants of White supremacists reported mental health diagnoses and similarly high rates of suicidal ideation. Mental illness is not an excuse for the behaviors and beliefs, but an example of another vulnerability that makes these individuals susceptible to strong support groups that often hold extremist beliefs. References Simi P et al. Am Sociol Rev. 2017 Aug 29. doi: 10.1177/00031224177282719. Bubolz BF and Simi P. Am Behav Sci. 2019. doi: 10.1177/0002764219831746. Simi P et al. J Res Crime Delinquency. 2016. doi: 10.1177/002242781567312. Windisch S et al. Terrorism Polit Violence. 2020. doi: 10.1080/09546553.2020.1767604. Ask a researcher: Pete Simi. What domestic groups pose the largest threats? University of Nebraska, Omaha. 2021 Jan 14. National Counterterrorism Innovation, Technology, and Education Center. A U.S. Department of Homeland Security Center of Excellence. McDonald-Gibson C. ‘Right now, people are pretty fragile.’ How coronavirus creates the perfect breeding ground for online extremism. Time. 2020 Mar 26. Garcia-Navarro L. Masculinity and U.S. extremism: What makes young men vulnerable to toxic ideologies. NPR. 2019 Jan 27. Life After Hate. Larry King Now. 2019 Jan 23. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Frank Chen, MD, joins host Lorenzo Norris, MD, to discuss the impact of the COVID-19 pandemic on patients with schizophrenia. Dr. Chen is the chief medical director for Houston Behavioral Healthcare Hospital and Houston Adult Psychiatry. He is a speaker for Alkermes and Otsuka. Dr. Chen has served on advisory boards for Alkermes, Intracellular Therapies, Otsuka, and Teva Pharmaceuticals. Dr. Norris is associate dean of student affairs and administration at George Washington University. He has no disclosures. Take-home points Schizophrenia is associated with an increased risk of death from COVID-19, even when controlling for other medical comorbidities. Individuals with schizophrenia have many biological and situational risk factors for COVID-19, including an elevated risk of metabolic syndrome from antipsychotic medications, higher rates of nicotine addiction, a greater likelihood of living in a group setting, limited access to medical care, and the underlying inflammatory state of schizophrenia. Summary An article published in JAMA Psychiatry in January 2021 evaluated a large cohort of patients in a New York health system and identified schizophrenia as the second most highly associated risk factor for 45-day mortality from COVID-19, after the risk factor of advanced age. The study controlled for other medical comorbidities to avoid confounding the results. However, it is essential to remember that individuals with schizophrenia have environmental and biological factors that increase their risk of infection and complications from COVID-19, such as metabolic syndrome, cigarette smoking, limited access to health care, and living in a group or institutional setting. Dr. Chen points out that many patients with schizophrenia already have skills to adapt to the stresses of the pandemic. For example, individuals with schizophrenia might already be accustomed to living with a certain level of fear and uncertainty inherent to their thought disorder. He also comments that negative symptoms make social distancing easier for individuals with schizophrenia than for other people. Dr. Chen notes that telepsychiatry has been a boon to treating individuals with schizophrenia, because using this tool is almost like making a “home visit.” Telemedicine removes the barriers to care, such as transport and resistance to coming to the office. Adaptation to telepsychiatry has varied among different patient populations. Dr. Chen says some of his “higher functioning” patients with more controlled and stable lives did not want to see their clinician via video. They preferred the “secure” and more private setting of an office. Ultimately, psychological flexibility and ability to adapt influence the amount of stress people experience during crisis. References Nemani K et al. JAMA Psychiatry. 2021 Jan 27. doi: 10.1001/jamapsychiatry. 2020.4442. Mazereel V et al. Lancet. 2021 Feb 3. doi: 10.1016/S2215-0366(2)30564-2. Muruganandam P et al. Psychiatry Res. 2020 Jun 29. doi: 101016/j.psychres.2020.113265. Kozloff N et al. Schizophr Bull. 2020 Jul;46(4):752-7. Smith BM et al. J Contextual Behav Sci. 2020 Oct;18:162-74. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

We are still experiencing the direct hit in addition to the aftermath of the SARS-CoV-2 coronavirus, especially its devastating psychiatric impact.  It's always darkest before dawn, isn't it?  Let's lighten the path, shall we, in episode 12 of Clinical Correlation. Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

John Koo, MD, and Scott A. Norton, MD, MPH, join host Lorenzo Norris, MD, for this special edition of the Psychcast. This is a crossover episode with our sister podcast, Dermatology Weekly. Dr. Koo is a psychiatrist and a dermatologist at the University of California, San Francisco. He has no disclosures. Dr. Norton is a dermatologist with the Uniformed Services University of the Health Sciences in Bethesda, Md., and with George Washington University, Washington. He has no disclosures. They are featured in an article on this topic online at MDedge.com/Psychiatry. Dr. Norris is associate dean of student affairs and administration at George Washington University. He has no disclosures. Take-home points Delusional infestation or delusions of infestation, also known as delusional parasitosis, is a fixed false belief that one has an infestation of animate or inanimate pathogens, despite strong evidence against infestation. Common precipitants of delusional infestation include previous exposure to external or internal parasites, stress, and travel. The condition is more common among highly functional older women. A recent study estimated the prevalence of delusional infestation as 1.9/100,000, though the condition is an area of limited study. Delusional infestation is poorly recognized by physicians, therapists, and families, which leads patients to search for an external cause of the symptoms and contributes to distress for patients and their loved ones. Patients with delusional parasitosis often lack insight into their disease, and it can be difficult to persuade them to take the recommended treatment of antipsychotics. Low-dose pimozide, a first-generation antipsychotic, is the most common treatment for delusional infestation, particularly because it does not have Food and Drug Administration approval as a treatment for psychosis. Therefore, patients are less biased against taking this medication. Summary Delusions of infestation are a monosymptomatic hypochondriacal psychosis in which the only delusion present is one of infestation, and patients do not have other symptoms of psychotic spectrum illness. Secondary delusions of infestation may occur in individuals who use drugs, such as methamphetamine or cocaine, or who have a primary psychotic disorder, such as schizophrenia. Delusions of infestation is related to Morgellons disease, which is defined as a skin condition characterized by the presence of “threads” or filaments that patients believe are embedded in their skin and might be accompanied by stinging and itching sensations. Patients with delusions of infestation usually present to a primary care physician or ED with symptoms of abnormal sensations of their skin, including crawling sensations. In addition, patients usually bring personal proof of their condition, such as a small bag of “specimens,” including pieces of lint, threads, or scabs. Some patients also bring in journals detailing the timing and associated factors of their symptoms. Dr. Norton advises that physicians treating the patients with delusions of infestation should mentally prepare themselves against initial bias and set aside time for longer visits or several follow-up visits. Dr. Norton starts with the premise that the patient has an actual infestation or other underlying cause of their pruritus and performs a thorough, full-body exam for dermatologic conditions, and examines the materials patients bring with them using a double-headed microscope – so that he and the patient can look at the specimens together. Dr. Koo often tells patients that they have Morgellons disease because it does not include the stigmatizing term of “delusional.” He reframes Morgellons as an infestation that cannot be cured by internal or external antiparasitic medications. He then pivots away from etiology to validation of their emotions and eventually to treatment. Dr. Koo usually often starts treatment with pimozide because it is an antipsychotic with FDA approval for Tourette syndrome – not schizophrenia. This perceived absence of a connection of the medication to psychiatric illness allows patients to be more open to taking the medication. For primary delusional infestation, Dr. Koo starts with pimozide. The dose, which is daily and taken orally, starts low at 0.5 mg and goes up by 0.5 mg every 2-4 weeks. The aim is to get up to 3 mg per day. Low doses of pimozide and other antipsychotics lead to decreased sensation of itching and formication. Dr. Koo refers to his treatment plan as a “trapezoid-like dosage strategy.” Once he gets the patient to 3 mg, he continues the medication until all the symptoms disappear and then continues the medication for an additional 3 months. Dr. Koo then slowly tapers the dosage over an additional few months. The keys to successful treatment include communicating with patients and working collaboratively with them. This approach builds trust and rapport. References Brown GE et al. J Clin Exp Dermatol Res. 2014;5:6. doi: 10.4172/2155-9554.1000241. Kohorst JJ et al. JAMA Dermatol. 2018 May 1;154(5):615-7. Lepping P et al. J Am Acad Dermatol. 2017 Oct;77(4):778-9. Middelveen MJ et al. Clin Cosmet Investig Dermatol. 2018;11:71-90. Lepping P et al. Acta Derm Venereol. 2020 Sep 16. doi: 10.2340/00015555-3625. Freudenmann RW et al. Br J Dermatol. 2012 Aug;167(2):247-51. Wolf RC et al. Neuropsychobiology. 2020;79:335-44. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

George T. Grossberg, MD, conducts a Masterclass examining emerging treatment options for Alzheimer’s disease that are tied to the new research on the microbiome. Dr. Grossberg is the Samuel W. Fordyce professor and director of geriatric psychiatry in the department of psychiatry and behavioral neuroscience at Saint Louis University. He disclosed that he is a consultant for Acadia, Alkahest, Avanir, Axovant, Axsome Therapeutics, Biogen, BioXcel, Genentech, Karuna, Lundbeck, Novartis, Otsuka, Roche, and Takeda; receives research support from the National Institute on Aging, Janssen, and Genentech/Roche; performs safety monitoring for ANAVEX, EryDel, Intra-Cellular Therapies, Merck, and Newron; and serves on the data monitoring committee of ITI Therapeutics. Dr. Grossberg also serves on the speakers’ bureau of Acadia. Take-home points Dr. Grossberg discusses burgeoning research about treatment of Alzheimer’s disease (AD) by altering the microbiota using diet and medications. The microbiome refers to the entirety of microorganisms that live throughout the body. Microbiota are those organisms that live within the gut. Dysbiosis refers to a microbial imbalance, which has been linked to numerous disorders, including inflammatory diseases, psychiatric illness, obesity, diabetes, and more recently, AD. The gut-brain axis describes the impact of microbiota and GI tract health on the brain. Periodontal disease, as a marker of inflammation and as part of the microbiome, is linked to AD. Increasing research into the role of the microbiome, inflammation, and AD has revealed promising treatments. Sodium oligomannate, a drug approved for mild to moderate AD in China, has been shown to slow the progression of AD by remodeling the microbiota and suppressing the production of specific amino acids that promote neuroinflammation. Summary The microbiota has many purposes, including digestion, communication with the immune system, generation of signaling peptides, refining vitamins, and producing antioxidants. Many factors influence the microbiome, including diet, use of antibiotics, exposure to breast milk as an infant, stress, and old age. The gut microbiota can be altered by consuming “prebiotics,” which are food sources that influence the composition of the microbiota. These foods include fermented foods such as yogurt, kombucha, sauerkraut, and kimchi. The Mediterranean diet also has good sources of prebiotics. Birthing method (C-section versus vaginal birth) also influences the microbiota; a recent study shows that an infant’s microbiota after C-section can be altered by giving them an early fecal transplantation from the mother. As further proof of the link between periodontal disease and AD, a recent study identified the presence of Porphyromonas gingivalis, a bacteria that causes gum disease, in the brain in close proximity to the tau tangles of AD. Gingipain, the toxin secreted by this bacteria, is found in high concentrations in brains of individuals with AD. Dr. Grossberg reviewed his “recipe” for AD prevention and treatment: Recommend adequate activity in four spheres: Physical, mental, social, and spiritual. Treat and control all cardiovascular risk factors, including smoking, obesity, diabetes, hypertension, and hyperlipidemia. Recommend good oral hygiene based on the increasing research about the link of periodontal disease and AD. Recommend dietary changes, including a prebiotic or probiotic, and the Mediterranean diet. Dietary changes may also include supplements such as curcumin, B-complex multivitamin, and vitamin E. Control exposure to air pollution as possible. Use a combination pharmacotherapy of an N-methyl-D-aspartate antagonist and a cholinesterase inhibitor for individuals with AD. References Jones ML et al. Gut Microbes. 2014 Jul 1;5(4):446-57. Askarova S et al. Front Cell Infect Microbiol. 2020;10:104. Beydoun MA et al. J Alzheimers Dis. 2020;75(1):157-72. Wang X et al. Cell Res. 2019 Oct;29(10):787-803. Korpela K et al. Cell. 2020 Oct 15;183(2):324-34. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

In episode 11 of Clinical Correlation, Dr. Kohanski offers more pearls to approaching that seemingly innocent chief complaint of insomnia.  She welcomes listener commentary as always.   Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Rebecca W. Brendel, MD, JD, and Allen R. Dyer, MD, PhD, join guest host Carol A. Bernstein, MD, to discuss the ethical challenges that have been occurring during the COVID-19 pandemic. Dr. Brendel is director of law and ethics at the Center for Law, Brain, and Behavior at Massachusetts General Hospital, Boston. She also serves as director of the master of bioethics degree program at Harvard Medical School, Boston. Dr. Brendel has no disclosures. Dr. Dyer is professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as vice chair for education at the school of medicine and health sciences. Dr. Dyer has no disclosures. Dr. Bernstein, a past president of the American Psychiatric Association, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures. Take-home points Medical ethics often deal with decisions between doctors and patients, but during the COVID-19 pandemic, the medical community has been forced to reckon with ethics on a population scale. Examples of ethical challenges include issues of scarcity, justice, transparency, and navigating distrust of the medical system. In the beginning of the pandemic, individuals such as Dr. Brendel and Dr. Dyer participated in ethical planning so that hospital systems would be prepared to deal with scarcity of resources that could result in some individuals going without lifesaving interventions. During times of scarcity, transparency and accountability are necessary, because the community will ask questions about the fairness and justice of specific outcomes. The philosophy of utilitarianism is a reason-based decision-making model that strives to maximize the greatest good for the greatest number, and it has been commonly used as a template for ethical discussions during the pandemic. Yet, utilitarianism calculus is complicated by questions of how to define “good” and the challenge of accurately predicting the outcomes. Summary In situations of urgency, demand, and scarcity, ethics usually turns to utilitarianism with the intention of maximizing the greatest good for the greatest number. Inevitably, people or populations are harmed. Especially in the beginning of the COVID-19 pandemic, American society grappled with the issue of scarcity and allocation of medical resources, ranging from personal protective equipment, ventilators, medical staff, ICU space, and the vaccine.   Now we must think about the ethical decisions influencing COVID-19 vaccination, including weighing the risks and benefits of who gets the vaccine and when – and how certain vaccine schedules forestall the spread in the population. For example, institutionalized individuals are at great risk of contracting COVID-19, yet society debates the “good” of vaccinating elderly in nursing homes versus incarcerated individuals. Question of defining good and grappling with the consequences are present throughout the entire vaccination algorithm. Communities contend with the question of who in their ranks are essential workers: Health care workers? Teachers? Restaurant staff? Factory workers? Justice and transparency are commonly discussed ethical principles, especially when we think about the algorithms created to allocate resources. Transparency is required to foster trust in the public health system, and actors within the system must demonstrate their accountability through being honest about the evidence behind policy decisions, following set parameters, and acknowledging historical reasons for distrust. The pandemic has pushed society to think about the ethics of community solidarity and reflect on governmental and individual responsibility of protecting the health and well-being of the community. As the pandemic ravaged the U.S. economy and further disadvantaged already vulnerable communities, we must use this opportunity to reexamine the ethics of how health care is distributed in the United States, and work toward a just and equitable system. References Ethics and COVID10: Resource allocation and priority-setting. 2020 World Health Organization. AMA Journal of Ethics. COVID-19 Ethics Resource Center. Emanuel EJ et al. N Engl J Med. 2020 May 21. doi: 10.1056/NEJMsb2005114. Dyer AR and Khin EK. Int Encycl Soc Behav Sci. 2015;63-70. The principles of medical ethics with annotations especially applicable to psychiatry, 2013 edition. American Psychiatric Association. American Psychiatric Association. Ethics.psychiatry.org.  *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com