Innovations in Psychiatry Newsletter
We are back in your inbox this month with a candid interview with Dr. Craig Chepke, who is in private practice in North Carolina and serves as Adjunct Associate Professor of Psychiatry for Atrium Health and Adjunct Assistant Professor of Psychiatry at the University of North Carolina School of Medicine. Dr. Chepke and I dove right into several hot topics, including the role and use of pharmacogenomics, trends in people newly seeking care during COVID who have undiagnosed ADHD, how COVID has changed the way we practice, and telemedicine as the new paradigm shift in patient treatment and communication.
Last issue we gave you key insights from Donald W. Black, MD, and Jeffrey R. Strawn, MD, FAACAP—faculty from Medscape’s upcoming virtual conference, CP/AACP Psychiatry Update 2021: Solving Clinical Challenges, Improving Patient Care. Drs. Black and Strawn shared thoughts on the far-reaching psychological effects of the COVID-19 quarantine on patients—including adolescents, and current treatments of the negative symptoms of schizophrenia, and more. If you missed it, you can find that interview here.
Make sure to check out the Suggested Readings from Dr. Chepke in the areas of personalized medicine, bioethics, and obesity, inflammation and cognition in this issue.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Annals of Clinical Psychiatry, NEJM, and JAMA Psychiatry. Also, don’t miss the link to the APA Child & Adolescent Telepsychiatry Toolkit. This section is designed to have best practices information in one place at your fingertips to stay informed—enjoy!
Don’t forget to check out details for the Innovations in Psychiatry: Virtual Spring Conference 2021 here.
Thank you to Dr. Chepke for his critical contribution and candor. Please contact me at [email protected] with any comments and/or suggestions.
Hot Topics in Psychiatry: A Candid Chat with Craig Chepke, MD, FAPA
Craig Chepke, MD, FAPA is in private practice at Excel Psychiatric Associates in Huntersville, NC and is an Adjunct Associate Professor of Psychiatry for Atrium Health and an Adjunct Assistant Professor of Psychiatry for the University of North Carolina School of Medicine. He has special interests in treatment-resistant and severe mental illness, movement disorders, ADHD, and sleep medicine.
Colleen: The use of pharmacogenomics in psychiatric treatment is a divisive issue, but I’ve heard you use the phrase, “You can’t let perfect be the enemy of the good” when discussing this topic. Do you think it’s underused? Is it misused?
Dr. Chepke: The best word to describe pharmacogenomics (PGX) in psychiatry might be misunderstood. I readily concede that there is not conclusive evidence that PGX improves outcomes, and that if used without properly educating the patient about its strengths and limitations, it could be detrimental to outcomes. However, PGX is like any other tool we use in medicine—it can be used well, or it can be used badly. It’s still in a nascent state and is nowhere near perfect, but that doesn’t mean that it shouldn’t be used at all. Imagine if physicians in 1895 looked at the plain film X-ray and said “Eh, come back to me when it can scan in 3 dimensions.” There’d have been a lot of preventable morbidity and mortality the following 75 years until the CT came along!
I wouldn’t advocate for everyone to start ordering PGX on every patient, but I don’t think that anyone can ignore it altogether. People are suffering and dying from psychiatric illness every day, and we can’t throw away any opportunity to try to do better than we’re able to now. No intervention in medicine works 100% of the time. With medications, we’re very comfortable with the statistical concept of Number Needed to Treat, but I’ve heard many colleagues say that they ordered PGX 2-3 times and “It wasn’t helpful,” so they abandoned it.
Those who are adamant that PGX has no value in psychiatry might look at other fields of medicine like oncology, where the use of genetic data has completely transformed the field. I’m sure we could find quotes from oncologists decades ago belittling the use of pharmacogenomics in cancer treatment that haven’t aged well. Our patients need help too desperately to keep our heads stuck in the sand. I think we need to study pharmacogenomics, order it where appropriate, and use our experiences to generate hypotheses to contribute back to research that can improve and potentially validate them. A variation of the quote you used in the question that we say frequently in psychiatry is “It’s about progress, not perfection.” That’s where I think we’re at with PGX, but the future is exciting.
Colleen: Difficulties stemming from the pandemic have driven many people to seek psychiatric treatment for the first time. Have you noticed any interesting trends in people newly seeking care during COVID?
Dr. Chepke: Most of the patients I’ve seen recently who are new to psychiatric treatment say that their symptoms are coming from issues caused by the pandemic. However, I’ve found that most of them have actually been struggling for much longer than that, and probably should have come in for care years before. The pandemic just gives them a convenient and socially acceptable reason to make the leap in overcoming the stigma that still accompanies mental health treatment. But I’m okay with scapegoating the pandemic if it gets people the help they need!
Another interesting pattern is that a lot of the adults who have been coming in are reporting depression and anxiety and lack of response to antidepressants. However, they don’t really fit the presentation of someone with treatment-resistant depression— which is an area I have a lot of experience in diagnosing and treating. They’re often reasonably high-functioning people who tell me things like they’re anxious because they feel so overwhelmed with their responsibilities that they just shut down, so they always feel behind. They say they’re depressed because they never fulfilled the potential in life that they (or others) thought they should. Their self-esteem is terribly low and their support network is often very small because they either let their relationships lapse or have burned bridges because they have no filter.
Everything about these people screams ADHD, but they were able to avoid an ADHD diagnosis in childhood because they had few or no behavioral problems that would prompt a closer look by teachers or guidance counselors, and they were able to "brute force" their way into decent or even good grades with a combination of intelligence, willpower, and creative study hacks.
Working from home can be great for some people, but for those with ADHD, the loss or change in structure and routine can cause them to decompensate, especially if the degree of difficulty has increased by having to facilitate remote learning for their children. I think we need to be on the lookout for these types of presentations, not just now during the pandemic, but at all times. Making the right diagnosis and effectively treating ADHD can be lifechanging, and it’s better late than never.
Colleen: Dr. Chepke, many say COVID has changed the way medicine is practiced. How do you see this in practicing psychiatry? Will these be short-term or lasting changes?
Dr. Chepke: I think being forced outside of our comfort zones is the best thing that could happen to the field of medicine. As the philosopher Jiddu Krishnamurti wrote, “Tradition becomes our security, and when the mind is secure, it is in decay.” The pandemic has forced me to adopt or create different skillsets in many cases to get the job done. Here’s a sample of things the pandemic has helped me learn how to:
Screen for movement disorders such as tardive dyskinesia over video.
Decide if someone glancing away is watching their pet dart by or is responding to internal stimuli.
Sit in silence while someone types a long passage that she doesn’t want her abusive spouse to hear.
Help someone grieve the loss of a parent they couldn’t see because of a nursing home lockdown.
Keep someone out of the hospital because they’d rather end their life than risk getting COVID on an inpatient unit.
Fake an unstable connection when I don’t know what to say.
Another notable change I’ve seen (which is old hat to my social worker wife) is that when a patient conducts a session on their own home turf rather than making a pilgrimage to our offices with our rules, there’s a subtle yet powerful shift in the dynamics of shared decision making.
I fully anticipate that many of the changes we've seen with telemedicine will be persistent— there's no putting this genie back in the bottle. A lot depends on what government and private insurers do, but patients have become accustomed to easy access to telemedicine in the past year, so I doubt that politicians could justify not making the changes to Medicare and Medicaid permanent to their constituents. After that, private insurers will fall in line. While it's not perfect, and some aspects are worse, there are too many advantages for the field not to adopt at least a hybrid model of in-person and virtual visits, which is what I anticipate doing with my clinical practice in the future. I certainly plan to keep the new skills the pandemic made me learn out of necessity!
Colleen: Dr. Chepke, the psychological effects of the COVID-19 quarantine are far-reaching. What is your advice to the community psychiatrist who is grappling with the challenges this pandemic has presented?
Dr. Chepke: I'd boil it down to the idea that telemedicine is about preparation, preparation, preparation. Time management is always difficult in psychiatry, but I think it's more challenging during the pandemic. Many people are starving for human contact, so I’ve found that sessions have tended to run longer with many patients. I've been trying to adapt by setting clearer boundaries, such as starting the session by reminding patients how much time we have allotted for the session and asking them to come to the appointment with an agenda for what they want to discuss so we can hit the ground running at the start of the session.
I've also noticed that I’ve been spending a greater percentage of sessions talking as opposed to listening compared to before the pandemic started, and that patients have been much more interested in knowing how I am doing than before. I think that the high degree of uncertainty in everyone's lives is making some people crave reassurance a little more than usual. There's a wide variety of viewpoints on how much self-disclosure mental health clinicians should engage in, but I've found that spending a few seconds giving them a glimpse of something that's been a challenge for me has really helped normalize my patients' struggles to adapt. In turn, it seems to really loosen them up and help engage them in the work of the session.
Also, make sure you are actually doing okay! I won't use the dreaded "B-word" (burnout), but I think we should take advantage of the increased access and convenience afforded by telemedicine to enter into therapy ourselves? Many of us were in personal psychotherapy as a part of our training, and I’ve used the excuse of COVID to get back in to therapy to brush up on my coping skills.
Another trend I’ve noticed is that patients are looking to me for advice on accurate information on COVID-19 topics like the efficacy of masks, distancing, and now vaccines. We may not have been trained in infectious diseases, but we have the relationship to be able to combat rapid expansion in the spread of misinformation that’s occurred in society recently. I think we should be well-suited to this, as evidence-based medicine was designed to combat misinformation from anecdotes and confirmation bias in the practice of medicine!
Colleen: What do you think will help solve the conundrum of frontline practitioners regularly having to address mental health conditions that they do not know how to treat or even in many cases diagnose?
Dr. Chepke: This is a tough situation for frontline practitioner, and I feel for them because they didn’t train or sign up for managing psychiatric conditions, but there’s simply not enough mental health professionals to see everyone who needs it. Making a good diagnosis is always important in medicine, and the lack of biomarkers in psychiatry makes it hard for clinicians who lack the training and clinical experience. One of the most difficult diagnoses to make in psychiatry is unfortunately a commonly encountered one, which is differentiating between major depressive disorder (MDD) and bipolar depression. I think bipolar disorder is both overdiagnosed and underdiagnosed—it’s just misdiagnosed a lot. Some studies estimate 1 out of 4 patients who are treated for MDD in primary care settings actually have bipolar disorder. I’d recommend using screening tools such as the Mood Disorder Questionnaire, which is the historical gold standard, or possibly the Rapid Mood Screener, which was developed very recently by a group of colleagues I know and respect highly, with industry funding, and shows promise. Another tip for psychiatric diagnosis is to never underestimate the power of collateral information!
In terms of treatment, I’d recommend focusing initially on three high-yield items that can help put out some fires regardless of diagnosis.
First, assess the patients’ sleep. Finding and treating insomnia or obstructive sleep apnea in your patients will not only improve their daytime wakefulness, it will also pay dividends in a wide variety of psychopathology. I tell my patients, "Sleep is the foundation of mental health, and without a good foundation, your whole house will crumble."
Next, check on how much news and social media the person is consuming on a daily basis. Almost every time I ask this question, I get back a sheepish grin and the response “too much.” This is not a new problem by any means, but it seems to have spiked to new heights with the pandemic, and social and political unrest, and has been driving a lot of anxiety, as well as insomnia. I’ve given “prescriptions” to patients to limit their intake of these from any source to a set amount— usually either 30 or 60 minutes, either all at once or in divided doses as they choose. Modern smartphones can be set to enforce limits on an app-by-app basis, and that’s helped patients to stick with the limits.
Finally, if they’ve already been prescribed psychotropics, actively and directly assess their adherence to treatment. Don’t assume that they’re taking their meds exactly as prescribed, if at all. This is true across any chronic illness, not just psychiatric conditions. One study showed that concordance between clinician estimates of antipsychotic adherence and claims data was about 50%— no better than a coin flip. One technique that helps make conversation easier and more likely to get an honest answer is to normalize it. I say something along the lines of, “I take a medication for stomach acid, and I forget it about once a week and don’t realize it until I get the worst heartburn. How often do you tend to miss doses of your medication?” Rather than lecturing them about needing to take it perfectly, explore their reasons. Is it that they think it doesn’t work, that it causes side effects, or do they have trouble affording it? This information is critical to guide your next steps. After all, the efficacy of any medication is 0% if the person doesn’t actually take it.
Article: Escitalopram in Adolescents with Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study. Strawn, J. R., Mills, J. A., Schroeder, H., et al. The Journal of Clinical Psychiatry81.5 (2020): 0-0.
Dr. Craig Chepke: The unassuming title of this article buries the lede of the trial’s noteworthy use of one of the most divisive topics in contemporary psychiatry— pharmacogenomics. Much work remains to be done to make pharmacogenomics ready to deploy for all patients, and this study offers a valuable blueprint on how studies can generate hypotheses. While controversial, I believe that discounting the necessity to figure out how to use pharmacogenomics to personalize treatment is tantamount to discarding the importance of knowing the effect of renal or hepatic function on medication efficacy and tolerability.
Article: A historical review of placebo-controlled, relapse prevention trials in schizophrenia: The loss of clinical equipoise. Lawrence, Ryan E., Paul S. Appelbaum, and Jeffrey A. Lieberman. "A historical review of placebo-controlled, relapse prevention trials in schizophrenia: The loss of clinical equipoise." Schizophrenia Research (2020).
Dr. Craig Chepke: As a field, we always want long-term data for the medications we prescribe, and randomized withdrawal studies are the most common way that the efficacy of psychotropics is studied beyond the acute phase. This paper explores the vital question of whether these studies are still ethical in a chronic and degenerative brain disease like schizophrenia where evidence has shown cumulative duration of untreated psychosis leads to worse longterm functional outcomes.
Obesity, Inflammation, and Cognition
Article: Liraglutide improves memory in obese patients with prediabetes or early type 2 diabetes: a randomized, controlled study. Vadini, F., Simeone, P. G., Boccatonda, A., et al. International Journal of Obesity44.6 (2020): 1254-1263.
Dr. Craig Chepke: People with severe mental illness are at greater risk of obesity and metabolic disease, and psychotropic medications add fuel to that fire. Beyond the mortality risk of these conditions, there’s significant evidence that the inflammatory state associated with obesity and insulin resistance contributes to cognitive abnormalities. Phase 3 trials are about to begin for another GLP-1 receptor agonist, semaglutide, in Alzheimer’s Disease, so even if you haven’t added these to your armamentarium as I have, you should at least keep your eyes on this class of medications.
Psychiatry Resource Section
Clinical Psychiatry News Article: Reproductive psychiatry in 2021: Old questions and new challenges
NEJM Audio Interview: An International Look at Covid-19:
Annals of Clinical Psychiatry Article: Obsessive Compulsive Personality Disorder and Obsessive-Compulsive Disorder: Clinical Characteristics, Diagnostic Difficulties, and Treatment
Current Psychiatry Article: COVID-19 drives physician burnout for some specialties
JAMA Psychiatry Article: Suicide Prevention in the COVID-19 Era—Transforming Threat Into Opportunity
APA Child & Adolescent Telepsychiatry Toolkit:
Hot Topics in Psychiatry: Our Thought Leaders Weigh In
E-News Inaugural Issue
Welcome to Psychiatry in Practice E-Newsletter. I am excited to take on the management of this new Medscape publication with this inaugural issue! As you will see in this and future issues, we have some e-news features in store for you that will benefit all practicing psychiatrists. Designed to keep you up to date on the latest research, meetings coverage, and best practices, Innovations in Psychiatry will improve your patient care and save you time by keeping you up to speed with the latest critical content from multiple channels.
Every issue will feature a candid interview with one or multiple thought leaders in psychiatry. In this inaugural issue, I interview Donald W. Black, MD, and Jeffrey R. Strawn, MD, FAACAP—faculty from Medscape’s upcoming virtual conference, CP/AACP Psychiatry Update 2021: Solving Clinical Challenges, Improving Patient Care. These faculty share their thoughts on how COVID has changed the way psychiatrists practice, the far-reaching psychological effects of the COVID-19 quarantine on patients—including adolescents, and current treatments of the negative symptoms of schizophrenia. These thought leaders bring a critical knowledge of current issues and challenges in psychiatry, as well as pulse on current best practices, to both this interview and to the conference at which they present. CP/AACP Psychiatry Update 2021 is a MedscapeLIVE! event.
In this e-news, we will also feature Suggested Readings in which experts will provide not only their own recommendations of current articles to read, but critical article takeaways as well.
Given the ever-changing nature of psychiatry and the current healthcare environment, we are also including a Psych Resource section to keep you updated on critical research, resources, and new developments. Please look to us as a collective resource of all things psychiatry. This includes association guidelines and updates, COVID and other general topic publications, and other helpful psychiatry best practices information in one place at your fingertips to stay informed.
Get ready to be engaged and entertained, as well as educated, in the coming months. We have great things in store for you!
Don’t forget to check out details for the Innovations in Psychiatry: Virtual Spring Conference 2021 here. Thank you to this month’s interview participants and upcoming meeting faculty, Dr. Donald W. Black and Dr. Jeffrey R. Strawn for their critical contributions.
Here’s to a new Medscape tool designed to keep you plugged in and informed, to the new names and faces you will see in these issues, and to developing a lasting rapport with you, the readership! We want to be your go-to source of information in all things psychiatry. Please contact me at [email protected] with any comments and/or suggestions.
Hot Topics in Psychiatry: Our Thought Leaders Weigh In
Donald W. Black, MD, Professor of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City, Iowa.
Jeffrey R. Strawn, MD, FAACAP is Associate Professor of Psychiatry & Pediatrics, Associate Vice Chair of Research, Director, Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati, Cincinnati Children's Hospital Medical Center.
Colleen: Dr. Strawn, how has the shift to telepsychiatry affected your practice?
Dr. Strawn: While telepsychiatry can be very effective for pediatric patients, there are certainly limitations, particularly in assessing young children. Also, I’ve found myself limited in some of the work with younger children where the examination often involves here-and-now interactions and play. Subtleties of these interactions and the transactional quality of play are often lost with telemedicine. That being said, with adolescents there are some very helpful tips that can make a telepsychiatry appointment more successful. Many of these are available through the websites of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry. For telehealth, like most of what we do, preparation and training are of paramount importance. First, we have generally recommended that clinicians log in several minutes early to download and install software updates. Second, it is very important to have a back-up telephone number for the patient should technical difficulties or connectivity problems arise. Then, there are certain preparations for the office environment; we recommend more lighting than we would frequently have in the office.
In some of my work with adolescents, I’ve found that they’re more comfortable with the telepsychiatry setting.
Colleen: Dr. Black, how has COVID impacted your practice? What have you done to mitigate any negative effect (practice-wise or clinically)?
Dr. Black: Covid has been a huge problem on the inpatient unit where I work. Staff and patients were initially very anxious about it, although that has lessened as we’ve learned more about transmission. We’ve had to develop protocols to keep safe. For example, COVID-positive patients are not admitted, but will go to a COVID unit first. The inpatient unit has a mixed population, and some patients won’t wear masks, such as dementia patients, while others do. We’ve had to adjust our own behavior in response to maintain safety. We have team meetings on Zoom, for example. Interestingly, COVID has become a focus of some patients’ delusions.
Colleen: Dr. Strawn, during quarantine, and we are seeing an uptick in mental health issues in adolescents. What have you found to be effective in treating this particular population in these circumstances?
Dr. Strawn: Many of my patients—who are often children, adolescents, and young adults—have struggled with the frequent shifts in their schools and families in the transition to and from various forms of non-traditional instruction. In parallel, their parents have taken on the roles of educators and guidance counselors while struggling with their own adjustments at work. I have seen amazing examples of flexibility and resilience. Much of what I have done has been to encourage and support this flexibility and resilience and to help them to problem solve when they have gotten stuck. I have also tried to support creative and safe ways in which they can maintain closeness while being physically distanced from their peers. I find myself more frequently explaining that the loneliness or frustration that we're discussing is not something that I can 'fix' with titration of an SSRI or a change in medication. For me, as a psychiatrist, I have felt much more frequently that I am 'with' my patients as they often poignantly describe their struggles related to COVID-19.
Colleen: Dr. Black, in your recent study, what were your findings regarding the association between comorbid disorders and changes in gambling activity?
Dr. Black: First, nearly all people with a gambling disorder have comorbid mental health or addictive disorders. But the relationship between the comorbid disorder and gambling is complicated. Typically, those with depression or PTSD gamble more when the disorder is worse, whereas with some disorders, such as agoraphobia and social phobia. At least among younger gamblers, if substance abuse is more sever, gambling behavior is less. This is an example of a “substitute addiction.” That is, as one addiction subsides, the other takes over.
Colleen: Dr. Black, what is your advice regarding treatment of the negative symptoms of schizophrenia?
Dr. Black: Negative symptoms are unfortunately very common in patients with schizophrenia, and are more disabling than are positive symptoms, such as hallucinations and delusions. Sadly, we don’t have good treatments for negative symptoms. For this reason, it is important to determine if the symptoms are due to the patient’s psychotic disorder, or perhaps due to an accompanying depression, which can be treated, or perhaps reflect extrapyramidal side effects, which also can be treated. Newer medications on the horizon may be more effective in treating these symptoms.
Article: Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, Linney C, McManus MN, Borwick C, Crawley E. Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19. J Am Acad Child Adolesc Psychiatry. 2020 Nov;59(11):1218-1239.e3. doi: 10.1016/j.jaac.2020.05.009. Epub 2020 Jun 3. PMID: 32504808; PMCID: PMC7267797.
Dr. Jeffrey Strawn: This article is important in that it highlights the hardship of isolation for children and adolescents and sounds the alarm that we must, as clinicians, be prepared for post-pandemic, post-quarantine psychiatric sequelae. It reminds us that social isolation may leave a scar even after we have been vaccinated, returned to classes and after school activities and once again think about 'curves' as grade adjustments rather than new cases or hospitalizations.
Article: Well-being, burnout, and depression among North American psychiatrists. Summers RF, et al. Am J Psychiatry 2020; 177: 955-964.
Dr. Donald Black: Burnout is pervasive among physicians in general. Summers et al focus on psychiatrists and look at risk factors which has implications for intervention.
Psychiatry Resource Section
Current Psychiatry Article: The rebirth of psychedelic psychiatry
Annals of Clinical Psychiatry Article: Validity of Pilot Adult ADHD Self- Report Scale (ASRS) to Rate Adult ADHD Symptoms
Clinical Psychiatry News Article: APA apologizes for past support of racism in psychiatry
Managing Depression in Primary Care: A Collaborative Care Approach (CME/CE Certified Supplement)
NEJM Perspective: Testing in a Pandemic — Improving Access, Coordination, and Prioritization: