Innovations in Psychiatry Newsletter

November 2022

5 Minutes With Dr. Henry Nasrallah… Round 2! 
 
Introduction

We’re back this month again with Dr. Henry Nasrallah, Chair of the recent hybrid 21st Annual Psychopharmacology Update. Dr. Nasrallah and I continue our 5 Minutes With segment this month and explore thoughts on the biggest challenge of treating (BPD) in 2022; most frustrating treatment issue; most promising and useful recent research in schizophrenia treatment; challenges in faculty development and mentorship; and most rewarding aspect of the job.

We spoke last month about the 21st Annual Psychopharmacology Update, the keynote lecture, the most underutilized therapies for major depression, bipolar disorder, and schizophrenia, and schizophrenia treatment in 2022 versus 2000. Read Part 2 of this interview below for his thoughts on more topics.

Don’t Miss!
Psychiatry Winter Update 
Thursday-Saturday December 1-3, 2022; Omni La Costa, Carlsbad, California

  • 3-day conference on up-to-date, clinically relevant information in treatment of Depressive Disorder, ADHD, Schizophrenia, Bipolar Disorder, and Sleep Disorders.
  • Other hot topics: Cultural Competence, Youth Mental Health, Maternal Mental Health, and a Special Session on Neuropsychiatry—looking at cognition and psychosis across the diagnostic spectrum

Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=664112

Psychiatry Update Spring
June 8-10, 2023; Marriott Marquis Chicago, Chicago, Illinois

  • Full 2.5-day meeting with interactive presentations, discussion and networking opportunities, and in addition to the scientific sessions, there will be informative Bonus Presentations and an exciting Keynote speaker.
  • Explore the latest advances in the treatment and management of Major Depressive Disorder, ADHD, Schizophrenia, and Bipolar Disorder, plus other clinically relevant hot topics: healthcare resilience, updates and innovations in fast-acting antidepressants, newly emerging digital therapeutics and updates in neuropsychiatry.
  • Our internationally renowned faculty will present the most up-to-date, clinically relevant information to assist you in the treatment of your patients 

Keep up to date on current research with this month’s Psych Resource section, featuring articles from Clinical Psychiatry News, Current Psychiatry, MDEdge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below.

From the University of Cincinnati and Current Psychiatry, thank you to all the faculty and attendees of the Psychopharmacology Update. And a special thank you to Dr. Nasrallah for this month’s interview! Click here to register and view it at your leisure. Happy Holidays! –Colleen Hutchinson
 

 

Interview 

Henry A. Nasrallah, MD, is Chair, Psychopharmacology Update; Editor-in-Chief, Current Psychiatry; President, American Academy of Clinical Psychiatrists (AACP); Vice-Chair for Faculty Development and Mentorship; Professor of Psychiatry, Neurology, & Neuroscience; Director, Neuropsychiatry and Schizophrenia Programs, University of Cincinnati College of Medicine, Cincinnati, OH.

What is your most frustrating treatment issue?
Dr. Nasrallah:
Few patients with schizophrenia, major depression, bipolar disorder, GAD, OCD, and personality disorders (like borderline or narcissistic personality disorders) achieve full remission and recovery. The majority languish with partial response and disability. Sometimes, misdiagnosis leads to inaccurate treatment, delaying full response.
Also, the lack of any approved treatment for negative symptoms or cognitive deficits in schizophrenia remains a huge unmet need.
 
What is the most promising and useful recent research in schizophrenia treatment? 
Dr. Nasrallah:
The emergence of non-dopaminergic pathways for treating psychotic symptoms including: 1) muscarinic mechanisms of action, 2) TAAR 1 agonists, and 3) serotonin 5ht-2a inverse agonists. Early studies are very promising.
  
Biggest challenge of treating borderline personality disorder (BPD) in 2022: 
Dr. Nasrallah:
The biggest challenge in treating BPD is the lack of an FDA-approved pharmacotherapy, which can be used in tandem with dialectic behavior therapy (DBT). Thus, clinicians continue to treat individual BPD symptoms (off-label) such as depression, labile mood, impulsivity, anxiety or psychotic symptoms, sometimes in necessary polypharmacy.
 
Biggest challenge in faculty development and mentorship: 
Dr. Nasrallah:
1) Time commitment. Everyone in psychiatry is stretched to the limit due to high demand and workforce shortages. 2) Lack of sufficient mentors. 3) Lack of rewards for mentors compared to generating RVUs. 4) Mentees have to decide the type of mentorship they need to develop into excellent clinicians, educators, researchers, or administrators.
 
Most rewarding aspect of the job: 
Dr. Nasrallah:
Watching past mentees shine and become medical directors, department chairs, and prominent, NIH-funded investigators with numerous publications in peer-review journals—and excellent mentors in their own right.

What is the most recent landmark article you have overseen publication of as Editor of Current Psychiatry?
Dr. Nasrallah:
Every issue of Current Psychiatry contains very important articles that are relevant for busy psychiatric practitioners (who are our 45,000 subscribers). It is difficult to mention only one because it would be unfair to the other excellent articles, each of which is particularly relevant to various psychiatric subspecialists. I strongly recommend browsing through each issue and the reader will immediately see an article that provides the latest advances in a given disorder across all age groups and across biological, psychological, and social aspects of psychiatry.

 
Psychiatry Resource Section

JAMA Psychiatry Viewpoint: Supported Employment and Psychiatric Intervention
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2796905

MDEdge Clinical Psychiatry News Article: Postpartum posttraumatic stress disorder: An underestimated reality?
https://www.mdedge.com

New England Journal of Medicine Perspective: Prescribing Opioids for Pain — The New CDC Clinical Practice Guideline
https://www.nejm.org/doi/full/10.1056/NEJMp2211040

Current Psychiatry Article: Incorporating positive psychiatry with children and adolescents
https://www.mdedge.com

APA Learning Center: Advancing Equity and Justice in Psychiatry: BPA and APA Leaders Address Opportunities and Challenges for the Future—Credits CME: 1.25, Participation: 1.25
https://education.psychiatry.org/diweb/catalog/item?id=11013882

Medscape CME & Education: Clinical Connect: Clinical Queries in Bipolar Depression: How Do You Provide Patient-Centered Care?—Credit CME/CE AMA PRA: 0.25; Authors: Leslie Citrome, MD, MPH; Joseph F. Goldberg, MD
https://www.medscape.org/viewarticle/984159

Clinical Psychiatry News Article: Electrolyte disturbances a harbinger of eating disorders?
https://www.mdedge.com

Current Psychiatry Article: Emergency contraception for psychiatric patients
https://www.mdedge.com

 

October 2022

Daily 2

—by Colleen Hutchinson

Welcome back to Day 2 of Medscape’s 21st Annual Psychopharmacology Update. Today’s agenda includes Masterclass I: Therapeutic Strategies for Treatment-Resistant Anxiety Disorders, Masterclass II: Therapeutic Strategies for Treatment-Resistant Psychotic Disorders, and Masterclass III: Therapeutic Strategies for Treatment-Resistant Mood Disorders. 
Dr. Leslie Citrome echoed the thoughts so many of us are having regarding the meeting in general: “It’s great to be back in person!” 
“This conference provides an opportunity to update clinical practice using evidence-based techniques,” Dr. Diana Martinez, faculty for the Cannabis Workshop, shared. In her presentation yesterday, titled A Focus on Medical Cannabis and Psychiatric Patients, With an Update on Ketamine and Psilocybin, she shared that “While repurposing controlled substances as medications holds promise, there is a great need for clinical trials.” Access her talk online to learn more about where we are with current evidence-based options, and where we need to go.
If you wish to access previous presentations and join in virtually today or in the future at your leisure, register here

Dr. Joseph Goldberg, longtime faculty and Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, New York, shares: "Healthcare practitioners from all disciplines who treat patients with mood disorders, anxiety disorders, psychosis, and substance use disorders will benefit from this state-of-the-art educational program, which, after two decades, stands out as a landmark annual event in the world of psychopharmacology continuing medical education."

Dr. Jeffrey Strawn presents three times in today’s Masterclass I: Therapeutic Strategies for Treatment-Resistant Anxiety Disorders. His presentations include Generalized Anxiety Disorder, Panic Disorder, and Attention Deficit Hyperactivity Disorder.
“Treating anxiety disorders can be difficult,” Dr. Strawn explained. “This will be a great chance for us to discuss what to do when first-line treatments fail, disappoint, or produce side effects.” 

Dr. Citrome follows Dr. Strawn’s talk in Masterclass II: Therapeutic Strategies for Treatment-Resistant Psychotic Disorders with his presentation, Delusional Disorder and Schizoaffective Disorder: The Forgotten Stepchildren of Refractory Psychoses. Asked about his upcoming presentation, he quipped, “When was the last time you heard about delusional disorder?” Don’t miss it!

One of the highlights of Day 2 will also be Dr. Goldberg’s talk in Masterclass III: Therapeutic Strategies for Treatment-Resistant Mood Disorders, is Treatment-Resistant Mood Disorders: Bipolar and Unipolar Depression. “This masterclass will provide a comprehensive, evidence-based overview of strategies to manage treatment-resistant forms of major depression and bipolar disorder,” Dr. Goldberg shares. “Attendees will learn about what works and what does not, and how to match the right treatment for the right patient based on his/her unique clinical profile.

We hope you’ve been able to view these MedscapeLIVE! 21st Annual Psychopharmacology Update presentations this week live virtually or in person, but if not, go online and register here to view any and all sessions of the conference, join us live for these Masterclasses today, and don’t forget to access all past content online here. You don't want to miss out!
—by Colleen Hutchinson

 

 

October 2022

Daily 1

—by Colleen Hutchinson

Welcome to Medscape’s 21st Annual Psychopharmacology Update! On behalf of MedscapeLIVE!, the University of Cincinnati and Current Psychiatry, we welcome you to click here and check out Medscape’s hybrid meeting. To register for in-person or virtual attendence, click here. Day 1 (October 28) is the Optional Workshops & Keynote Presentation, and Day 2 (October 29) comprises the three Masterclasses on treatment resistance in multiple psychiatric syndromes. Keynote presenter Charles A. Nemeroff, MD, PhD highlighted a strength of this meeting, explaining that “The faculty are a group of leaders in psychopharmacology from leading university medical centers describing state of the art science and practice.”
Dr. Paul Keck, who presents in Masterclass III on Saturday, is happy to see it’s back: “This is an extraordinary educational resource for our community, and I’m delighted it’s an annual event in Cincinnati.”

Today there are three Preconference Workshops  on the latest advances in Addiction, Medical Cannabis, and Telepsychiatry. This includes a 3-prong presentation from Dr. Edwin Salsitz in the Addiction Workshop, about which he shared, "Understanding Addiction from the Inside OutYou never do what addicted people do, or do you?” And on his talk, The Fentanyl Crisis, he added, “I discuss: How is fentanyl different from other opioids and why does it matter?

Also on Day 1, we are excited for Dr. Nemeroff’s Keynote Presentation on management of treatment resistant depression, titled Current and Future Treatment of Depression: Glass Half Full or Half Empty? On this topic, Dr. Nemeroff shared: “After a hiatus of several years, we are witnessing breakthroughs in the treatment of depression ranging from novel drug combinations to psychedelics and advances in neuromodulation.” Don’t miss it!

Chaired by Henry Nasrallah, MD, this event is a comprehensive update for all attendees—in person and virtual. Dr. Nasrallah highlighted the strength of the agenda, stating: “In one day, you will acquire the absolute latest evidence-based guidance for managing the very complicated and treatment-resistant patients across psychotic, mood, and anxiety disorders by the most qualified experts.”

Dr. Jeffrey Strawn shared his thoughts: “I'm looking forward to learning from my colleagues, Drs. Nemeroff and Nasrallah, and discussing treatment resistant anxiety disorders.” That is first on the agenda on Saturday morning, October 29, with a panel of the experts in place to bring attendees up to speed—Dr. Strawn, Dr. Nemeroff, and Dr. Nasrallah. 

Dr. Paul Keck follows that up with his presentation Treatment-Resistant Mania in Masterclass III and shared the perspective of being both faculty and attendee: “When I listen to presentations, I try to distill what I can take back to the clinic. I hope my presentation is useful to psychiatrists taking care of people who are suffering through manic episodes.
In terms of what attendees will come away with, Dr. Nasrallah stated, “Attending the 21st Annual Psychopharmacology Update will enable psychiatric clinicians to manage the most challenging and difficult-to-treat patients in their clinics.”    

Join us to learn critical advances and breakthroughs care to better help your patients. Don’t miss it!
—by Colleen Hutchinson

 

October 2022

5 Minutes With… Dr. Henry Nasrallah!  
 
Introduction

We’re back this month with Dr. Henry Nasrallah, Chair of the upcoming hybrid 21st Annual Psychopharmacology Update. Dr. Nasrallah is also the Editor-in-Chief of Current Psychiatry; President, American Academy of Clinical Psychiatrists (AACP); Vice-Chair for Faculty Development and Mentorship and Professor of Psychiatry, Neurology, & Neuroscience; and Director, Neuropsychiatry and Schizophrenia Programs at the University of Cincinnati College of Medicine. Dr. Nasrallah is a well-respected researcher and has published in multiple therapeutic areas. As Editor of Current Psychiatry, he also brings an informed perspective to where we are in research and treatment options for psychiatric conditions. 
We speak this month on the meeting, the keynote lecture, the most underutilized therapies for major depression, bipolar disorder, and schizophrenia, and schizophrenia treatment in 2022 versus 2000. Read Part 1 of this interview below for his thoughts on a few current topics, and don’t miss Part 2 of this interview next month.

Quick! It’s almost here: Psychopharmacology Update (21st Annual)
Friday/Saturday October 28-29, 2022; Westin, Cincinnati, Ohio 

  • Full-day, 3-part Masterclass focusing on treatment-resistance in multiple psychiatric syndromes. Part 1: Schizophrenia, Delusional and Schizo-affective Disorders; Part 2: Anxiety Disorders; Part 3: Mood Disorders.
  • PRECONFERENCE workshops on the latest advances in Addiction, Medical Cannabis, and Telepsychiatry Friday, October 28th, 2022

Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=663485

Psychiatry Winter Update 
Thursday-Saturday December 1-3, 2022; Omni La Costa, Carlsbad, California

  • 3-day conference on up-to-date, clinically relevant information in treatment of Depressive Disorder, ADHD, Schizophrenia, Bipolar Disorder, and Sleep Disorders.
  • Other hot topics: Cultural Competence, Youth Mental Health, Maternal Mental Health, and a Special Session on Neuropsychiatry—looking at cognition and psychosis across the diagnostic spectrum

Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=664112

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDEdge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below.

On behalf of the University of Cincinnati and Current Psychiatry, it is our pleasure to invite you to attend the Psychopharmacology Update on October 29, 2022. Thank you to Dr. Nasrallah for this month’s interview! Click here to register!

–Colleen Hutchinson

 

Interview 

Henry A. Nasrallah, MD, is Chair, Psychopharmacology Update; Editor-in-Chief, Current Psychiatry; President, American Academy of Clinical Psychiatrists (AACP); Vice-Chair for Faculty Development and Mentorship; Professor of Psychiatry, Neurology, & Neuroscience; Director, Neuropsychiatry and Schizophrenia Programs, University of Cincinnati College of Medicine, Cincinnati, OH.

Why attend the hybrid 21st Annual Psychopharmacology Update?
Dr. Nasrallah:
Because in one day, you will acquire the absolute latest evidence-based guidance for managing the very complicated and treatment-resistant patients across psychotic, mood, and anxiety disorders by the most qualified experts. Attending the 21st Annual Psychopharmacology Update this week will enable psychiatric clinicians to manage the most challenging and difficult-to-treat patients in their clinics.

Keynote lecture by Dr. Charles Nemeroff— Current and Future Treatment of Depression: Glass Half Full or Half Empty: 
Dr. Nasrallah: A tour de force from one of the world’s experts in mood and anxiety disorders and the neurobiological consequences of trauma in children and adults. Be there!

Underutilized therapies in my specialty: 
Dr. Nasrallah: 
Schizophrenia: By far the underutilization of long-acting second-generation antipsychotics, especially early after the first episode of psychosis, and the use of clozapine for the 30% of patients who do not respond to dopamine receptor antagonists. A huge reduction of disability and suicide and a significant improvement in the outcome of schizophrenia can be achieved if long-acting injectables (LAI) and clozapine are used widely.
Bipolar disorder: Lithium is vastly underutilized.
Major depression: Neuromodulation (especially ECT) is very underutilized.

The difference between treating schizophrenia in 2000 versus today in 2022:
Dr. Nasrallah:
In 2000, research disclosed that psychotic episodes of schizophrenia are associated with brain tissue loss, treatment resistance, very high suicide risk and functional disability. So in 2022, psychiatrists realize that we must do whatever it takes to prevent any psychotic recurrence. Because poor adherence is the #1 cause for relapse in schizophrenia, the use of long-acting antipsychotics must be used very early, right after discharge from the first hospitalization.
 
Another difference from 2000 is a better understanding of the neurodevelopmental etiology of schizophrenia. Advances in molecular genetics and GWAS studies have uncovered hundreds of risk genes for schizophrenia on all chromosomes, along with CNVs and mutations, in addition to various adverse events during pregnancy. Thus, we now realize that schizophrenia is a very heterogeneous syndrome comprised of several hundred diseases (biotypes,) all of which share a similar phenotype of positive, negative, and cognitive symptoms. 79% of this syndrome is genetic.
 
Also, in contrast to 2000 when a “chemical imbalance” (i.e., deficit of monoamines) is the cause of major depression, in 2022 we know from research advances that loss of brain-derived neurotrophic factor (BDNF) and loss of neurogenesis in the hippocampus are more likely to be the neurobiological causes of depression.

 
Psychiatry Resource Section

JAMA Psychiatry Editorial: Ultrarare Coding Variants and Cognitive Function in Schizophrenia—Unraveling the Enduring Mysteries of Neuropsychiatric Genetics
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2795511

MDEdge Clinical Psychiatry News Article: Study finds systemic AD treatment relieves depressive symptoms along with skin symptoms
https://www.mdedge.com

New England Journal of Medicine Perspective: Work Hours and Depression in U.S. First-Year Physicians
https://www.nejm.org/doi/full/10.1056/NEJMc2210365

New England Journal of Medicine: Transforming Management of Opioid Use Disorder with Universal Treatment
https://www.nejm.org/doi/full/10.1056/NEJMp2210121

APA Learning Center: Clinical Approaches for Reproductive Psychiatry —Credits CME: 1.5, Participation: 1.5
https://education.psychiatry.org/diweb/catalog/item?id=10971669

Medscape CME & Education: Clinical Connect: Does the Mechanism Matter? Breaking Down Novel Pharmacology in Bipolar Depression and Schizophrenia —Credit CME/CE + ABOM MOC: 0.5; Authors: Deanna L. Kelly, PharmD, BCPP; Christoph U. Correll, MD; Joseph F. Goldberg, MD
https://www.medscape.org/viewarticle/982702

Clinical Psychiatry News Article: Confirmed: ECT tops ketamine for major depression
https://www.mdedge.com

Current Psychiatry Article: Positive psychiatry: An introduction
https://www.mdedge.com/psychiatry/article/258302/positive-psychiatry-introduction

 

 

September 2022

Catching Up with Dr. Holly Swartz: Are You Up to Date on Research to Practice for Bipolar Disorder
  
Introduction

We’re back this month with a very informative interview with Holly A. Swartz, MD, who is Professor of Psychiatry at the University of Pittsburgh and Treasurer of the International Society for Bipolar Disorders, Pittsburgh, PA. She also serves as Editor-in-Chief of the American Journal of Psychotherapy. Dr. Swartz served as faculty at the recent Medscape 2022 Psychiatry Spring Update. She is a well-respected researcher in bipolar disorder treatment, and has published quite a bit in this therapeutic area, including on neurobiological and behavioral mechanisms of circadian rhythm disruption in bipolar disorder, and co-authoring the recent literature review and agenda for future research as part of the International Society for Bipolar Disorders Chronobiology Task Force. We discussed her recent article on machine learning algorithm to predict depressive disorders, and what we know and don’t know about treating bipolar spectrum disorders—and off-label treatments for them.
Also, don’t miss Dr. Swartz’s Rapid Fire responses on a number of topics below!

Housekeeping on the latest CME opportunities—3 meetings to add to your calendar:
Quick! It’s almost here: Psychopharmacology Update (21st Annual)
Friday/Saturday October 28-29, 2022; Westin, Cincinnati, Ohio 

  • Full-day, 3-part Masterclass focusing on treatment-resistance in multiple psychiatric syndromes. Part 1: Schizophrenia, Delusional and Schizo-affective Disorders; Part 2: Anxiety Disorders; Part 3: Mood Disorders.
  • PRECONFERENCE workshops on the latest advances in Addiction, Medical Cannabis, and Telepsychiatry Friday, October 28th, 2022

Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=663485

Psychiatry Winter Update 
Thursday-Saturday December 1-3, 2022; Omni La Costa, Carlsbad, California

  • 3-day conference on up-to-date, clinically relevant information in treatment of Depressive Disorder, ADHD, Schizophrenia, Bipolar Disorder, and Sleep Disorders.
  • Other hot topics: Cultural Competence, Youth Mental Health, Maternal Mental Health, and a Special Session on Neuropsychiatry—looking at cognition and psychosis across the diagnostic spectrum

Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=664112

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below.

Thank you to Dr. Swartz for this month’s interview! Please contact me at [email protected] with any comments.

–Colleen Hutchinson

 

Interview 

Holly A. Swartz, MD, is Professor of Psychiatry at the University of Pittsburgh; Editor-in-Chief, American Journal of Psychotherapy; and Treasurer of the International Society for Bipolar Disorders, Pittsburgh, PA.

One topic you’ve published on is using machine learning algorithm to predict depressive disorders. Can you tell us more about this and any meaningful advancements?
Dr. Swartz:
My colleagues and I recently finished a study using machine learning techniques to better understand how verbal and non-verbal behaviors in the patient-therapist dyad predict working alliance and, ultimately, patient outcomes. Our work so far has focused on features of dyadic behavior associated with the therapeutic relationship, an important predictor of psychotherapy outcomes. A recent report from our group shows that therapists’ linguistic entrainment with patients has a significant impact on patients’ perception of the therapeutic alliance. This is important because a good therapeutic relationship is associated with better outcomes in psychotherapy. It suggests that therapists should pay attention to the synchrony of language used during psychotherapy sessions to promote a better working alliance. The next step in our work will be to see how this translates to depression outcomes.

Your presentation at Medscape’s 2022 Psychiatry Spring Update was Bipolar Spectrum Disorders: Individualizing Treatment and Updates in Advancements. You said: “Less is known about treating bipolar spectrum disorders, including bipolar II disorder, compared to bipolar I disorder, yet over 3 million people in the US suffer from these spectrum conditions.” Where are we with current evidence on management?
Dr. Swartz:
Unfortunately, treatments for bipolar II disorder and related bipolar spectrum disorders remain understudied. In the absence of clear evidence, we often end up treating those with bipolar spectrum disorders as if they have bipolar I disorder. Some research supports this practice, such as trials of quetiapine and lumateperone for bipolar depression where individuals with bipolar II disorder were included in the registration trials and had outcomes similar to those with bipolar I disorder. However, in other instances, such as treatment with antidepressant medications, as monotherapy or an adjunct, treatment outcomes differ between bipolar I and II disorder. Interestingly, we have considerable information about psychotherapies as treatments for bipolar II depression. Fortunately, most of the bipolar-specific psychotherapies (CBT, Interpersonal and Social Rhythm Therapy, Family Focused Therapy) appear to be helpful for individuals with bipolar II disorder.

What is the current role of off-label interventions for treating bipolar spectrum disorders?
Dr. Swartz:
Unfortunately, almost all treatments for bipolar spectrum disorders are off-label because no medication has an FDA indication specifically for bipolar spectrum disorders. Many commonly used medications for bipolar I disorder are also used off-label for bipolar II disorder and related conditions including lamotrigine, antidepressant medications, and second-generation antipsychotics. More studies are needed to formally test the efficacy of these treatments in bipolar II disorder. 

Another topic you’ve researched is neurobiological and behavioral mechanisms of circadian rhythm disruption in bipolar disorder, including co-authoring the recent literature review and agenda for future research as part of the International Society for Bipolar Disorders Chronobiology Task Force (CTF). Are there take-home points for practicing clinicians at this stage of research in this area?
Dr. Swartz:
Circadian rhythms are very important in bipolar disorders. Some studies suggest that vulnerabilities of the circadian system may contribute to the etiology of bipolar disorders. Bodily functions such as sleep, energy, appetite, and concentration which are, in part, controlled by the circadian system are characteristically dysregulated in bipolar disorders. In our research, we have shown that helping people develop and maintain very regular daily routines (“social rhythms”) as a means of stabilizing underlying disturbances in circadian rhythms improves outcomes with bipolar disorders. There is growing interest in somatic therapies for bipolar disorder, such as light and dark therapies, as well as psychotherapies that impact circadian function. Key messages from this research include the importance of quality darkness at night (no screens, no light at all) and consistent daily routines.

 

Thought Leader Rapid Fire 

Best recent medical journal article I read:

Tabuteau H, Jones A, Anderson A, Jacobson M, Iosifescu DV. Effect of AXS-05 (Dextromethorphan-Bupropion) in Major Depressive Disorder: A Randomized Double-Blind Controlled Trial. Am J Psychiatry. 2022 Jul;179(7):490-499.

Using antidepressants to treat bipolar II depression:  

 Ok, if done judiciously and with caution

Best tool in my clinical arsenal: 

Interpersonal Psychotherapy

My mentor: 

 John Markowitz, MD and Ellen Frank, Ph.D.

One thing I wish my patients understood better:

Psychotherapy is as important as medication

Telepsychiatry: 

Here to stay

Digital therapeutics/devices in mental health treatment:

Extends the reach of conventional treatments

The role of second-generation antipsychotics in the treatment of bipolar depression: 

Not a class effect; some work well and others not so much

Using machine learning algorithm to predict depressive disorders:

New frontier

Most critical new advance in my area of medicine: 

NMDA antagonism

Psychiatry Resource Section

JAMA Psychiatry Viewpoint: Transdisciplinary Science and Research Training in Psychiatry: A Robust Approach to Innovation
https://jamanetwork.com/journals/jamapsychiatry/currentissue

MDEdge Clinical Psychiatry News Article: Unconventional wisdom: Major depression tied to childhood trauma is treatable
https://www.mdedge.com

New England Journal of Medicine Perspective: Personality Disorders
https://www.nejm.org/doi/full/10.1056/NEJMra2120164

APA Learning Center: "Doctor, Are You Sure I Am Bipolar?" Challenges in the Differential Diagnosis of Bipolar Disorder —Credits CME: 1.25, Participation: 1.25
https://education.psychiatry.org/diweb/catalog/item?id=6497505

Medscape CME & Education: Clinical Connect: Addressing Residual Symptoms and Preventing Relapse in Major Depressive Disorder —Credit CME/CE + ABOM MOC: 0.5; Author: Gregory W. Mattingly, MD
https://www.medscape.org/viewarticle/981406

Clinical Psychiatry News Article: Timing of food intake a novel strategy for treating mood disorders?
https://www.mdedge.com

New England Journal of Medicine Perspective: Hospital Standards of Care for People with Substance Use Disorder
https://www.nejm.org/doi/full/10.1056/NEJMp2204687

 

 

August 2022

What’s New for Children and Adolescents in ADHD Treatment—and More! 

Ann Childress, MD, Speaks About What’s New in ADHD Treatment for Adolescents, her Recent Article on Variable Patterns of Remission From ADHD in Child and Adolescent Psychiatric Clinics, Digital Media Use and Adolescent ADHD, and Rapid Fire! 
  

Introduction

We’re back this month with a candid interview with Margaret H. Sibley, PhD. Dr. Sibley served as faculty at the recent Medscape 2022 Psychiatry Spring Update and is Associate Professor of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Licensed Clinical Psychologist at Seattle Children’s Hospital. Dr. Sibley is also a well-respected researcher specializing in ADHD diagnosis and treatment in adolescence and adulthood, and has published 100+ scientific works on the topic, plus a book on the psychosocial treatment of adolescent ADHD. We discussed the association of digital media use and subsequent symptoms of ADHD among adolescents, engaging adolescents with ADHD and helping them become independent, new therapies in the ADHD armamentarium—including beyond pharmacologic, some of her recent research papers and findings, and treatment algorithms and programs for pediatric patients whose families believe remission is the goal and a realistic endpoint.
Also, don’t miss Dr. Sibley’s Rapid Fire responses on a number of topics below!

Housekeeping on the latest CME opportunities—3 meetings to add to your calendar:
Psychopharmacology Update (21st Annual)
Friday/Saturday October 28-29, 2022; Westin, Cincinnati, Ohio 

  • Full-day, 3-part Masterclass focusing on treatment-resistance in multiple psychiatric syndromes. Part 1: Schizophrenia, Delusional and Schizo-affective Disorders; Part 2: Anxiety Disorders; Part 3: Mood Disorders.
  • PRECONFERENCE workshops on the latest advances in Addiction, Medical Cannabis, and Telepsychiatry Friday, October 28th, 2022

Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=663485

Psychiatry Winter Update 
Thursday-Saturday December 1-3, 2022; Omni La Costa, Carlsbad, California

  • 3-day conference on up-to-date, clinically relevant information in treatment of Depressive Disorder, ADHD, Schizophrenia, Bipolar Disorder, and Sleep Disorders.
  • Other hot topics: Cultural Competence, Youth Mental Health, Maternal Mental Health, and a Special Session on Neuropsychiatry—looking at cognition and psychosis across the diagnostic spectrum

Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=664112

Neurology Exchange Virtual Conference
Tuesday-Thursday, September 20-22, 2022

  • Livestreamed sessions each evening will present the latest education in neurology and discuss practical application of emerging advances into clinical care 
  • Nationally renowned faculty experts will engage you and your fellow learners in the live virtual sessions

Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=674045

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 

Thank you to Dr. Sibley for this month’s interview! Please contact me at [email protected] with any comments.

Colleen Hutchinson

 

Interview 

Margaret H. Sibley, Ph.D. is Associate Professor of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Licensed Clinical Psychologist at Seattle Children’s Hospital and a researcher who specializes in the diagnosis and treatment of ADHD in adolescence and adulthood, having published over 100 scientific works on this topic, as well as a book on the psychosocial treatment of adolescent ADHD.

In my recent interview with Dr. Ann Childress, she named as best recent article your article, “Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD,” published in the American Journal of Psychiatry. The article shares that it is estimated that childhood ADHD “remits by adulthood in approximately 50% of cases; however, this conclusion is typically based on single endpoints, failing to consider longitudinal patterns of ADHD expression. The authors investigated the extent to which children with ADHD experience recovery and variable patterns of remission by adulthood.”
Your conclusion states: “The MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood…Although intermittent periods of remission can be expected in most cases, 90% of children with ADHD in MTA continued to experience residual symptoms into young adulthood.”  What does this mean for practicing psychiatrists, and the treatment algorithms and programs they apply to pediatric patients whose families may 1) believe “remission” is the goal and a realistic endpoint, and 2) continue with or cease treatment protocols based on assumed “remission” status?

Dr. Sibley: I think clinicians should communicate with families of newly diagnosed children that effective treatment for ADHD promotes management of symptoms and reductions of impairment, but rarely leads to permanent remission of a person’s ADHD-related traits. There are very successful people with ADHD and a lot of hope for living a fulfilling life with this disorder. Some people even leverage their symptoms into strengths. However, as people with ADHD get older, they need to learn to write their owner’s manual for what helps them succeed and be the best version of themselves. Overcoming your ADHD can be hard work and takes commitment. The ingredients for success are different for everyone, but could be living a healthy lifestyle (diet, exercise, sleep, screen time limits), staying consistent with a medication that is working, pursuing an educational or vocational track that fits your strengths, and/or seeking out supportive relationships that build your self-esteem. 
Providers need to know that patients should continue to be monitored even after treatment is discontinued, because recurrence of symptoms is the rule rather than the exception—potentially triggered by increased demands that can accompany life changes like a transition to middle school. The good news is, with the right steps taken, periods of good functioning are to be expected. As patients enter adolescence and adulthood, cognitive-behavioral therapy approaches are often helpful in figuring out the factors that support an individual’s success. Parents should anticipate challenges that are coming down the road and increase supports during these times.

A topic you’ve published on is the association of digital media use and subsequent symptoms of ADHD among adolescents. How would you characterize the association based on your experience and the research?
Dr. Sibley:
Compared to their peers, adolescents with ADHD have more trouble managing their use of technology—particularly when it comes to setting boundaries on use and acknowledging when it’s appropriate to stop the fun and move on to responsibilities like schoolwork or chores. This is because motivational dysregulation is one of the core areas of impairment for teenagers with ADHD. There isn’t any strong research suggesting that overuse of digital technology causes ADHD; however, as a society, we certainly seem to be shortening our attention span by conditioning our brains to seek media that is briefer and more stimulating. Parents of teenagers have an important role in setting limits on media use for youth with and without ADHD, to help them learn to set boundaries on screen time and support brain health.

In your presentation, Supporting Patients Through the Transition to Independence, what are the main take-home points for practicing clinicians?
Dr.  Sibley:
Patient engagement is a central developmental issue in the treatment of ADHD. Psychologists have been developing strategies to better engage adolescents with ADHD in non-pharmacological treatment and these strategies also lend themselves well to pharmacological treatment. Medication providers can do things like promote shared decision-making between parents and youth, help adolescents set personally meaningful goals that are linked to treatment, and use Motivational Interviewing to strengthen commitment to treatment. It is also important to start planning the transition to post-high school life several years beforehand. Parental supports should be gradually tapered over time rather than abruptly when the youth finishes high school. I recommend referral to a cognitive-behavioral therapy (CBT) therapist who specializes in ADHD treatment in the later years of high school to help the youth start collecting strategies to manage their own ADHD, and to support parents in tapering off supports.

Your presentation at Medscape’s 2022 Psychiatry Spring Update was in Session IV: New Horizons in ADHD, which focused on new treatment options. What’s new in terms of therapy for ADHD that was shared in the session?
Dr. Sibley:
 On the non-pharmacological front, we discussed how CBT approaches, particularly when combined with Motivational Interviewing, are gaining a lot of traction in the treatment of both adolescent and adult ADHD. There are several commercially available treatment manuals that support these approaches. Another treatment to keep an eye on is mindfulness. Based on Eastern psychological approaches, this treatment is showing promising research for helping improve emotion regulation for people with ADHD (and parents of children with ADHD).

You coauthored the article “Empirically-informed guidelines for first-time adult ADHD diagnosis” in Journal of Clinical and Experimental Neuropsychology. What are some of the main guidelines?
Dr. Sibley:
One of the biggest take homes in this article is to cast a wide net on information gathering when you are assessing first-time ADHD diagnoses in adults. ADHD has a lot of mimics, its symptoms are subjective, it overlaps with other disorders, and it is a diagnosis that confers benefits to the patient (both psychological and societal). Believe it or not, research tells us that most people who report elevated ADHD symptoms do not actually have ADHD once a careful diagnostic procedure is applied. Even though it takes more work for the clinician, if you want to be confident in your diagnosis, you should always get at least one collateral report of the person’s symptoms (parent, adult sibling, spouse, close friend), try to gather good information about the person’s functioning in childhood and adolescence (ideally from the adult’s parent or school records), and establish impairment (that the symptoms chronically prevent the person from succeeding at work, in relationships, and in fulfillment of life responsibilities). You should also consider medical causes of symptoms (aging, endocrine changes, obesity, cardiac problems), other mental disorders with symptoms that can mimic ADHD (anxiety, depression, bipolar, post-traumatic stress), and substance use. 
In the end, the treatment for ADHD’s mimics is different than the treatment for ADHD, and we may be doing harm if we do not properly match patients with the correct treatment. Right now, we have a lot of information spreading about ADHD through personal testimonials on social media. These stories are relatable but, research suggests, often are not accurate depictions of ADHD. Providers need to be gatekeepers of accurate ADHD diagnosis in an era where a lot of individuals are inaccurately self-diagnosing.  

 

Thought Leader Rapid Fire:

Best recent medical journal article I read:

Yeung A, Ng E, Abi-Jaoude E. TikTok and Attention-Deficit/Hyperactivity Disorder: A Cross-Sectional Study of Social Media Content Quality. The Canadian Journal of Psychiatry. 2022 Feb 23:07067437221082854.

Most challenging issue my colleagues and I face today:

Getting the families of adolescents with ADHD to hang in there, even though progress in treatment is sometimes slow.

Important elements in the New Conversation on Stimulant Use

Indisputably, medication is an important tool in our toolbox for treating ADHD. However, by combining medication with non-pharmacological treatments we can: (1) amplify the benefits of medication, (2) reduce lifetime medication exposure by allowing patients to stay on lower doses, and (3) target issues not targeted by medication (e.g., study skills, healthy routines). Combined treatment is actually shown to be highly cost-effective in terms of getting maximal return on your investment in ADHD care.

One thing I wish parents of my pediatric ADHD patients understood better:

Sometimes you’ll do things today that won’t pay off or show results for years. Do them anyway.

Digital therapeutics in mental health treatment:

Will likely be the future if we can find tools with good evidence of improving outcomes that are meaningful to patients.

New treatment options for ADHD:

With expanding understanding of factors that contribute to ADHD severity, we have new potential targets for treatment. A couple emerging ADHD treatments with good data are mindfulness and multinutrient supplements. Providers should tolerate safe new treatments but should educate patients on their pros and cons relative to established treatments. At present, medications and CBT remain the mainstays. We must be vigilant of exciting new ideas and make sure scientific testing is rigorous before we promote new treatments to patients—particularly when they are costly or burdensome. Neurofeedback is a good example of a treatment that initially got a lot of buzz, but consistently turned out to be ineffective when the appropriate scientific methods were eventually applied. 

The biggest obstacle to effective treatment for adolescents with ADHD: 

Engagement.

Telepsychiatry:

Is an important way to connect with patients who have barriers to coming into the clinic. However, we can’t lower our standards of care when switching to this modality.

My mentor:

I am fortunate to have many mentors! I especially appreciate the guidance and support of the senior investigators on the Multimodal Treatment of ADHD study. They’ve taught me what it means to be a good collaborator and look at data in an honest way.

Best tool in my clinical arsenal:

Motivational Interviewing

 

Psychiatry Resource Section

JAMA Psychiatry Viewpoint: Gender Disparity in Cognitive Load and Emotional Labor—Threats to Women Physician Burnout
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2793303

MDEdge Clinical Psychiatry News Article: Infographic: Is physician behavior on social media really so bad?
https://www.mdedge.com

New England Journal of Medicine Perspective: Hospital Standards of Care for People with Substance Use Disorder
https://www.nejm.org/doi/full/10.1056/NEJMp2204687

APA Learning Center Free Members August Course of the Month: Racial Inequity and Discrimination in Mental Health: Promoting Equity In Crisis Services and the Criminal Legal System —Credits CME: 1.0, Participation: 1.0
https://education.psychiatry.org/diweb/catalog/item?id=10908710

Medscape CME & Education: Why Motivation Matters: Targeting Anhedonia in Patients With Bipolar I Depression —Credit CME/CE + ABOM MOC: 0.5; Author: Manpreet Singh, MD, MS; Joseph Goldberg, MD
https://www.medscape.org/viewarticle/978068

Clinical Psychiatry News Commentary: TikTok’s impact on adolescent mental health
https://www.mdedge.com

New England Journal of Medicine Perspective: Research to Move Policy — Using Evidence to Advance Health Equity for Substance Use Disorders
https://www.nejm.org/doi/full/10.1056/NEJMp2202740

 

 

July 2022

What’s New for Children and Adolescents in ADHD Treatment—and More!

Ann Childress, MD, Speaks About What’s New in ADHD Treatment, her Recent Article—Stimulants—in Child and Adolescent Psychiatric Clinics, pearls from Medscape’s 2022 Psychiatry Spring Update, and Rapid Fire! 
  

Introduction

We are back in your inbox this month with a candid interview with Ann Childress, MD. Dr. Childress served as faculty at the Recent Medscape 2022 Psychiatry Spring Update and is President of the Center for Psychiatry and Behavioral Medicine; Clinical Associate Professor, Kirk Kerkorian School of Medicine, University of Nevada Las Vegas; and Adjunct Associate Professor, Touro University Nevada College of Osteopathic Medicine. We discussed emerging therapies in the ADHD armamentarium—including beyond pharmacologic, some of her recent research papers and findings, the process of finding the right formulation and dose for the average patient, and the effectiveness of a digital therapeutic for pediatric ADHD treatment.
Also, don’t miss Dr. Childress’s Rapid Fire responses on a number of topics below!

The recent hybrid MedscapeLIVE! 2022 Psychiatry Spring Update can be accessed online for here for anyone who did not make it in person. MedscapeLIVE! and the American Academy of Clinical Psychiatrists invite you to visit this link to register. 

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 

Thank you to Dr. Childress for participation in this month’s interview! Please contact me at [email protected] with any comments and/or suggestions. Happy Spring!

–Colleen Hutchinson

 

Interview with Ann Childress, MD: ADHD—New Horizons, New Options 

Ann Childress, M.D. is President of the Center for Psychiatry and Behavioral Medicine, Clinical Associate Professor, Kirk Kerkorian School of Medicine, University of Nevada Las Vegas and Adjunct Associate Professor, Touro University Nevada College of Osteopathic Medicine.

Your presentation at Medscape’s recent 2022 Psychiatry Spring Update was in Session IV: New Horizons in ADHD, which focused on new treatment options; last year, you also coauthored the article “Reviewing the role of emerging therapies in the ADHD armamentarium” in Expert Opinion on Emerging Drugs. What are the new therapies for ADHD shared in the session and your article?
Dr. Childress: Several new medications have been approved by the Food and Drug Administration for the treatment of ADHD since the start of 2021. Qelbree® (viloxazine extended release) is the first nonstimulant capsule, a norepinephrine reuptake inhibitor, that can be opened and sprinkled on food. It is the first nonstimulant approved for the treatment of ADHD in adults since 2002. Dyanavel XR® (amphetamine extended-release chewable tablets) is the first extended-release amphetamine medication that can be chewed. XelstrymTM (dextroamphetamine transdermal system) is an amphetamine patch that can be applied to the skin and its duration of effect is linked to patch wear time. All of these medications are indicated for the treatment of ADHD in patients ages 6 years and older.

In your presentation, Case Conundrums in ADHD: Managing Comorbid Psychiatric Disorders, what are the main takeaways for practicing clinicians?
Dr. Childress:
It is important to obtain a thorough history when assessing patients. If a patient presents complaining of feeling anxious and/or depressed, it is important to assess symptoms and ask about stressors. For example, a patient with ADHD may be feeling overwhelmed because they are having difficulty completing work tasks due to trouble focusing and procrastination secondary to ADHD.

Your recent article in Child and Adolescent Psychiatric Clinics of North America, “Stimulants,” states: “Multiple AMPH and MPH products have been approved to treat ADHD in the past two decades. The formulations differ in the percentage of IR and ER ingredients, technology used and dosage form. The properties determine the unique pharmacokinetics of each product. As pharmacokinetics and pharmacodynamics are tightly linked, the onset and duration vary between formulations. These distinctions allow clinicians to choose among different formulations to best suit the needs of individual patients. Although the differences may seem small, they may be extremely important to a patient with difficulties at a particular time of day or tolerability issues with one formulation and not another.” One of the key points listed is: “A patient’s individual needs should be taken into account when prescribing a stimulant.” 
How long of a process is finding the right formulation and right dose for the average patient?
Dr. Childress:
It is important to understand when the patient is having difficulties. For example, if early morning is a big problem, I would want to prescribe a medication with a quick onset of effect. If a child is having most problems in an afterschool program, I am going to choose a medication that will be effective during that time. Some patients may need a medication that is effective for up to 16 hours. 

Furthermore, when prescribing a medication, one must ensure that the dose of medication is optimized. The starting dose of a stimulant is usually not the optimal dose. Patient symptoms should be monitored, and the dose increased to balance symptom control and tolerability.

You coauthored the article “Effectiveness of a digital therapeutic as adjunct to treatment with medication in pediatric ADHD” in npj digital medicine (Nature). What were your findings?
Dr. Childress:
In that study, we looked at the change in ADHD-related impairment in subjects aged 8 to 14 years before and after 4 weeks of using the AKL-T01 intervention. We evaluated subjects taking stimulants with continued impairment and subjects not taking stimulants who had impairment as shown by their Impairment Rating Scale scores. ADHD-related impairment improved significantly in both groups (On Stimulants: −0.7, p < 0.001; No Stimulants: −0.5, p < 0.001.) 

In terms of stimulant selection and management, is there anything of note that you have adopted within your own process, or any step you find critical, to identifying the best combination (formulation and dosage) for your patient in the timeliest manner?
Dr. Childress: Once you begin treatment it is critical to monitor patient symptoms and side effects and adjust medication dose to achieve the best response. We know that most patients will respond to either amphetamine or methylphenidate products. However, some patients may respond better to one class. If someone has efficacy or tolerability issues with one class of drug, I switch to another class.

 

Thought Leader Rapid Fire:
 

Best recent medical journal article I read: 

Variable Patterns of Remission from ADHD in the Multimodal Treatment Study of ADHD by Sibley et. al.

Most challenging issue my colleagues and I face today: 

Keeping patients with ADHD engaged in treatment long-term. 

Best tool in my clinical arsenal: 

Variety of medication formulations available to treat ADHD.

My mentor:

Floyd R. Sallee

One thing I wish my patients understood better:

 Importance of continuing treatment long-term.

Telepsychiatry

Although it is here to stay, I prefer in-person visits. Subtle behavioral symptoms may be missed on the video screen.

Efficacy and Safety of PRC-063, Extended-Release Multilayer Methylphenidate in Adults with ADHD: 

We demonstrated that the drug has an effect 16 hours after dosing without causing significant sleep disruption.

Digital therapeutics in mental health treatment:

Give us the opportunity to engage more patients in treatment.

Guanfacine extended release for the treatment of ADHD in children and adolescents:

In my practice, I use it as an adjunct to stimulant treatment for patients who respond to stimulants but continue to have significant impairment prior to onset of effect for stimulants and after the effect wears off.

 

 

 

Psychiatry Resource Section

JAMA Psychiatry Comment and Response: Cerebrovascular Disease and Sleep-Disordered Breathing Need to Be Accounted for in Cognitive Impairment Following COVID-19
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2793946

MDEdge Clinical Psychiatry News Article: Generalized anxiety disorder: 8 studies of biological interventions
https://www.mdedge.com/psychiatry/article/255914/anxiety-disorders/generalized-anxiety-disorder-8-studies-biological

New England Journal of Medicine Article: Research to Move Policy — Using Evidence to Advance Health Equity for Substance Use Disorders
https://www.nejm.org/doi/full/10.1056/NEJMp2202740

APA Learning Center Free Members July Course of the Month: Psychedelic-Assisted Psychotherapy for PTSD: Theory, Technique and Context—Credits CME: 0.75, Participation: 0.75
https://education.psychiatry.org/diweb/catalog/item?id=9422913

Medscape CME & Education: Integrating Modern Antipsychotic Therapies into Practice for the Care of Patients with Schizophrenia —Credit CME/CE + ABOM MOC: 0.5; Author: Christoph U. Childress, MD
https://www.medscape.org/viewarticle/971943

Current Psychiatry Pearls: BOARDING psychiatric patients in the ED: Key strategies
https://www.mdedge.com/psychiatry/article/255028/boarding-psychiatric-patients-ed-key-strategies?channel=133

New England Journal of Medicine Perspective: Chronic Traumatic Encephalopathy in the Brains of Military Personnel
https://www.nejm.org/doi/full/10.1056/NEJMoa2203199

 

 

June 2022

Psychiatry June: Schizophrenia—An Inside Look with Thought Leader Dr. Christoph Correll

Christoph U. Correll, MD, speaks about the recent Medscape 2022 Psychiatry Spring Update, the latest on schizophrenia treatment and approaches, the transition from adolescence to adulthood in patients with schizophrenia, his new COH-FIT Project, the most challenging issues he faces today, and our 
Rapid Fire!  

 
Introduction

We are back in your inbox this month with a candid interview with Christoph U. Correll, MD. Dr. Correll served as faculty at the Recent Medscape 2022 Psychiatry Spring Update and is Professor of Psychiatry and Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; and Investigator, Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, New York. We discussed novel approaches and treatments in schizophrenia, some of his recent research papers and findings, and his COH-FIT Project, among other things.
Also, don’t miss Dr. Correll’s CME presentation link included below in our Psych Resource Section to CME/CE credit from Dr. Correll via Medscape CME & Education: Integrating Modern Antipsychotic Therapies into Practice for the Care of Patients with Schizophrenia.

The hybrid MedscapeLIVE! 2022 Psychiatry Spring Update, which just took place in Chicago June 16th-18th. in collaboration with the American Academy of Clinical Psychiatrists, can be accessed online for virtual viewing and participation registration for anyone who did not make it in person. MedscapeLIVE! and the American Academy of Clinical Psychiatrists invite you to visit this link to register and access the 2022 Psychiatry Spring Update

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 

Thank you to Dr. Correll for participation in this month’s interview! Please contact me at [email protected] with any comments and/or suggestions. Happy Spring!

Colleen Hutchinson

 

Interview with Christoph U. Correll, MD: Schizophrenia—An Inside Look 

Christoph U. Correll, MD, is Professor of Psychiatry and Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; and Investigator, Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, New York.
 
In your presentation, The Power of Early Intervention and the Therapeutic Alliance for Patients with Schizophrenia, what are the main take-home points for practicing clinicians?
Dr. Correll:
Main takeaways are the following:

  • Schizophrenia remains an all too often severe, relapsing, and functionally debilitating disorder
  • Early recognition and intervention are associated with improved outcomes 
  • The duration of untreated psychosis must be reduced via general public education, anti-stigma campaigns, low-threshold service access, and early recognition efforts
  • Integrated and collaborative care is associated with improved outcomes
  • Effective treatment depends on effective communication with patients, their caregiver partners and among multidisciplinary treatment team members
  • Motivational interviewing skills can facilitate treatment engagement and an effective shared decision-making process 
  • Aiming at enhancing patient autonomy depends on helping patients make healthy decisions, not allowing the illness to stay in charge. 

You also presented on Novel Approaches in Schizophrenia Treatment. What is new in terms of therapy for schizophrenia that was shared?
Dr. Correll:
There have been recent FDA approvals in the area of schizophrenia for the following:

  • Lumateperone, a novel antipsychotic modulating dopamine, serotonin and via D1 modulation glutamatergic transmission, with robust antipsychotic efficacy at 42 mg/day and minimal adverse effect liability
  • Olanzapine combined with samidorphan, an opioid antagonist, which has confirmed olanzapine-like efficacy with significantly less weight gain risk than olanzapine
  • 6-monthly paliperidone palmitate long-acting injectable that is as effective and safe as the 3-monthly formulation of paliperidone

Moreover, there have been encouraging phase 1b, 2, or 3 results for the following:

  • TAAR1 agonist ulotaront for total psychotic symptoms (including negative and depressive symptoms) in patients with acutely exacerbated schizophrenia
  • M1/M4 agonist xanomeline + trospium for total psychotic symptoms (including negative symptoms) in patients with acutely exacerbated schizophrenia
  • M4 positive allosteric modulator emraclidine for total psychotic symptoms in patients with acutely exacerbated schizophrenia
  • Adjunctive pimavanserin for negative symptoms in stable patients with predominant negative symptoms

Novel mechanism action drugs for schizophrenia, including total, residual positive, negative, and cognitive symptoms, remain an urgent need.

Your recent article in European Neuropsychopharmacology, “The transition from adolescence to adulthood in patients with schizophrenia: Challenges, opportunities and recommendations,” is an Expert Opinion Paper. Can you give some highlights from what you and your coauthors share about transitioning of care in schizophrenia in terms of challenges and potential approaches?
Dr. Correll: Early onset schizophrenia, i.e. illness onset before age 18 years, is associated with poorer outcomes than adult-onset schizophrenia. This difference is likely due to neurodevelopmental disruption of relevant biopsychosocial milestone achievement. The transition from adolescent to adult mental health care is challenged by often inadequate mental health service provisions for young people with schizophrenia with special needs to reintegrate into social, educational, and vocational networks. Specialized training programs for coordinated, team-based care targeting youth mental health are largely missing. Flexible and individualized transition timing from youth to adult services is also needed. Balancing increasing patient autonomy with ongoing family/care partner support as well as approaches that enhance continuity of care are key for improving symptomatic and functional outcomes.

You just coauthored a letter commenting on the article “Clozapine and the risk of haematological malignancies” in Lancet Psychiatry. Much has been published on clozapine and adverse effects. What are the main pearls from this latest publication and your response?
Dr. Correll: In a Finnish nationwide case-control and cohort study of people with schizophrenia aged 18 to 85 years, Tiihonen and colleagues (Tiihonen J, et al. Lancet Psychiatry. 2022;9(5):353-362) individually matched cases of lymphoid and hematopoietic tissue malignancy with up to ten controls without cancer by age, sex, and time since first schizophrenia diagnosis. Controlling for comorbid conditions, 375 patients with hematologic malignancies vs. 3,734 matched patients without cancer were analyzed, while 55,949 people entered the cohort study. Results indicated a cumulative incidence of hematological malignancies in 61 cases / 100,000 person-years when treated with clozapine versus 41 cases / 100,000 person-years when treated with non-clozapine antipsychotics, translating into a difference of 20 cases per 100,000 person-years. Over 17 years of follow-up, altogether 37 deaths occurred due to hematological malignancy versus only 3 deaths due to agranulocytosis in Finland. 
In our response (de Leon J, et al. Lancet Psychiatry. 2022 Jul;9(7):537-538), we agreed that the 3 cases of death due to agranulocytosis indicate the safety of clozapine after blood monitoring implementation, but made the points that clinicians need to monitor for and manage the risk of pneumonia, and that myocarditis risk is similar to agranulocytosis. Worldwide since 2000, 433 deaths in clozapine-treated patients were explained by agranulocytosis versus 1,992 by pneumonia and 484 by myocarditis. Finally, we agreed with Tiihonen et al that the elevated absolute risk of death related hematological cancers is small (1 in 5000 patients greater risk) and vastly offset by the previously observed absolute risk reduction in all-cause mortality with clozapine, translating into a risk reduction for all-cause mortality in 1 in 3.3 patients versus no antipsychotic use, and 1 in 10 patients versus treatment with non-clozapine antipsychotics (Taipale H, et al. World Psychiatry. 2020 Feb;19(1):61–68). 
Hence the benefit-to-risk ratio of clozapine for patients with treatment-resistant schizophrenia remains solid and clozapine remains vastly underutilized.

Can you tell us a little about the COH-FIT project? (Collaborative Outcomes study on Health and Functioning during Infection Times)
Dr. Correll:
The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT; www.coh-fit.com) is a large international anonymous online survey for the general population of countries affected by COVID-19 around the globe. Launched by Prof. Marco Solmi, who now works in Ottawa, Canada, and myself, COH-FIT involves more than 230 investigators, has been translated into more than 30 languages, and has been endorsed by numerous national and international professional organizations. The COH-FIT project aims to characterize the effects of the COVID-19 pandemic and measures to control it on physical and mental health and identify risk and protective factors that will inform prevention and intervention programs for the current and future pandemics. Adults, adolescents, and children can participate, with caregivers needing to sign in first to give e-consent for their minors. 
Since May 2020, over 185,000 people from 155 countries on 6 continents have participated in the COH-FOT project, including snowball recruitment as well as representative samples. However, more participants from all over the world are needed to help us help others navigate the pandemic and its ramifications (www.coh-fit.com). The design papers for the adult and pediatric populations have already been published this past February in the Journal of Affective Disorders, and a validation paper of the measures selected to assess a broad psychopathology (or “p” factor) in multiple languages is currently under review. We expect first main outcome papers to be published in the fall of 2022.

 
Thought Leader Rapid Fire:

Best recent medical journal article I read:

Taipale H, Tanskanen A, Correll CU, Tiihonen J. Real-world effectiveness of antipsychotic doses for relapse prevention in patients with first-episode schizophrenia in Finland: a nationwide, register-based cohort study. Lancet Psychiatry. 2022 Apr;9(4):271-279.  

Most challenging issue my counterparts and I face today:

Nonadherence to effective medications for mental illness; mentally and physically impairing adverse effects of psychotropic mediations; physical comorbidity; premature mortality in the mentally ill; insufficiently addressed illness domains (e.g., negative symptoms, cognitive dysfunction anosognosia, resistant mental illness, suicidality, etc); stigma; comorbid substance abuse; insufficient functional recovery; lack of biomarkers, precision medicine and personalized treatment for the mentally ill.

Best tool in my clinical arsenal:

Education, empathy, experience, engagement and enthusiasm. 

My mentor:

John M. Kane, MD

One thing I wish my patients understood better:

The side effects of the mental illness most often by far outweigh the side effects of psychotropic medications that can be adjusted.

Telepsychiatry:

A highly valuable tool that needs to remain reimbursed, and in our arsenal, to individualize and extend care.

Link between mental disorders and increased risk to develop CVD:

Likely multidetermined via genetics, unhealthy lifestyle, insufficiently treated mental illness, and some psychotropic drugs, but remediable by “keeping the body in mind,” i.e., routine monitoring and adequate management of both the psychiatric and medical morbidities.

Digital therapeutics in mental health treatment:

Highly promising for the future; we need more of it and must implement it more.

Clozapine and the risk of hematological malignancies:

Minimal (20 excess cases per 100,000 patient years), monitorable, and by far outweighed by clozapine’s advantages, including for reduction of overall mortality.

 

 

 
Psychiatry Resource Section

JAMA Psychiatry Viewpoint: Tempering Optimism Concerning the Recent Decline in US Suicide Deaths
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2791247

MDEdge Clinical Psychiatry News Article: Schizophrenia patients in long-term facilities benefit from lower-dose antipsychotics
https://www.mdedge.com

Current Psychiatry Evidence-Based Reviews: Paraphilic disorders and sexual criminality
https://www.mdedge.com

New England Journal of Medicine Article: PTSD — Seeking the Ghost in the Machine
https://www.nejm.org/doi/full/10.1056/NEJMe2204710

APA Learning Center Free Members June Course of the Month: Cognitive Behavioral Therapy for Suicidal Behavior —Credits CME: 1.0, Participation: 1.0
https://education.psychiatry.org/diweb/catalog/item?id=9418268

Medscape CME & Education: Integrating Modern Antipsychotic Therapies Into Practice for the Care of Patients With Schizophrenia —Credit CME/CE + ABOM MOC: 0.5; Author: Christoph U. Correll, MD
https://www.medscape.org/viewarticle/971943

New England Journal of Medicine Perspective: When Naloxone Isn’t Enough
https://www.nejm.org/doi/full/10.1056/NEJMp2202387

Current Psychiatry Pearls: BOARDING psychiatric patients in the ED: Key strategies
https://www.mdedge.com/psychiatry/article/255028/boarding-psychiatric-patients-ed-key-strategies?channel=133

 

 

June 2022

Daily 3

—by Colleen Hutchinson

Welcome back to Day 3 of Medscape’s 2022 Psychiatry Spring Update! Today’s agenda includes Session VII: New Frontiers in Psychiatry. Dr. Greg Mattingly shared that there is quite a bit going on in research right now. “There are many exciting innovations to help improve outcomes for patients. Digital therapeutics, glutamate, neural steroids, novel non-dopaminergic treatments for schizophrenia—all incredibly exciting!”

If you wish to access previous presentations and join in virtually today or in the future at your leisure, register here

Dr. Sagar Parikh presents on Day 3 with Exploring the Clinical Utility of Pharmacogenomics. “There are positive hurricanes—like the hurricane of new approaches and treatments, he stated. “From digital interventions through genetic testing to taking psychedelics, psychiatry is evolving quickly.  This session promises to ground you!” He continued: “With my presentation, genetic tests are real, but applying them in the context of antidepressant choice is tricky. This session will clarify practical points as well as summarize key evidence about how to use pharmacogenomic results to help tailor medication strategies.”

One of the highlights of Day 2 was Dr. Ann Childress’s presentation on Case Conundrums in ADHD: Managing Comorbid Psychiatric Disorders. “Because comorbid psychiatric illnesses are common in patients with ADHD,” she explained, “it is often difficult to differentiate ADHD symptoms from those of mood and anxiety disorders. The Case Conundrums in ADHD: Managing Comorbid Psychiatric Disorders session featured several patient cases and demonstrate how to make an accurate diagnosis and develop treatment plans.” Register and access this and more here.
 
Medscape’s 2022 Psychiatry Spring Update includes this and much more in advances and breakthroughs in neuroscience and mental health care that you can take back to your patients. Don’t miss it—Register here!

—by Colleen Hutchinson

 

June 2022

Daily 2

—by Colleen Hutchinson

Welcome back to Day 2 of Medscape’s 2022 Psychiatry Spring Update!! Today’s agenda includes Sessions III, IV, V, and VI: Making Waves in Major Depressive Disorder, New Horizons in ADHD, Advancements in Bipolar Disorder, and Leveling the Playing Field in Mental Health.  At the conference yesterday, Medscape featured many thought leaders sharing critical insights and takeaways on mental health conditions. Giving updates on current research and best practices, faculty brought attendees up to speed on the latest advances in patient care and treatment options. If you wish to access yesterday’s presentations for learning and join in live today and tomorrow, you can register here.

If you are unable to attend in person or missed yesterday’s slate of talks, register here and take advantage of the virtual features Medscape has provided. 

Read on to see some of the critical content to be gained from Day 2 of the conference.

Conference Chair Dr. Greg Mattingly chairs Session III: Making Waves in Major Depressive Disorder and shares some new pearls regarding therapy for MDD that we will learn about.
Glutamate, neural plasticity and resilience is the new language in MDD. We’ve moved beyond a world that just modulates monoamines.” He continued, “We now have intranasal, IV, and soon oral medications that directly modulate glutamate with other treatments submitted to the FDA that may enable a treat-when-needed approach for individuals struggling with MDD.” 

Dr. Mattingly also presents on Innovations in ADHD: Pharmacologic and Nonpharmacologic Advancements, and shares some pearls that attendees should come away with from that talk: “We just had the first new nonstimulant approved for adult ADHD in more than 20 years and we have the first ever digital treatment approved by the FDA for children with ADHD. In our digital world, the need to optimize outcomes in our patients with ADHD has never been more important! We will be covering all of this and more.”

He also commented on Session V: Advancements in Bipolar Disorder, and what attendees have to look forward to. “We now have several recently approved bipolar medications that tend to be either weight neutral or even promote weight loss,” Dr. Mattingly stated. “We also have the first medication approved for both Bipolar 1 and 2 depression, which was shown to work with or without a mood stabilizer.”
Dr. Margaret Sibley discussed the importance of Session IV: New Horizons in ADHD, stating, “ADHD is among the most common mental health diagnoses--and among the most complicated to effectively treat due to challenges with comorbid conditions that create case complexity, patient engagement challenges, and dilemmas in treatment selection. The New Horizons in ADHD will offer cutting edge strategies to facilitate the delivery of engaging and effective care to patients." 

On her presentation, Supporting Patients Through the Transition to Independence, Dr. Sibley shares: "One of the greatest challenges facing providers is how to support patients as the transition to young adulthood. Providers will be given a toolkit of pre-transition and post-transition strategies to reduce reliance on parents and help young adults find their niche and successfully manage symptoms post-high school.” She also commented on what’s moving the needle on treatment options for ADHD: “I think the most promising science is in acknowledging the multiple biological and environmental factors that influence symptom severity and building combined treatments that draw on a variety of approaches to individualize care to the unique factors underlying each patient's ADHD symptoms.”

Dr. Holly Swartz presents in Session V on the topic of Bipolar Spectrum Disorders: Individualizing Treatment and Updates in Advancements. “Less is known about treating bipolar spectrum disorders, including bipolar II disorder, compared to bipolar I disorder,” she explained.  “And, yet, over 3 million people in the US suffer from these spectrum conditions. My talk will review current evidence about management of bipolar spectrum disorders, helping you to deliver evidence-informed care to your patients with these conditions. We will explore clinical conundrums (Can I use antidepressants to treat bipolar II depression?) and the role of second generation antipsychotics in the treatment of bipolar depression. Dr. Swartz added that her talk will conclude with a review of promising—albeit off-label—interventions for treating bipolar spectrum disorders.

Join us for advances and breakthroughs in neuroscience and mental health care that you can take back to your patients-- register here!
—by Colleen Hutchinson

 

June 2022

Daily 1

—by Colleen Hutchinson

Welcome to Medscape’s 2022 Psychiatry Spring Update! On behalf of MedscapeLIVE! and the American Academy of Clinical Psychiatrists, you are invited to attend (virtually or in person) the hybrid 2022 Psychiatry Spring Update. Please register here!

At the dynamic hybrid 2022 conference, faculty is sharing critical insights on current issues and challenges, including: 
     
Making Waves in Major Depressive Disorder

New Horizons in ADHD

Innovations in Schizophrenia

Advancements in Bipolar Disorder

Leveling the Playing Field in Mental Health

New Frontiers in Psychiatry

Psychiatry Today: Unique Challenges and Perspectives

Other clinically relevant hot topics on the agenda include healthcare burnout, updates and innovations in telemedicine, COVID-19’s impact on societal mental health, and newly emerging digital therapeutics.

Chaired by Gregory W. Mattingly, MD, this event promises to be a comprehensive update for all attendees. “The world of neuroscience is absolutely exploding!” said Dr. Mattingly. “I am extremely excited to bring together some of our country’s top researchers, teachers and clinicians to discuss the most recent breakthroughs in neuroscience and mental health care.”

If unable to attend in person, register here and take advantage of the virtual features Medscape has provided, including a “virtual coffee house” to network with colleagues and ask questions of faculty during Q&A sessions, and accessing the virtual platform for on-demand access at your leisure after the event.
We are looking forward to seeing colleagues in person and online in Chicago! Register here and read on to see the most critical content from the first day of the conference

Day 1 includes two presentations from Dr. Christoph Correll in Session I: Innovations in Schizophrenia—Patient-centered Care in Schizophrenia. Dr. Correll who stated, "The Medscape Psychiatry Update Spring meeting is not to be missed, as it brings highly relevant and updated information that is evidence-based and that can be used in the clinical context." 
On his topics, he added, “Early intervention, therapeutic alliance and maintenance treatment and are key care elements of preventive psychiatry that targets functional recovery, aiming beyond symptom remission.” 
Regarding what is on the horizon in research and treatment options, Dr. Correll explained, "For seventy years since the serendipitous discovery of chlorpromazine, postsynaptic dopamine blockade has remained the hallmark of antipsychotic activity. We are currently at the brink of a paradigm expansion into non-postsynaptic dopamine blockade treatments with clinical relevance for people living with psychotic disorders." Exciting topic—don’t miss this session!

The second session of the day is Psychiatry Today: Unique Challenges & Perspectives. Led by conference planner Donald W. Black, MD, this session is a wide-ranging overview of all current practitioner topics in psychiatry. Dr. Kiki Chang presents first on “When the System Is Down: Post-COVID Impact on Societal Mental Health” and offers this on what to expect: 

“The COVID-19 pandemic has created havoc on mental health in the US, particularly among youth, who were already experiencing a crisis in the past 10 years. This talk discusses the challenges that the pandemic brought regarding rates of anxiety and depression and also discusses the impact of coronavirus infection directly on the brain.” Dr. Chang added, “Furthermore, other infections are also known to lead directly to psychiatric symptoms, including OCD, tics, and depression, best characterized by the syndrome known as PANS/PANDAS in youth.” 

Dr. Jay Shore follows that talk with “The Future of Practice Is Virtual.” Dr. Shore weighed in on the session focus: “The COVID pandemic has permanently transformed the delivery of psychiatric care through the rapid adoption and use of virtual technologies and treatments.” Regarding his talk, he added, “Psychiatrists must become experts in provider-patient relationships across multiple technologies and settings in order to individualize treatment to patient needs.”
In terms of what is moving the needle on treatment options in this regard, he stated, “Psychiatrist and psychiatric organizations have an opportunity to understand and enact best practices in virtual care for their practices and services.”    

Join us to learn critical advances and breakthroughs in neuroscience and mental health care to better help your patients. Don’t miss it!

by Colleen Hutchinson

 

May 2022

Psychiatry May: An Interview with Thought Leader Dr. Greg Mattingly

Gregory W. Mattingly, MD, Speaks About the Upcoming 2022 Psychiatry Spring Update, What’s on the Horizon for ADHD Treatment, and Rapid Fire! 
 

Introduction

We are back in your inbox this month with a candid interview with Gregory W. Mattingly, MD. Dr. Mattingly is Associate Clinical Professor and Psychopharmacology Instructor at the Washington University School of Medicine in St. Louis and is also the President of the Midwest Research Group. Dr. Mattingly is President Elect of the American Professional Society for ADHD and Related Disorders (APSARD), and he also serves as Conference Chair of the 2022 Psychiatry Spring Update, which this year is in Chicago on June 16th-18th. Presented by MedscapeLIVE! as a hybrid event in collaboration with the American Academy of Clinical Psychiatrists, it promises to be a comprehensive update for all attendees. We are looking forward to seeing colleagues in person in Chicago at this conference, but in addition, Medscape is offering a live streaming virtual participation registration for anyone who cannot make it in person this June.

Some of this year’s session themes include: 

  • Making Waves in Major Depressive Disorder
  • New Horizons in ADHD
  • Psychiatry Today: Unique Challenges and Perspectives
  • Innovations in Schizophrenia
  • Advancements in Bipolar Disorder
  • Leveling the Playing Field in Mental Health
  • New Frontiers in Psychiatry

On behalf of MedscapeLIVE! and the American Academy of Clinical Psychiatrists, you are invited to visit this link and register to attend (virtually or in person) the 2022 Psychiatry Spring Update. Please register here

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 

Thank you to Dr. Mattingly for making the upcoming conference of extreme value to attendees based on a cutting-edge agenda and stellar faculty, and for participation in this month’s interview! Please contact me at [email protected] with any comments and/or suggestions. Happy Spring!

Colleen Hutchinson

 

Interview with Gregory W. Mattingly, MD 

Gregory W. Mattingly, MD is an Associate Clinical Professor of Psychiatry and a Psychopharmacology Instructor at The Washington University School of Medicine in St. Louis, Missouri. He earned his medical degree and completed his residency at Washington University where he received a Fulbright Scholarship. In addition to his clinical and research practice, he is a consultant and evaluator for both the NFL and MLB. Serving on the board of directors for APSARD, Dr. Mattingly has been a principal investigator in more than 300 clinical trials and his research has been published in numerous national and international journals.

As the Conference Chair of the 2022 Psychiatry Spring Update, what are you most looking forward to in Chicago? 
Dr.  Mattingly:
The world of neuroscience is exploding!! I am extremely excited to bring together some of our country’s top researchers, teachers and clinicians to discuss the most recent breakthroughs in neuroscience and mental health care.

In your presentation, Innovations in ADHD: Pharmacologic and Nonpharmacologic Advancements, what are one or two pearls that attendees should come away with and be able to translate to practice? What are the main take-home points for practicing clinicians?
Dr.  Mattingly: We just had the first new nonstimulant approved for adult ADHD in more than 20 years and we have the first ever digital treatment approved by the FDA for children with ADHD. In our digital world, the need to optimize outcomes in our patients with ADHD has never been more important! We will be covering all of this and more.

You chair Session III: Making Waves in Major Depressive Disorder. What is new in terms of therapy for MDD that we will learn about?
Dr. Mattingly:
Glutamate, neural plasticity and resilience is the new language in MDD. We’ve moved beyond a world that just modulates monoamines.  We now have intranasal, IV, and soon oral medications that directly modulate glutamate with other treatments submitted to the FDA that may enable a treat-when-needed approach for individuals struggling with MDD. 

You also chair Session V: Advancements in Bipolar Disorder. What will attendees have to look forward to?
Dr. Mattingly:
We now have several recently approved bipolar medications that tend to be either weight neutral or even promote weight loss. We also have the first medication approved for both Bipolar 1 and 2 depression, which was shown to work with or without a mood stabilizer. 

There are many exciting innovations to help improve outcomes for patients. What do you feel is the most exciting or effective of these that advance patient care?
Dr. Mattingly:
Digital therapeutics, glutamate, neural steroids, novel non-dopaminergic treatments for schizophrenia—all incredibly exciting so it is unfair to make me choose!

 

Thought Leader Rapid Fire:

Most critical new advance in my area of medicine:

Modulating glutamate and neural steroids

Best recent medical journal article:

STARD 2 in JAMA by Dr Fava and colleagues at Harvard

Most challenging issue my counterparts and I face today:

Apathy and burnout!

Biggest, or one of the biggest, honors of my career to date:

Being selected as the President Elect for APSARD-the American Professional Society for ADHD and Related Disorders  

Best tool in my clinical arsenal:

Empathy

My mentor:

Too many to mention! Sam Guze, the forefather of DSM3 and the Chair of Psychiatry at Washington University during my training

One thing I wish my patients understood better:

That we all have a story, and no family is immune to mental health challenges 

Telepsychiatry:

Allows me to reach out to those in need.

Most exciting recent innovation in mental health:

Telepsychiatry-both good and bad!!

Digital therapeutics in mental health treatment:

An extremely exciting area looking at ADHD, mood, cognition, and all types of therapy…… 

 

 

Psychiatry Resource Section

JAMA Psychiatry Original Investigation: Association of Screen Time with Internalizing and Externalizing Behavior Problems in Children 12 Years or Younger: A Systematic Review and Meta-analysis
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2790338

MDEdge Clinical Psychiatry News Article: Telehealth continues to loom large, say experts
https://www.mdedge.com/psychiatry/article/254423/business-medicine/telehealth-continues-loom-large-say-experts

Current Psychiatry Evidence-Based Reviews: Cats, toxoplasmosis, and psychosis: Understanding the risks
https://www.mdedge.com/psychiatry/article/254207/schizophrenia-other-psychotic-disorders/cats-toxoplasmosis-and-psychosis

New England Journal of Medicine Article: The E-Cigarette Flavor Debate — Promoting Adolescent and Adult Welfare
https://www.nejm.org/doi/full/10.1056/NEJMp2119107

APA Learning Center Free Members May Course of the Month: Ketamine for Depression: Is the Hype Holding Up? Mechanisms and Evidence —Credits CME: 1.25, Participation: 1.25
https://education.psychiatry.org/diweb/catalog/item/eid/C2200405

JAMA Psychiatry Viewpoint: Toward Risk-Benefit Assessments in Psychedelic- and MDMA-Assisted Therapies
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2791320

MDEdge Clinical Psychiatry News Literature Review: Clinically Challenging Cases in Bipolar Disorder—Credit CMW: 0.5
https://www.medscape.org/viewarticle/955484

New England Journal of Medicine Article: Physicians as Political Pawns — The Texas Directive on Gender-Affirming Care and Other Moves
https://www.nejm.org/doi/full/10.1056/NEJMp2203746

Current Psychiatry Pearls: Managing bipolar disorder in women who are pregnant
https://www.mdedge.com/psychiatry/article/254217/bipolar-disorder/managing-bipolar-disorder-women-who-are-pregnant

 

 

April 2022

Hot Topics in Psychiatry: Donald W. Black, MD, Weighs in on The Upcoming Psychiatry Spring Update, Exciting New Advances, and Rapid-Fire Responses! 

Introduction

We are back in your inbox this month with a candid interview with Dr. Donald W. Black, who is Past-President of the American Academy of Clinical Psychiatrists (AACP) and Professor of Psychiatry at University of Iowa Carver College of Medicine in Iowa City, Iowa. Dr. Black is also part of the Planning Committee of the 2022 Psychiatry Spring Update, which this year is presented by MedscapeLIVE! as a hybrid event in collaboration with the American Academy of Clinical Psychiatrists. The planning committee is looking forward to seeing colleagues in person in Chicago on June 16th-18th at this conference. In addition, Medscape is offering a live streaming option for virtual participation.

Some of this year’s session themes include: 

  • Making Waves in Major Depressive Disorder
  • New Horizons in ADHD
  • Psychiatry Today: Unique Challenges and Perspectives
  • Innovations in Schizophrenia
  • Advancements in Bipolar Disorder
  • Leveling the Playing Field in Mental Health
  • New Frontiers in Psychiatry

On behalf of MedscapeLIVE! and the American Academy of Clinical Psychiatrists, you are invited to visit this link and register to attend (virtually or in person) the 2022 Psychiatry Spring Update. Please register here

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 

Thank you to Dr. Black for his participation in this month’s issue! Please contact me at [email protected] with any comments and/or suggestions.

Colleen Hutchinson

 

Interview with Donald W. Black, MD

Dr. Black is Past-President of the American Academy of Clinical Psychiatrists (AACP) and Professor of Psychiatry at University of Iowa Carver College of Medicine in Iowa City, Iowa.

In 2021, we have seen advances in psychiatric research and treatment options. What do you feel is the most exciting or effective of these advances for your practice?
Dr: Donald Black:
There has been an explosion in the number and types of evidence-based psychotherapies for a variety of mental disorders. When I entered practice many years ago, none of the psychotherapies available at the time had a supportive evidence base but were popular mainly because of tradition. That has changed dramatically. Other exciting developments include the burgeoning interest in new biological treatments. Once confined to electroconvulsive therapy, we now have ketamine, transcranial magnetic stimulation, and other technologies. 

What are you looking forward to specifically 2022 Psychiatry Spring Update June 16-18?
Dr: Donald Black:  First, I am looking forward to an exciting meeting where I can see old friends and meet new ones in person. This has been a long time coming, but it is worth the wait. Next, there is a lineup of great speakers and even better topics to keep everyone informed about the latest developments in psychiatry, across a spectrum of disorders. We are all looking forward to seeing our colleagues in person in Chicago on June 16th-18th. And since we are offering a live streaming option for virtual participation, anyone and everyone who wishes to can participate, regardless of ability to travel or existing schedule conflict. 

Looking ahead to 2022, what are you looking forward to?
Dr: Donald Black:
The pandemic has been a game changer in how virtual care is viewed by providers as well as payers. There is no doubt that it is effective, safe, and convenient. I doubt the practice of psychiatry will ever quite be the same as it was before the pandemic.

In our inaugural January 2021 issue, you both spoke to some of the challenges COVID has presented for you as clinicians (within the inpatient unit, with use of telepsychiatry, etc). Do these challenges still exist as the most difficult obstacles to treatment, or are there new ones that have developed?
Dr: Donald Black: Challenges still exist, and, for me, the most vexing problem is that many of my patients choose not to be vaccinated. With their obesity, multiple comorbidities, or histories of smoking and substance abuse, they are at risk for severe COVID19 illness, or even death. I try as best I can to encouraged them to get vaccinated, but they resist.

 

Thought Leader Rapid Fire

Most critical new advance in psychiatry: new medications for psychotic disorders and tardive dyskinesia
My mentor: the late, great George Winokur, who helped define the medical model of psychiatry
Advice that has helped in my career: Never turn down any invitation
Best tool in my clinical arsenal: My gift of speech
COVID-necessitated virtual format mental health programs: As a presenter, it’s like speaking to a brick wall
Favorite Medscape meeting historically and why: My last in-person meeting before the pandemic was in Las Vegas in 2019. A great place and a fun meeting…
Biggest, or one of the biggest, honors of my career to date: To serve as President of the American Academy of Clinical psychiatrists, a great organization
Biggest challenge you face as a psychiatrist today: Now serving as an administrator for the VA, to keep the place fully staffed
Best recent medical journal article I read: Not an article, but an editorial: Henry Nasrallah’s “We are physicians, not providers, and we treat patents, not clients!” Current Psychiatry February 2020. (This article can be accessed here: https://cdn.mdedge.com/files/s3fs-public/CP01902005.PDF)

 

Psychiatry Resource Section

JAMA Psychiatry Viewpoint: Estimating Psychiatric Bed Shortages in the US
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2789297

MDEdge Clinical Psychiatry News Article: Meta-analysis confirms neuroprotective benefit of metformin
https://www.mdedge.com/psychiatry/article/253887/diabetes/meta-analysis-confirms-neuroprotective-benefit-metformin

APA Learning Center Free Members April Course of the Month: Inpatient Psychiatric Evaluation for Organ Transplantation —Credits CME: 0.5, Participation: 0.5
https://education.psychiatry.org/diweb/catalog/item?id=9167685

JAMA Psychiatry Viewpoint: Toward Ecologically Sustainable Mental Health Care—A Call for Action from Within Psychiatry
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2790779

MDEdge Clinical Psychiatry News Literature Review: Long-term cannabis use linked to dementia risk factors
https://www.mdedge.com
 
New England Journal of Medicine Article: Laboratory Diagnosis of Creutzfeldt–Jakob Disease
https://www.nejm.org/doi/full/10.1056/NEJMra2119323

 

 

March 2022

Rapid Fire with Some Psychiatry Thought Leader

Introduction

We are back again this month with some of our thought leaders in psychiatry talking shop in a rapid-fire format—including their biggest career honor to date, where they go for continuing education, what they look forward to in 2022, favorite meeting/conference, best recent publication, and biggest challenge they face as a psychiatrist today. Read on for some tidbits and insights from these thought leaders, including Dr. George Grossberg, Dr. Jon Grant, Dr. Craig Chepke, and Dr. Leslie Citrome.

Our last issue included discussion with Dr. Rifaat S. El-Mallakh on new research in treatment of bipolar disorder, being a Current Psychiatry board member, and where psychopharmacology fits in with interventional psychiatry in his psychiatrist’s arsenal. If you missed it, you can find that interview here.

On behalf of Medscape and the American Academy of Clinical Psychiatrists, you are invited to the 2022 Psychiatry Spring Update, this year presented as a hybrid event. We are looking forward to seeing our colleagues in person in Chicago from June 16th to 18th but are also offering a live streaming option for virtual participation. You don’t want to miss it! Register here

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 
Thank you to Drs. Citrome, Chepke, Grossberg, and Grant for their perspectives this month. Please contact me at [email protected] with any comments and/or suggestions.

Colleen Hutchinson

 

Thought Leader Rapid Fire

Leslie Citrome, MD, MPH, is Clinical Professor, Psychiatry and Behavioral Sciences, New York Medical College, New York, New York. 
Jon E. Grant, MD, JD, MPH, is Professor, Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, Chicago, Illinois.
George T. Grossberg, MD, is Professor, Director Division of Geriatric Psychiatry
Department of Psychiatry & Behavioral Neuroscience, St. Louis University School of Medicine, St. Louis, Missouri.
Craig Chepke, MD, FAPA, is Medical Director, Excel Psychiatric Associates, Adjunct Associate Professor of Psychiatry, Atrium Health, Adjunct Assistant Professor of Psychiatry, University of North Carolina School of Medicine, Huntersville, North Carolina.

Favorite Medscape meeting historically and why: 
Dr. Citrome: The Summer Neuropsychiatry meeting—it covers topics that other conferences don't.
Dr. Chepke: I enjoy the Winter Medscape Psychiatry Update because it seems like there tends to be a lot of important data readouts and presentations later in the year, so there are a lot of exciting updates that can be discussed at the Winter meeting. 
Dr. Grossberg: Current Psychiatry/AACP Annual Meeting because it is practical—clinically useful.
Dr. Grant: The AACP annual meeting—it is for clinicians.

Biggest, or one of the biggest, honors of my career to date: 
Dr. Citrome:
Being elected as President, American Society of Clinical Psychopharmacology.
Dr. Grant: Being asked to work on the ICD-11 for the WHO.
Dr. Grossberg: The Fleishman-Hillard Award for Contributions to Geriatrics.
Dr. Chepke: Earlier this year when I was named to the Steering Committee of Psych Congress. The opportunity to have a hand in shaping the educational platform for so many psychiatric clinicians is an incredible honor and responsibility.

Biggest challenge you face as a psychiatrist today: 
Dr. Citrome:
As a clinician, having treatments that are predictably effective.
Dr. Grant: The level of patient severity has increased.
Dr. Grossberg: My long waiting list.
Dr. Chepke: The biggest challenge I, and I think all psychiatrists, face is stigma that prevents patients from seeking needed care or wanting to stop medications that they really need to keep them well.

Best recent medical journal article I read: 
Dr. Chepke:
I loved Abi-Dhargham and colleagues’ article in the August issue of Schizophrenia Bulletin. I follow Dr. Abi-Dhargham and her group closely, as the research they do is always top notch and the manuscripts produced are clear and well written. This paper discusses dopamine D1 receptor stimulation as a potential therapeutic target for an incredibly important unmet need: cognition in schizophrenia. (Schizophren Bull 2022 Jan 21;48(1):199-210.)
Find it here: https://pubmed.ncbi.nlm.nih.gov/34423843/

Dr. Citrome: An article titled “Amyloid and Tau in Alzheimer's Disease: Biomarkers or Molecular Targets for Therapy? Are We Shooting the Messenger?” from Anand Kumar, Charles B Nemeroff, and colleagues. (Am J Psychiatry 2021 Nov;178(11):1014-1025.) 
Find it here: https://pubmed.ncbi.nlm.nih.gov/34734743/

Dr. Grant: Any of the historical short pieces in the British Journal of Psychiatry—most recently, one titled “William Hogarth's Depiction of Bedlam—Psychiatry in Pictures” by Dr. RH Mindham. (Br J Psych 2021;219(4):569.) 
Find it here: https://pubmed.ncbi.nlm.nih.gov/35048884/

Dr. Grossberg: An Alzheimer’s & Dementia article titled “Aducanumab: Appropriate Use Recommendations” by Drs. Jeffrey Cummings and Steve Salloway. (Alzheimers Dement 2021 Jul 27;10.1002/alz.12444.)
Find it here: https://pubmed.ncbi.nlm.nih.gov/34314093/

Where I go for continuing education now: 
Dr. Citrome: Medscape, of course! But also, USPC and NEI.
Dr. Grant: APA annual meeting; the journal FOCUS.
Dr. Grossberg: Journals and PubMed.
Dr. Chepke: I like to get my continuing education at live conferences, so I’ve been thrilled that some conferences have returned to in-person meetings.

What I am most looking forward to in 2022: 
Dr. Chepke:
We should have the readout results of the phase III trials for two new antipsychotics with non-dopaminergic mechanisms of action, the TAAR1 agonist, ulotaront, and the muscarinic agonist, xanomeline/trospium.
Dr. Citrome: Resuming face-to-face interactions in-person.
Dr. Grant: Attending conferences in person again.
Dr. Grossberg: Improvement in the Covid pandemic worldwide; a reliable, affordable blood test to diagnose Alzheimer's disease.

 

Psychiatry Resource Section

JAMA Psychiatry Viewpoint: Methadone on Wheels—A New Option to Expand Access to Care Through Mobile Units
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2787665

MDEdge Clinical Psychiatry News Article: FDA clears once-weekly transdermal patch for Alzheimer’s
https://www.mdedge.com

APA Learning Center Free Members November Course of the Month: Brain Networks in Psychiatric Disorders —Credits CME:1.25, Participation: 1.25
https://education.psychiatry.org/diweb/catalog/item?id=9166674

JAMA Psychiatry Viewpoint: The Rapid Rise in Investment in Psychedelics—Cart Before the Horse 
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2787968 

MDEdge Clinical Psychiatry News Article: Study: Majority of research on homeopathic remedies unpublished or unregistered
https://www.mdedge.com

Current Psychiatry Sponsored CME Supplement: Challenges in Treating Patients with Tardive Dyskinesia—Credits CME: 0.5, Participation: 0.5
https://cdn.mdedge.com/files/s3fs-public/1121_cp_td_supplement_v8.pdf

New England Journal of Medicine Article: Electroconvulsive Therapy
https://www.nejm.org/doi/full/10.1056/NEJMra2034954

Current Psychiatry Review: Autism spectrum disorder: Keys to early detection and accurate diagnosis
https://www.mdedge.com

 

 

February 2022

Hot Topics in Psychiatry: Rifaat S. El-Mallakh, MD, Weighs in on What’s New in the Psychiatrist’s Arsenal

Introduction

We are back in your inbox this month with a candid interview with Dr. Rifaat S. El-Mallakh, who is Professor and Director of Mood Disorders Research Program, Department of Psychiatry and Behavioral Sciences at the University of Louisville School of Medicine. Dr. El-Mallakh and I covered several current topics, including helpful new research in treatment of bipolar disorder, being a board member of Current Psychiatry, and a recently coauthored Current Psychiatry article that states that “the treatment of psychosis has seen a near explosion of creative development in both novel agents and new delivery modalities,” and how he would characterize where psychopharmacology fits in along with interventional psychiatry in his psychiatrist’s arsenal.
Our last issue included insights from Dr. Jacqueline Landess, who discussed the most challenging aspect of state psychiatric hospital matters she faces, and practical pearls from her recent Current Psychiatry article on confidentiality, privilege, and what you don’t know that can hurt you. We hope you enjoy the pearls and takeaways shared in this issue. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 
On behalf of the University of Cincinnati and Current Psychiatry, you are invited to visit this link and register for access to on-demand content from the Virtual 20th Annual Psychopharmacology Update MedscapeLIVE! event. Register here
Thank you to Dr. El-Mallakh for his participation in this month’s issue! Please contact me at [email protected] with any comments and/or suggestions.

Colleen Hutchinson

 

Interview with Rifaat S. El-Mallakh, MD

Hot Topics in Psychiatry: A Candid Chat with Rifaat S. El-Mallakh, MD
Dr. El-Mallakh is Professor and Director of Mood Disorders Research Program, Department of Psychiatry and Behavioral Sciences at the University of Louisville School of Medicine.

Colleen: You’ve published on various aspects of research on etiology and treatment of bipolar disorder. What have you found to be the most helpful new research for this condition?
Dr. El-Mallakh:
I believe clinicians do not understand the importance of understanding the pathophysiology of disease. The closer our treatment is to correcting the underlying physiology, the more effective and the less problematic it will be. The evidence that clinicians do not understand is in the dramatic reduction of the use of lithium and antiseizure medications in the management of bipolar illness. Let me explain: both mania and bipolar depression are associated with a doubling to quadrupling of the concentration of intracellular sodium. This reduces the resting potential and increases the excitability of neurons. All mood stabilizers (effective anti-epileptics and lithium) lower lithium entry in an activity-dependent manner—meaning that these agents directly correct a known pathophysiologic abnormality. On the other hand, antipsychotic medications, which have seen an over 600% increase in use over the last decade and which are placed as first choice medications in nearly all treatment guidelines, do not correct any known abnormality in the brains of our patients. Actually, quite the opposite. There are no primary abnormalities in amine metabolism of ill bipolar patients (all changes are secondary). So, we literally give medications that create new brain abnormalities because it helps us get a desired outcome. We have been doing this for a long time -- all clinicians are aware that in people with Parkinson's or Parkinsonism that there is no excess of acetylcholine, but creating a new abnormality in that neurotransmitter system with anticholinergics does reduce the clinical manifestation of the dopamine deficiency and improves clinical symptoms. The unfortunate consequence is that we have created new side effects such as cognitive dysfunction and increasing risk for TD. Similar issues happen with relying on antipsychotics versus mood stabilizers.
I first went into bipolar research in the 1980s believing that the pathoetiology of this condition would be deciphered by now. Unfortunately, we are no closer now than we were in the 1980s. So, to answer your question, I think research is actually moving in the wrong direction -- further away from trying to figure out the cause of these conditions.
 
Colleen: What do you find most interesting as an editorial board member of Current Psychiatry?
Dr. El-Mallakh:
I have been impressed by the utility of the articles in this journal. The editors have been very careful to make sure that everything that is published in Current Psychiatry leads to utility in clinical management and increasing the knowledge base of the clinicians. It is a great marriage of clinical medicine and preclinical science.

Colleen: Your recently coauthored Current Psychiatry article states that in the last decade, “the treatment of psychosis has seen a near explosion of creative development in both novel agents and new delivery modalities.” Given this, how would you characterize where psychopharmacology fits in along with interventional psychiatry in your psychiatrist arsenal?
Dr. El-Mallakh:
I think it is important to clarify some definitions. The term 'interventional psychiatry' is used for treatments that have more than minimal risk. This applies to things like ECT (electro-convulsive therapy), TMS (transcranial magnetic stimulation), ketamine infusions and esketamine administration, and so on. The only interventional aspect of antipsychotics is use of injections, and possibly inhalation (due to associated REMS program). The new treatments for psychosis that I was referring to are interventions that do not require dopamine blockade. These include resurrection of old ideas like using cholinergics as antipsychotics (the xanomeline-trospium combination), using an agonist for the trace amine-associated receptor (SEP-363856, which follows on research from the 1970s done at NIMH by Richard Wyatt), focusing on blockade of serotonin 2A (inverse agonist pimavanserin), or taking advantage of the differences between presynaptic and post-synaptic D2 so that you can get an antipsychotic effect with only 50% D2 receptor occupancy (lumateperone). Some of these may or may not pan out, but they are exciting. 
 
Colleen: While the FDA has approved esketamine use in depressed suicidal patients, another recent article from you states that “the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation.” How, then, should clinicians move forward in terms of inclusion of esketamine in their arsenal?
Dr. El-Mallakh: This paper was a product of the Suicide Prevention Taskforce of the National Network of Depression Centers. In that paper we made a point that some medications that may have an anti-suicide effect (like lithium and possibly antidepressants) and may have a rebound pro-suicide effect when they are discontinued. The question was, does esketamine have a similar rebound effect. We still do not know. We have 3 suicides among thousands of very high-risk patients in the esketamine studies. We presented this as a question that needs to be answered with additional research and not as an active concern. Just as an aside, it is important to remember that these are the first ever randomized studies in people who are high risk for suicide (usually we exclude these people from studies), so we really do not know what we should expect, and actually 3 suicides in nearly three thousand people is a low rate for such a high risk population. We just need to keep studying this to understand what we are doing.

 

Psychiatry Resource Section

Current Psychiatry Article: Assessing imminent suicide risk: What about future planning?
https://www.mdedge.com

JAMA Psychiatry Viewpoint: Social Determinants of Mental Health: Recommendations for Research, Training, Practice, and Policy
https://jamanetwork.com/journals/jamapsychiatry/newonline

MDEdge Clinical Psychiatry News Article: Burnout rates rising among psychiatrists
https://www.mdedge.com/psychiatry/article/252061/business-medicine/burnout-rates-rising-among-psychiatrists

APA Learning Center Free Members February Course of the Month: Screening for Unhealthy Alcohol and Drug Use: Screening Tools and Guidance for Implementation—Credits CME:1.0, Participation:1.0
https://education.psychiatry.org/diweb/catalog/item?id=9156362

New England Journal of Medicine Article: Electroconvulsive Therapy
https://www.nejm.org/doi/full/10.1056/NEJMra2034954

MDEdge Clinical Psychiatry News Article: Healthy gut tied to better cognition
https://www.mdedge.com

 

 

January 2022

An Interview with Dr. Jacqueline Landess

Introduction

Happy New Year from all of us at Medscape! On the heels of the holidays and the 20th Annual Virtual Psychopharmacology Update, we are taking a moment to pause and catch our breath. This month we open 2022 with a conversation with Jacqueline Landess, MD, JD. Dr. Landess is a Clinical Assistant Professor of Psychiatry and the Associate Training Director of the Forensic Psychiatry Fellowship at the Medical College of Wisconsin. She works at Mendota Mental Health Institute on a maximum-security forensic unit, and also consults with legal professionals on a wide variety of forensic issues through her private practice. 

In this issue, Dr. Landess discusses the most challenging aspect of state psychiatric hospital matters she faces, and practical pearls from her recent Current Psychiatry article on confidentiality, privilege, and what you don’t know that can hurt you. Dr. Landress also discusses her 2019 article, “Caring for patients on probation or parole.” We hope you enjoy the pearls and takeaways shared in this issue.
Our last issue included insights from Drs. Leslie Citrome, Brian Holoyda, and George Grossberg. These thought leaders took time to look back on the good, the bad, and the ugly of 2021 and give some predictions for this new year in psychiatry. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 

On behalf of the University of Cincinnati and Current Psychiatry, you are invited to visit this link and register for access to on-demand content from the Virtual 20th Annual Psychopharmacology Update MedscapeLIVE! event. Register here
Thank you to Dr. Goldberg for his participation in this month’s issue, as well as for serving as faculty for the conference and presenting on so many topics. 
Please contact me at [email protected] with any comments and/or suggestions. –Colleen Hutchinson

 

Interview

Hot Topics in Psychiatry: A Candid Chat with Jacqueline Landess MD, JD
Dr. Landess is a Clinical Assistant Professor of Psychiatry and the Associate Training Director of the Forensic Psychiatry Fellowship at the Medical College of Wisconsin. She works at Mendota Mental Health Institute on a maximum security forensic unit, and also consults with legal professionals on a wide variety of forensic issues through her private practice.

Colleen: In your 2021 article, Kahler v. Kansas and the Constitutionality of the Mens Rea Approach to Insanity (Landess JS, Holoyda BJ. Am Acad Psychiatry Law. 2021 Jun;49(2):231-240), you wrote: “We advocate for continued education of the public, legislators, and the judiciary regarding the use, application, and necessity of an affirmative insanity defense.” 
From your perspective, why is the insanity defense so important? 

Dr. Landess: There is considerable debate about the necessity and utility of an insanity test for criminal defendants. As a brief background, there has long been a recognition under criminal law- looking back to the 1500s and beyond- that those individuals who were “insane” at the time of their criminal acts should not be held criminally responsible. This test was defined further in the 1800s (the M’Naughten standard), which is the majority rule in the U.S. today. This test requires that an individual, due to a mental disease or defect, did not know the nature and quality of their criminal act or did not know what they were doing was wrong at the time of the crime. Of note, in the years after John Hinckley was found NGI in 1982, a number of states essentially abolished the insanity defense. Kansas did this relatively more recently (see our article cited above). Legislators in these states cited a number of reasons but cited sentiments that the insanity defense is mis- and overused, it allows the “bad guys” to “get out of jail free,” that psychiatry is an imprecise science, and utilizes “hired guns”, expert witnesses who render favorable opinions to the highest bidder. While there are certainly limitations to our work in forensic psychiatry, we do have data that challenges some of these popular conceptions (for instance, the NGI defense is rarely raised, and expert evaluators usually agree with each other’s opinions). We also understand how severe mental illness, such as schizophrenia, impacts a person’s ability to make decisions, rationalize, plan and control impulses.  However, the average layperson is not familiar with this data, does not understand psychiatric illness, the limitations of the defense, and dispositions of those found NGI.
All that to say, there are numerous clinical, ethical, and legal justifications for the NGI defense. I think it is very important for states to have this as an option for defendants, not the least because of the strong historical basis for the defense. First, certain penal goals, such as retribution and deterrence would not be served if we punish individuals who had no or limited comprehension of the wrongfulness of their acts at the time of the crime.  From an ethical and moral standpoint this is also unfavorable. Constitutionally, individuals also have a right to avoid cruel or unusual punishment. If someone was actually "insane" at the time they did a criminal act, then resulting punishments, including a death sentence, would seem to violate this right. And clinically, we recognize that individuals found NGI usually have a severe psychiatric illness for which they will need ongoing care. This is best done in state hospitals or community systems, rather than in correctional institutions, which is what a NGI commitment allows.

Colleen: What is, or what is one of, the most challenging aspect(s) of state psychiatric hospital matters that you deal with today?
Dr. Landess:
Fifty or more years ago, state psychiatric hospitals mostly cared for patients who were under civil commitment. Since that time, state systems have evolved and shifted their focus to treatment of forensic patients. In fact, in some states, state hospitals only or primarily treat forensic patients. These are patients who are committed for treatment due to incompetency to stand trial, not guilty by reason of insanity (NGI) or other reasons. Treating forensic patients can be quite gratifying; many of these individuals have never received adequate or consistent psychiatric care and present with complex and serious psychiatric, usually psychotic, illness. On the other hand, one of the most challenging aspects of treating forensic patients is the limited role you have in their long-term treatment and the unpredictable nature of discharge planning. For instance, once a patient leaves the state hospital, they could then stay in jail additional weeks, months, or longer.  It is uncertain whether they will be seen by a psychiatric provider, depending on the jail. They may or may not have access to the follow-up we arranged, depending on when they leave jail. Their medication may or may not be continued once at jail, due to cost or formulary concerns. They will not have insurance when they leave jail and will have to unsuspend their insurance or re-apply. We do our best to collaborate and coordinate care, but many times there are systems of care issues that are beyond our control and contribute to poor patient outcomes, recidivism, and relapse. 

Colleen: What are the main take-home points for practicing clinicians in your recent article in Current Psychiatry, “Confidentiality and privilege: What you don’t know can hurt you?”
Dr. Landess:
Confidentiality and privilege are related but distinct concepts. Most clinicians are familiar with confidentiality, which of course is our duty to keep a patient’s clinical information secure and private. Privilege, on the other hand, is owned by the patient, and prevents compelled disclosure of certain information during the course of legal proceedings. For instance, a patient may prevent a clinician from testifying or producing records of their psychiatric treatment in a civil or criminal lawsuit. In our recent article, we discuss a relatively unknown exception to privilege. In some states, a patient may automatically waive privilege in divorce and child custody proceedings merely by filing a lawsuit. What this means is that their records could automatically become discoverable to the opposing party, which could be an issue given the sensitive information that is disclosed and documented during psychiatric treatment. Though clinicians generally discuss the limits of confidentiality at the outset of treatment, we should also consider discussing exceptions to privilege as well, especially if a patient is contemplating divorce or seeking custody. 

Colleen: Can you share a couple of pearls from your 2019 article, “Caring for patients on probation or parole” that you coauthored with Dr. Brian Holoyda?
Dr. Landess:
In the U.S., approximately one in fifty individuals are on probation or parole, otherwise known as community supervision. In addition, it is also well-established that individuals in the justice system have higher rates of psychiatric illness, and some of the highest rates of substance use disorders. Generally, these individuals show a reduced incidence of relapse and recidivism if they engage in mental health treatment, and it is likely psychiatrists will encounter these patients in their practice. In our article, we discuss how some individuals on probation or parole may even be mandated to treatment, as a condition of their parole/probation or perhaps due to involvement in a mental health or drug court. This presents unique challenges for the clinician. Patients will often sign releases of information so that the clinician can communicate with the court or probation officers. The clinician must still be cautious and share only relevant information, keeping in mind their duty is to the patient and not the court. Another tip we discuss is the importance of not automatically assuming a patient with a legal history also has antisocial personality disorder. Context of antisocial acts, and the presence of a childhood history of conduct disorder, is crucial to making that diagnosis. If the patient does have antisocial personality, the clinician should continue to assess for and treat co-occurring conditions such as substance use disorders, posttraumatic stress, mood disorders and other conditions.

 

Psychiatry Resource Section

Current Psychiatry Article: Borderline personality disorder: 6 studies of biological interventions
https://www.mdedge.com/psychiatry/article/248107/personality-disorders/borderline-personality-disorder-6-studies-biological

JAMA Psychiatry Viewpoint: A Call to Revise the Diagnosis of Oppositional Defiant Disorder—Diagnoses Are for Helping, Not Harming
https://jamanetwork.com/journals/jamapsychiatry/currentissue

MDEdge Clinical Psychiatry News Article: Swell in off-label antipsychotic prescribing ‘not harmless’
https://www.mdedge.com

APA Learning Center Free Members November Course of the Month: Increasing access to evidence-based interventions for common mental disorders in underserved communities in the United States: Lessons from Low- and Middle-Income Countries—Credits CME:1.0, Participation:1.0
https://education.psychiatry.org/diweb/catalog/item?id=8393520

JAMA Psychiatry Original Investigation: The Subjective Experience of Childhood Maltreatment in Psychopathology
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2784534
 
MDEdge Clinical Psychiatry News Article: Social media use associated with depression in adults
https://www.mdedge.com

New England Journal of Medicine Article: Depression in Adolescents
https://www.nejm.org/doi/full/10.1056/NEJMra2033475

MDEdge Clinical Psychiatry News Article: COVID-19 mortality risk factors: An unexpected finding
https://www.mdedge.com/psychiatry/article/246789/intimate-partner-violence-assessment-era-telehealth

Current Psychiatry Article: Serotonin-mediated anxiety: How to recognize and treat it
https://www.mdedge.com

 

 

December 2021

Looking Back on 2021: A Year in Review 

Introduction

Happy Holidays from all of us at Medscape! the 20th Annual Virtual Psychopharmacology Update
In this issue, Drs. Leslie Citrome, Brian Holoyda, and George Grossberg look back on the good, the bad, and the ugly of 2021 and give some preditcions for the upcoming 2022 year in psychiatry.
Our last issue included insights from Dr. Joseph F. Goldberg, who is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York. Dr. Goldberg presented almost singlehandedly Medscape’s full-day course, Masterclass I: Complexities in the Pharmacotherapy of Mood Disorders, at the 20th Annual Virtual Psychopharmacology Update. In the November issue, Dr. Goldberg shared some pearls from his numerous presentations. Click here to see that interview and access takeaways as seen from the presenter’s perspective.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below.
On behalf of the University of Cincinnati and Current Psychiatry, you are invited to visit this link and register for access to on-demand content from the Virtual 20th Annual Psychopharmacology Update MedscapeLIVE! event. Register here.
Thank you to Drs. Grossberg, Holoyda, and Citrome or their participation in this month’s year in review. 
Please contact me at [email protected] with any comments and/or suggestions. Happy Holidays and Happy New Year! –Colleen Hutchinson

Looking Back on 2021: A Year in Review 

George T. Grossberg, MD, is the Samuel W Fordyce Professor and Director of the Division of Geriatric Psychiatry at St. Louis University School of Medicine.
Leslie Citrome, MD, is Clinical Professor of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York. He is Current Psychiatry’s Section Editor, Psychopharmacology.

Brian Holoyda, MD, MPH, MBA is a forensic and correctional psychiatrist. In his clinical practice, he treats inmates at a pre-trial detention facility in the Bay Area of California. He also has a private forensic practice and conducts forensic psychiatric evaluations around the United States. He specializes in the assessment of violence and sexual violence risk.
 

Colleen: What was your most memorable case or patient in the last year?
Dr. George Grossberg:
My most memorable case is a 72-year-old patient with treatment-resistant depression who failed pharmacotherapy, TMS, and ECT, who is now responding to a vagal nerve stimulator (VNS).

Dr. Leslie Citrome: Seeing patients in the office has been memorable for the masks - some were whimsical (dog faces), others way beyond edgy (with 4-letter curses written on them), and others took a more sartorial approach (matching kerchief or tie).

Dr. Brian Holoyda: My most memorable patient this year was a young man who came into custody after a fatal motor vehicle accident that occurred in the context of substance intoxication. It was wonderful to work with him during his time in custody and to help him adapt to the stressors of jail. It was also heartbreaking to watch him come to terms with the circumstances that led to his arrest and the aftershocks felt in his community.

Colleen: What has been your biggest challenge in 2021?

Dr. Holoyda: The biggest challenge of 2021 was managing severely psychotic and violent patients that entered custody after months off treatment, which sometimes entailed emergent medication administration. Thanks to California's new legislation, however, correctional psychiatrists in the state can now petition the court for involuntary treatment of pre-trial detainees who are determined to be dangerous and in need of psychotropic medication. This has improved patients' access to treatment and the safety of the correctional environment.

Dr. Citrome: Zoom fatigue!

Dr. Grossberg: My biggest challenge in 2021 was moving back to seeing patients in the office after mostly virtual visits last year due to Covid.

Colleen: What was the best source of education for you this year?
Dr. Grossberg:
For me, the best source of education is PubMed.

Dr. Citrome: This continues to be my colleagues and working together on projects, together with all the anonymous peer reviewers to whom we all owe a debt of gratitude.

Dr. Holoyda: The Carlat psychiatry podcast has been a consistently interesting and practical addition to my list of educational resources.

 

Psychiatry Resource Section

Current Psychiatry Article: Pediatric insomnia: Assessment and diagnosis
https://www.mdedge.com

JAMA Psychiatry Original Article: Effect of 3 Forms of Early Intervention for Young People With Borderline Personality Disorder: The MOBY Randomized Clinical Trial
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2787195

MDEdge Clinical Psychiatry News Article: Is prescribing stimulants OK for comorbid opioid use disorder, ADHD?
https://www.mdedge.com

APA Learning Center Free Course: Diagnosis and Management of Catatonia—Credits CME: 0.75, Participation: 0.75
https://education.psychiatry.org/diweb/catalog/item?id=8339404

JAMA Psychiatry Viewpoint: Two Hypotheses on the High Incidence of Dementia in Psychotic Disorders
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2784327

MDEdge Clinical Psychiatry News Article: Califf plans work on opioids, accelerated approvals on return to FDA
https://www.mdedge.com

New England Journal of Medicine Article: A Nobel Prize for Sensational Research
https://www.nejm.org/doi/full/10.1056/NEJMcibr2116227
 

 

November 2021

The Buzz from Psychopharmacology Update 2021—An Interview with Dr. Joseph F. Goldberg

Introduction

We are back again this month right on the heels of the 20th Annual Virtual Psychopharmacology Update. With this year’s focus on Rational Combination Therapies and Complexities in Psychotic and Mood Disorders, this full-day course included nationally renowned faculty teaching Master Classes within this focus. Masterclass I: Complexities in the Pharmacotherapy of Mood Disorders, was presented almost singlehandedly by Dr. Joseph F. Goldberg. Dr. Goldberg is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York. 
In this issue, Dr. Goldberg agreed to share some pearls from his numerous presentations. We hope you enjoy the pearls and takeaways as seen from the presenter’s perspective.
Our last issue included insights from Drs. Edwin Salsitz, Sanjay Gupta, and Leslie Citrome. We covered pearls that came out of the Telepsychiatry Workshop: Updates for Your Current Practice, the Addiction Workshop: Understanding Addiction, Scope of the Opioid Epidemic Focus on Fentanyl Crisis and Interesting Addiction Medicine Cases, and other presentations. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 
On behalf of the University of Cincinnati and Current Psychiatry, you are invited to visit this link and register for access to on-demand content from the Virtual 20th Annual Psychopharmacology Update MedscapeLIVE! event. Register here
Thank you to Dr. Goldberg for his participation in this month’s issue, as well as for serving as faculty for the conference and presenting on so many topics. 
Please contact me at [email protected] with any comments and/or suggestions.

Colleen Hutchinson

 

The Buzz from Psychopharmacology Update 2021 with Dr. Joseph Goldberg
Joseph F. Goldberg, MD, is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.
 

Presentation

Pearl(s)

One thing attendees learned that’s new

Overview of Assessment – do not treat first and ask questions later!

Take a detailed, systematic approach to diagnosis in mood disorders – do not rush; affirm corroborative features to establish the basis for a working diagnosis based on past and current symptoms, longitudinal course, epidemiology, family history, treatment response, and ruling out confounding factors

The majority of mood disorders are unipolar but for complex presentations consider polarity, psychosis, comorbidities, poor medication adherence, trauma histories, and other pertinent characteristics before crafting a treatment plan

Anxiety Disorders

Up to half of bipolar disorder patients may have a comorbid anxiety disorder; serotonergic antidepressants have not been shown to treat bipolar anxiety; high baseline anxiety substantially lowers treatment response in major depression

All FDA-approved treatments for bipolar depression have been shown to reduce concurrent anxiety symptoms; in major depression with prominent anxiety, newer serotonergic antidepressants such as vilazodone have demonstrated robust efficacy in anxious depression

OCD

Comorbid OCD occurs in 10-20% of bipolar disorder patients and worsens overall treatment outcome

In major depressive disorder with comorbid OCD that is incompletely responsive to serotonergic antidepressants, adjunctive medications with the largest effect size include aripiprazole and risperidone

ADHD and Cognitive Dysfunction 

10 to 20% of adults with bipolar disorder have comorbid adult ADHD; however, up to half of adults with bipolar disorder have slowed attentional processing as a separate phenomenon from ADHD

Vortioxetine in major depression has been shown to significantly improve attentional processing independent of its antidepressant effect; lisdexamfetamine added to mood stabilizers has preliminarily been shown to improve comorbid ADHD symptoms without destabilizing mood in adults with bipolar disorder

Psychotic Features

Half of manic episodes involve psychosis and predicts poorer recovery, greater likelihood of comorbid anxiety; psychosis occurs in up to 20% of major depression patients, often recurs across episodes, and carries a lower remission rate and higher suicide risk than nonpsychotic depression

ECT can be more efficacious, and have a lower relapse rate, in psychotic than nonpsychotic depression

Epilepsy 

Up to half of epilepsy patients have clinically significant features of depression; poorly controlled epilepsy can increase risk for suicide; 6% incidence of post-ictal psychosis

Anticonvulsants vary in psychotropic properties; some confer mainly antimanic efficacy (divalproex, carbamazepine), some have mainly antidepressant properties (e.g., lamotrigine) and certain other may cause rather than ameliorate psychosis or affective symptoms

Migraine

Migraine occurs in about 1/3 of adults with bipolar disorder; 9% of migraine sufferers have bipolar disorder. Shared mechanisms are thought to involve inflammatory processes

To the extent that depression-proneness may correlate with migraine, pharmacological parsimony may favor the use of agents that can target both migraine and depression, e.g., divalproex and/or lamotrigine

Tardive Dyskinesia

Presence of a mood disorder increases risk for developing tardive dyskinesia when taking any dopamine-blocking drug; older age, female sex, and duration of antipsychotic use are additional risk factors

Tardive dyskinesia symptoms can be more prominent during depressed phases of a mood disorder; aggressive treatment of depression may at least theoretically help to diminish risk for tardive dyskinesia

Insomnia

Important to recognize wide differential diagnosis of insomnia (primary insomnia versus sleep disturbance as the manifestation of a mood disorder versus as an adverse drug effect versus other causes); assure optimized sleep hygiene and absence of caffeine, alcohol, or other substances; consider role for sleep study if concerns about sleep apnea, periodic limb movement disorders, circadian rhythm disorder

Among second generation antipsychotics, aripiprazole, asenapine and cariprazine have no known impact on sleep architecture

Substance Use 

Substance use disorders are common comorbidities in mood disorders but can also cause mood disorders and disrupt the efficacy of psychotropic medications; hierarchically one must often treat intoxication/withdrawal/abstinence problems before being able to meaningfully diagnose and address mood symptoms; cannabis use disorder occurs in 20% of bipolar patients and can drive amotivation/apathy, cognitive complaints, and psychosis

A history of substance use disorder is a demonstrated risk factor for antidepressant-induced mania in bipolar disorder; divalproex has been shown to reduce drinking behavior in bipolar disorder patients with comorbid alcohol use disorder

Managing Metabolic Side Effects

Obesity and metabolic syndrome are disproportionately elevated in mood disorder patients.  Significant weight gain with second generation antipsychotics may be dose-related and can be predicted by early increases in weight, younger age, low baseline body mass index, nonwhite race/ethnicity and female sex

Lowest risk for significant weight gain with FDA-approved treatments for bipolar depression favors lurasidone and cariprazine; metformin has demonstrated the most robust efficacy among known antidote strategies for antipsychotic-associated weight gain, presumably by helping to overcome insulin resistance caused by some second-generation antipsychotics.  Pairing olanzapine with samidorphan 

 

Psychiatry Resource Section

Current Psychiatry Article: Borderline personality disorder: 6 studies of biological interventions
https://www.mdedge.com/psychiatry/article/248107/personality-disorders/borderline-personality-disorder-6-studies-biological

JAMA Psychiatry Viewpoint: A Call to Revise the Diagnosis of Oppositional Defiant Disorder—Diagnoses Are for Helping, Not Harming
https://jamanetwork.com/journals/jamapsychiatry/currentissue

MDEdge Clinical Psychiatry News Article: Swell in off-label antipsychotic prescribing ‘not harmless’
https://www.mdedge.com/psychiatry/article/249106/sleep-medicine/swell-label-antipsychotic-prescribing-not-harmless?channel=27970

APA Learning Center Free Members November Course of the Month: Increasing access to evidence-based interventions for common mental disorders in underserved communities in the United States: Lessons from Low- and Middle-Income Countries—Credits CME:1.0, Participation:1.0
https://education.psychiatry.org/diweb/catalog/item?id=8393520

JAMA Psychiatry Original Investigation: The Subjective Experience of Childhood Maltreatment in Psychopathology
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2784534
 
MDEdge Clinical Psychiatry News Article: Social media use associated with depression in adults
https://www.mdedge.com

New England Journal of Medicine Article: Depression in Adolescents
https://www.nejm.org/doi/full/10.1056/NEJMra2033475

MDEdge Clinical Psychiatry News Article: COVID-19 mortality risk factors: An unexpected finding

https://www.mdedge.com/psychiatry/article/246789/intimate-partner-violence-assessment-era-telehealth

Current Psychiatry Article: Serotonin-mediated anxiety: How to recognize and treat it
https://www.mdedge.com

 

 

October 2021

Hot Topics in Psychiatry: The Buzz from Psychopharmacology Update 2021—What Was Ho

Introduction

We are back again this month with some faculty from the 20th Annual Virtual Psychopharmacology Update, which was convened last week. With this year’s focus of Rational Combination Therapies and Complexities in Psychotic and Mood Disorders, this full-day course included nationally renowned faculty teaching a Master Class within this focus. 
For this issue, Dr. Edwin Salsitz, Dr. Sanjay Gupta, and Dr. Leslie Citrome agreed share some pearls from the meeting. Read on for a few tidbits from these thought leaders regarding fentanyl in drugs, 
Our last issue included insights from Henry A. Nasrallah, MD. Dr. Nasrallah is Vice-Chair for Faculty Development and Mentorship, Professor of Psychiatry, Neurology, & Neuroscience and Director, Neuropsychiatry and Schizophrenia Programs at the University of Cincinnati College of Medicine in Cincinnati, Ohio. We covered career challenges and accomplishments, Dr. Nasrallah’s favorite journals, his most frustrating treatment issue, thoughts on yoga for Parkinson’s, what treating BPD means, publication he is most proud of, and more. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 
On behalf of the University of Cincinnati and Current Psychiatry, you are invited to visit this link and register for access to content from the Virtual 20th Annual Psychopharmacology Update MedscapeLIVE! event. It’s right around the corner on October 23, and you don’t want to miss it! Register here.
Thank you to Dr. Edwin Salsitz, Dr. Sanjay Gupta, and Dr. Leslie Citrome for their participation and perspectives this month. Please contact me at [email protected] with any comments and/or suggestions.

–Colleen Hutchinson

 

The Buzz from Psychopharmacology Update 2021

Leslie Citrome, MD, MPH, is Clinical Professor, Psychiatry and Behavioral Sciences, New York Medical College, New York, New York. 
Sanjay Gupta, MD, is Chief Medical Officer, BryLin Behavioral Health System, Buffalo, New York, and Medical Director, Geriatric and Adult Psychiatry Endeavor Clinic, Buffalo, New York. 
Edwin Salsitz, MD, is Medical Director, Office-Based Opioid Therapy, Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel, and Associate Professor of Psychiatry, Mount Sinai Icahn School of Medicine, New York, New York.

In your presentation, Telepsychiatry Workshop: Updates for Your Current Practice, what are one or two pearls that attendees should come away with and be able to translate to practice?
Dr. Sanjay Gupta:
First, telepsychiatry is here to stay. Also, it is important to note that telepsychiatry is constantly changing, so practitioners should always check licensure details before starting. The rules in the public health crises related to COVID-19 are relaxed, but this could change at any time. Do not see an initial visit just by telephone. There are several minefields that should be negotiated appropriately. 
Lastly, the malpractice issues related to telepsychiatry are no different than with an in-person visit.

In your presentation, Addiction Workshop: Understanding Addiction, Scope of the Opioid Epidemic Focus on Fentanyl Crisis and Interesting Addiction Medicine Cases, what are one or two pearls that attendees should come away with and be able to translate to practice?
Dr. Salsitz:
One critical pearl is the understanding that for any illicit drug or any drug that is illicitly bought, you have to assume that drug is completely fentanyl or partially fentanyl and, therefore, it poses an overdose risk. That’s any drug at all that’s illicitly purchased or is considered an illicit drug.

Also, with regular use, fentanyl can be detected in urine toxicology for up to three weeks since its last use.

What is one new research to practice tool that you are happy to have in the practitioner’s arsenal?
Dr. Salsitz:
I am excited about improvements in harm reduction modalities in regard to the fentanyl epidemic, such as point of care fentanyl detection strips (FDS).

In the Masterclass II (Managing the Complexities and Comorbidities Associated with Schizophrenia and Related Disorders) for which you provided numerous valuable and timely presentations, what is one critical pearl that attendees should come away with and be able to translate to practice?
Dr. Citrome:
We have been overprescribing anticholinergic medications such as benztropine for people receiving antipsychotics. This has many consequences, including impairment of cognition, but also increased risk of developing tardive dyskinesia—and in those with tardive dyskinesia, making tardive dyskinesia worse.

 
Psychiatry Resource Section

JAMA Psychiatry Viewpoint: Addressing Structural Racism and Inequities in Depression Care
https://jamanetwork.com/journals/jamapsychiatry/currentissue

MDEdge Clinical Psychiatry News Article: The devil in the (masking) details
https://www.mdedge.com/psychiatry/article/248004/lotme/devil-masking-details

APA Learning Center Free Members November Course of the Month: Preventing Suicide in People with Opioid Use Disorder —Credits CME:1.0, Participation:1.0
https://education.psychiatry.org/diweb/catalog/item?id=8088340

JAMA Psychiatry Viewpoint: Expanding Current Approaches to Solve the Opioid Crisis
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2785026
 
MDEdge Clinical Psychiatry News Article: Sleep problems in mental illness highly pervasive
https://www.mdedge.com/psychiatry/article/247543/sleep-medicine/sleep-problems-mental-illness-highly-pervasive

New England Journal of Medicine Article: Maintenance or Discontinuation of Antidepressants in Primary Care
https://www.nejm.org/doi/full/10.1056/NEJMoa2106356

Current Psychiatry Pearls: Intimate partner violence: Assessment in the era of telehealth
https://www.mdedge.com/psychiatry/article/246789/intimate-partner-violence-assessment-era-telehealth

 

 

September 2021

Hot Topics in Psychiatry: 10 Questions With Dr. Henry A. Nasrallah

Introduction

We are back again this month with a candid interview with Henry A. Nasrallah, MD. Dr. Nasrallah is Vice-Chair for Faculty Development and Mentorship, Professor of Psychiatry, Neurology, & Neuroscience and Director, Neuropsychiatry and Schizophrenia Programs at the University of Cincinnati College of Medicine in Cincinnati, Ohio. In addition to keeping busy with those demanding roles, Dr. Nasrallah also serves as Editor-in-Chief of the journal Current Psychiatry, and he is also President of the American Academy of Clinical Psychiatrists (AACP).
Dr. Nasrallah also serves as Symposium Director for the 20th Annual Virtual Psychopharmacology Update, which is on October 23, 2021, with additional optional preconference workshops and keynote speaker on October 22. With this year’s focus of Rational Combination Therapies and Complexities in Psychotic and Mood Disorders, this full-day course will include nationally renowned faculty teaching a Master Class within this focus. 
For this issue, Dr. Nasrallah agreed to participate in a new 10 Questions With segment as we deviate from our normal interview format. In this new rapid-fire Q&A segment, we covered career challenges and accomplishments, Dr. Nasrallah’s favorite journals, his most frustrating treatment issue, thoughts on yoga for Parkinson’s, what treating BPD means, publication he is most proud of, and more. Read on for an inside look at some of these topics to keep current!
Our last issue included insights from Dr. Robert McCarron on several current topics, including his career challenges and accomplishments, asynchronous telepsychiatry (ATP), current guidance on diagnosis and treatment of MDD, and some of the latest research applicable to your practice. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below. 
On behalf of the University of Cincinnati and Current Psychiatry, you are invited to attend the Virtual 20th Annual Psychopharmacology Update MedscapeLIVE! event. It’s right around the corner on October 23, and you don’t want to miss it! Register here. 
Thank you to Dr. Nasrallah for his participation and perspectives this month. Please contact me at [email protected] with any comments and/or suggestions.

–Colleen Hutchinson

 

10 Questions with Dr. Henry Nasrallah

Henry A. Nasrallah, MD, is Vice Chair for Faculty Development and Mentorship; Professor of Psychiatry, Neurology, & Neuroscience; Director, Neuropsychiatry and Schizophrenia Programs; Director, Psychiatry CME Programs, University of Cincinnati College of Medicine.

Role as AACP President: To develop clinical psychiatrists into hard-nosed, evidence-based practitioners, with life-long learning habits.

My most frustrating treatment issue: Severe forms of psychopathology that rarely achieve remission, especially with childhood onset: the anxieties, OCD, PTSD, mood disorders, schizophrenia, and personality disorders.

Most promising and useful recent research in schizophrenia treatment: Current drug development for negative symptoms and cognitive deficits.

My mentors: At different stages of my career—John Romano during residency; Chris Gillin during my NIH fellowship; and George Winokur during my academic psychiatry career.

Yoga for Parkinson’s disease: Useful but underutilized adjunctive physical therapy for both the motor and mood symptoms of this serious neuropsychiatric disorder.

Innovations in Psychiatry conference: The can’t-miss educational experience for psychiatrists to remain on the cutting edge and learn about future advances.

Publication you are most proud of: For clinicians: Current Psychiatry, where I have served as Editor-in-Chief for 15 years. Current Psychiatry is the most useful and practical journal for busy practitioners, with the latest advances about the phenomenology and multi-modal treatments of psychiatric disorders. For researchers: 2 journals I founded: Schizophrenia Research and Biomarkers in Neuropsychiatry

Treating BPD: Juggling multiple pharmacological and psychosocial therapies.

Biggest challenge: Dealing with frequent personal problems of the hundreds of staff I supervised over the years, which demanded time and distracted me from teaching, research, editorial responsibilities, and patient care.

Most rewarding accomplishment: Giving back… Philanthropic donations to establish 5 Endowed Lectureships and a Neuroscience Center at several universities.

 
Psychiatry Resource Section

JAMA Psychiatry Viewpoint: Transforming Mental Health Care Delivery Through Implementation Science and Behavioral Economics
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2780654

MDEdge Clinical Psychiatry News Article Commentary: Is social media worsening our social fears? 
https://www.mdedge.com

APA Learning Center Free Members August Course of the Month: Computational Psychiatry and Future Perspectives—Credits CME:1.5, Participation:1.5
https://education.psychiatry.org/diweb/catalog/item?id=8278225

JAMA Psychiatry Special Communication: Pragmatic Precision Psychiatry—A New Direction for Optimizing Treatment Selection 
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2784467

MDEdge Clinical Psychiatry News Article: How to engage soldiers, veterans in psychiatric treatment
https://www.mdedge.com

New England Journal of Medicine Perspective: Criminalization of Gender-Affirming Care — Interfering with Essential Treatment for Transgender Children and Adolescents
https://www.nejm.org/doi/full/10.1056/NEJMp2106314

JAMA Psychiatry Original Investigation: Methamphetamine Use, Methamphetamine Use Disorder, and Associated Overdose Deaths Among US Adults
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2784468

 

August 2021

Hot Topics in Psychiatry: Dr. Robert M. McCarron on career challenges and accomplishments, asynchronous telepsychiatry (ATP), up-to-date guidance on diagnosis and treatment of MDD, and some of the latest applicable research.

Introduction

We are back again this month with a candid interview with Robert McCarron, DO. Dr. McCarron is Professor, Department of Psychiatry and Behavioral Medicine, Director of UCI Train New Trainers Primary Care Psychiatry Fellowship, and Assistant Dean, Continuing Medical Education at the University of California, Irvine School of Medicine. He is also Director of Education for the UCI Susan Samueli Integrative Health Institute. Dr. McCarron is a past president of the Central California Psychiatric Society, California Psychiatric Association and the Association of Medicine and Psychiatry, and is the Medicine / Psychiatry Section editor for Current Psychiatry. Dr. McCarron has numerous publications in unexplained physical complaints; pain management; depression and anxiety in the primary care setting; preventive medicine; medical / psychiatric cross-disciplinary education and psychiatric integrated care. He spends much of his time consulting on how best to provide “cross disciplinary training” at the interface of primary care medicine, chronic pain management, psychiatry, and integrative medicine, and is a national thought leader in psychiatric integrated education care. With a dual residency in internal medicine and psychiatry, Dr. McCarron went on to start the only two California-based combined internal medicine / psychiatry residency programs. In these roles, he received grant support to create and implement a “Med Psych” curriculum that can be used in the public mental health system by psychiatry residency training programs.
Dr. McCarron and I covered several current topics including his career challenges and accomplishments, asynchronous telepsychiatry (ATP), current guidance on diagnosis and treatment of MDD, and some of the latest research applicable to your practice.
Read on for an inside look at some of these topics to keep current!
Our last issue included insights from Dr. Leslie Citrome on new research in schizophrenia treatment, tardive dyskinesia, and eating disorders. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, and JAMA Psychiatry—check them out below. 
Don’t forget to check out details for Medscape’s upcoming virtual conference, Psychiatry Update 2021: Solving Clinical Challenges, Improving Patient Care, a MedscapeLIVE! event. It’s right around the corner and you don’t want to miss it!
Thank you to Dr. McCarron for his participation and perspectives this month. Please contact me at [email protected] with any comments and/or suggestions.

–Colleen Hutchinson

 
Interview

Hot Topics in Psychiatry: Dr. Robert McCarron on career challenges and accomplishments, asynchronous telepsychiatry (ATP), up-to-date guidance on diagnosis and treatment of MDD, and some of the latest applicable research.
Robert M. McCarron, DO, is the Director of Education, Susan Samueli Integrative Health Institute, and also Assistant Dean, Continuing Medical Education, and Director, UCI Train New Trainers Primary Care Psychiatry Fellowship, at the University of California, Irvine School of Medicine.

Colleen: What has been your biggest challenge and your most rewarding accomplishment in your career?
Dr. McCarron:
My biggest challenge has been to continually reconfigure and focus my time and energy toward those professional roles and goals most important to me. As an internist / psychiatrist with experience in pain medicine, integrative care and underserved care, I have many interests and it has been difficult to not do critical care/hospitalist internal medicine or more psychotherapy, for example. On the flip side, my biggest accomplishment has been to use my broad-based clinical experience to teach students, residents, fellows, and community-based clinicians in a more holistic manner. I feel blessed to be in the position of having a long-term, clinically practical (and hopefully positive) influence on those who practice medicine, particularly those who choose to address disparities in medicine by working with disadvantaged patient populations.  

Colleen: What is some of the latest research that is applicable to the current psychiatrist practice?
Dr. McCarron:
Those who struggle with mental illness, particularly severe illness, are uniquely vulnerable due to the inherent complexity of psychiatric disorders and increased likelihood for premature morbidity and mortality. Many of these patients receive suboptimal mental health, preventive, and primary care. Most of the behavioral health care delivered in the US is done so in the primary care setting, by primary care clinicians. The University of California, Irvine, Train New Trainers Primary Care Psychiatry Fellowship provides targeted “primary care psychiatric” training to frontline PCPs. Preliminary data show this type of training can both optimize and expand psychiatric care, particularly in underserved settings.

Colleen: Your 2018 article on telepsychiatry and other technologies for integrated care in Int Rev Psychiatry was prescient given the pandemic that has necessitated telehealth to some degree for practicing clinicians. How would you characterize the psychiatrist community’s adoption, and how has it played out with regard to outcomes and integrated care with the primary care arm?
Dr. McCarron: I believe asynchronous telepsychiatry (ATP) is an important adjunct to collaborative care. ATP allows the psychiatrists to see the patient and perform a mental status exam as part of a collaborative care assessment. Peter Yellowlees, MD, is at the forefront of this type of evolving practice and has written extensively in the area. It’s important to note that ATP is designed to greatly expand access to care and serve as an important connector with primary care teams.

Colleen: Congratulations on your May 2021 publication in Annals of Internal Medicine (Depression. Ann Intern Med. 2021 May;174(5):ITC65-ITC80). Can you share some of the main pearls this article provides regarding up-to-date guidance on diagnosis and treatment of MDD?
Dr. McCarron: For some, depression can be difficult to treat. It’s important for psychiatrists to use both psychopharmacology and psychotherapy tools when partnering with patients to help manage complex mood disorders. Use of motivational interviewing, particularly assessment of willingness to change maladaptive behavior, is a critical component to the treatment of any medical condition, including depression.

 
Psychiatry Resource Section

JAMA Psychiatry Original Investigation: Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care—A Pragmatic Randomized Comparative Effectiveness Trial
https://jamanetwork.com

MDEdge Clinical Psychiatry News Article: Pandemic unveils growing suicide crisis for communities of color
https://www.mdedge.com

Current Psychiatry Article: Becoming vaccine ambassadors: A new role for psychiatrists
https://www.mdedge.com

APA Learning Center Free Members August Course of the Month: Computational Psychiatry and Future Perspectives—Credits CME:1.5, Participation:1.5
https://education.psychiatry.org/diweb/catalog/item?id=8278225

New England Journal of Medicine Perspective: Depression in Adolescents
https://www.nejm.org/doi/full/10.1056/NEJMra2033475

 

July 2021

Hot Topics in Psychiatry: Dr. Leslie Citrome on New Research in Schizophrenia Treatment, Tardive Dyskinesia, and Eating Disorders

Introduction

We are back again this month with a candid interview with Leslie Citrome, MD, MPH, MBA. Dr. Citrome is a Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla, New York and has a private practice in Pomona, New York. Dr. Citrome is on the Board of Directors of the American Society of Clinical Psychopharmacology and the Mental Health Association of Rockland County. He was the Founding Director of the Clinical Research and Evaluation Facility at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, New York, and has dedicated almost 20 years of government service researching the psychopharmacological treatment of severe mental disorders. His main research has been in psychopharmacologic approaches to schizophrenia and management of treatment-refractory schizophrenia, bipolar disorder, major depressive disorder, and aggressive and violent behavior management. He also currently serves as a consultant in clinical trial design and interpretation.
Dr. Citrome and I covered several current topics, including the most promising new research in psychopharmacology—specifically schizophrenia, recent updates he has published on eating disorders and tardive dyskinesia, and experience with mentorship—both being mentored and providing mentorship. Read on for an inside look at some of these topics to keep current!
Our last issue included insights from Dr. Brian Holoyda, including the new findings in psychedelics, violence, and psychiatric treatment, Oregon’s legalization of medicinal use of psychedelics, and his recently published update on sexsomnia. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDEdge Psychiatry, and JAMA Psychiatry—check them out below. 
Thank you to Dr. Citrome for his participation and perspectives this month. Please contact me at [email protected] with any comments and/or suggestions.

–Colleen Hutchinson

 

Interview

Hot Topics in Psychiatry: Dr. Leslie Citrome on promising research in psychopharmacology, an update on eating disorders, takeaways from his article on tardive dyskinesia, and his recently published update on eating disorders.
Dr. Citrome is Clinical Professor of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York. He is Current Psychiatry’s Section Editor, Psychopharmacology. Dr. Citrome also currently serves as a consultant in clinical trial design and interpretation.

Colleen: What is some of the most promising research in psychopharmacology on the horizon that you feel may make a significant difference for patients?
Dr. Citrome:
There are exciting new advances in the medication treatment of schizophrenia. In late stages of clinical development are novel compounds that work without directly blocking postsynaptic dopamine receptors, and thus these agents avoid the problem of drug-induced movement disorders such as tremor, rigidity and akathisia. Also avoided are elevations in prolactin and alterations in glucose and lipid metabolism. One of the agents is SEP-363856 and is a trace amine-associated receptor 1 (TAAR1) agonist, thought to work by modulating neurotransmission in monoaminergic neurons. SEP-363856 also has serotonin 5HT1D, 5HT1A, and 5HT7 receptor binding properties. In a phase 2, randomized, double-blind, 4-week study comparing effects of SEP-363856 to placebo in patients with schizophrenia, SEP-363856 was superior to placebo in reducing the symptoms of schizophrenia and was not associated with extrapyramidal symptoms, akathisia, or hyperprolactinemia. Adverse events included somnolence and gastrointestinal symptoms. Another agent that offers a different mechanism of action is the combination of xanomeline (a muscarinic M1/M4 agonist) and trospium (a muscarinic receptor antagonist that has minimal, if any, penetration of the blood brain barrier, blocking unwanted peripheral cholinergic side effects of xanomeline). This medication reduced the symptoms of schizophrenia to a greater extent than placebo in a phase 2, randomized, double-blind, 5-week study. The most common adverse events in the xanomeline–trospium group were constipation, nausea, dry mouth, dyspepsia, and vomiting. The incidences of somnolence, weight gain, restlessness, and extrapyramidal symptoms were similar for xanomeline–trospium as for placebo. Of note, both of these studies were published in the New England Journal of Medicine. 

Colleen: Regarding your recently published update on eating disorders, where do we stand in terms of diagnosis and treatment?
Dr. Citrome:
Eating disorders are more common than what most people and clinicians think. Although anorexia nervosa and bulimia nervosa may be more obvious to detect, binge eating disorder (BED) is generally invisible to others. People with BED generally binge eat in secret and are often unaware that their loss of control in how they eat is actually a treatable disorder. BED can occur in both men and women, and in any ethnic/racial group. BED is more common than anorexia nervosa and bulimia nervosa combined. BED is often comorbid with other psychiatric and non-psychiatric disorders, and screening for BED is a worthwhile endeavor for both psychiatric specialty care and primary care. It can be as simple as asking people about their appetite (a standard question when getting a history during any routine evaluation) followed by "Talking about appetite, have you ever eaten more than you intended?” or “Did you feel like it wasn’t possible to stop?’’ Available effective treatments include psychological treatments such as cognitive behavioral therapy and medication treatments such as lisdexamfetamine. 

Colleen: During your career, what has been your experience with mentorship—both being mentored and providing mentorship, and what advice do you have for medical school students seeking to become psychiatrists?
Dr. Citrome: Mentor-mentee relationships often emerge serendipitously, especially during clinical rotations and many medical students can identify influential teachers that they have interacted with and reach back out to them when pondering career choices post-graduation. For medical students contemplating a career in psychiatry, asking faculty for advice is a good start and it is not unusual for enduring collegial friendships to begin this way. Looking back at my own experience, it was contact with an attending psychiatrist during my psychiatry rotation that led me to a summer research project, additional contact with other members of the department, and ultimately to a recommendation to a residency program where one of my mentors had recently been a chief resident. Today I serve as a mentor/advisor/colleague/teacher to psychiatric residents and junior faculty across different institutions, sometimes by chance (networking at professional meetings and finding that we have similar interests) and at other times by design (programs designed to link up mentees with mentors through our local district branch of the American Psychiatric Association and through the American Society of Clinical Psychopharmacology).

 

Psychiatry Resource Section

JAMA Psychiatry Original Investigation Article: Three Important Considerations for Studies Examining Pathophysiological Pathways in Psychiatric Illness; In-depth Phenotyping, Biological Assessment, and Causal Inferences
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2777613

MDEdge Clinical Psychiatry News Article: Are you at legal risk for speaking at conferences?
https://www.mdedge.com

Current Psychiatry Pearls Article: Improving nonverbal communication during telepsychiatry sessions:
https://www.mdedge.com/psychiatry/article/242368/practice-management/improving-nonverbal-communication-during

APA Learning Center Free Members July Course of the Month: Seeing Through the Smoke: Medicolegal Implications of Medical Marijuana—Credits CME:1.75, Participation:1.75
https://education.psychiatry.org

New England Journal of Medicine Perspective: From Crime to Care — On the Front Lines of Decarceration
https://www.nejm.org/doi/full/10.1056/NEJMp2107013

 

June 2021

Hot Topics in Psychiatry: Dr. Brian Holoyda on psychedelics, violence, and psychiatric treatment, Oregon’s legalization of medicinal use of psychedelics, and sexsomnia

Introduction

We are back again this month with a candid interview with Brian Holoyda, MD, MPH, MBA. Dr. Holoyda is a forensic and correctional psychiatrist. In his clinical practice, he treats inmates at a pre-trial detention facility in the Bay Area of California, and he also has a private forensic practice and conducts forensic psychiatric evaluations around the US. He specializes in the assessment of violence and sexual violence risk. His research interests include rare paraphilic disorders, psychedelic drugs, and atypical group beliefs
Dr. Holoyda and I covered several current topics regarding his research and expertise, including the new findings in psychedelics, violence, and psychiatric treatment, Oregon’s legalization of medicinal use of psychedelics, and his recently published update on sexsomnia.
Read on for an inside look at some of these topics to keep current!
Our last issue included insights from Dr. Diana Martinez, including the latest research on efficacy and application of cannabis, new findings in cocaine addiction treatment, advances in the study of transcranial magnetic stimulation for alcohol use disorder and also chronic pain, and the issue of women being underrepresented in academic research in the field of psychiatry. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, and JAMA Psychiatry—check them out below. 
Don’t forget to check out details for Medscape’s upcoming virtual conference, Psychiatry Update 2021: Solving Clinical Challenges, Improving Patient Care, a MedscapeLIVE! event. It’s right around the corner and you don’t want to miss it!
Thank you to Dr. Holoyda for his participation and perspectives this month. Please contact me at [email protected] with any comments and/or suggestions.

Colleen Hutchinson

 

Interview

Hot Topics in Psychiatry: Dr. Brian Holoyda on new research in psychedelics, violence, and psychiatric treatment, Oregon’s legalization of medicinal use of psychedelics, and his recently published update on sexsomnia
Brian Holoyda, MD, MPH, MBA is a forensic and correctional psychiatrist. In his clinical practice, he treats inmates at a pre-trial detention facility in the Bay Area of California. He also has a private forensic practice and conducts forensic psychiatric evaluations around the United States. He specializes in the assessment of violence and sexual violence risk. He has served as a consultant to People for the Ethical Treatment of Animals (PETA) about animal cruelty and interpersonal violence. His research interests include rare paraphilic disorders, psychedelic drugs, and atypical group beliefs.

Colleen: You recently participated in an MDedge Psychcast, titled Psychedelics, violence, and psychiatric treatment: early and emerging research. What are the main take-home points for practicing clinicians?
Dr. Holoyda: Psychedelic drugs like psilocybin are receiving increasing research interest for the treatment of various psychiatric conditions. Psilocybin and related compounds may gain FDA approval as psychotherapeutic agents within the next 10 years. Oregon, however, has already passed legislation legalizing psychedelic-assisted psychotherapy before the compounds have been properly studied and approved, in part to circumvent their use under a medical model. This situation raises important issues regarding both the model of their administration, as well as how psychedelics may be administered in a psychiatric context.
 
Due to their risk for potential adverse effects, including agitation and violence, and liability concerns resulting from negative outcomes of psychedelic use, psychedelic-assisted psychotherapy should occur in a medically monitored setting. Recent research studies assessing psychedelics’ therapeutic potential have largely excluded individuals with a personal or family history of disorders like bipolar disorder and psychotic disorders that may predispose individuals to challenging experiences, otherwise known as “bad trips.” Individuals considering treatment with psychedelics for psychiatric indications therefore require proper screening by qualified medical professionals. In addition, psychiatrists involved in psychedelic-assisted psychotherapy should ensure that patients undergo a thorough informed consent procedure, since patients are likely to lose the capacity to make decisions regarding their care in the context of a high-dose psychedelic journey. For example, a patient may become agitated or aggressive during a psilocybin journey and require either physical restraint or the administration of a sedative, an intervention to which he may be unable to give or withhold consent in the moment. Adequate informed consent, then, will reduce the risk of potential malpractice litigation in such cases.

Colleen: While it can be considered progress that the state of Oregon recently legalized medicinal use of psychedelics, what are your thoughts on the proposed models for administration?
Dr. Holoyda: There are numerous legal considerations regarding psychedelic-assisted psychotherapy occurring in non-medically monitored settings. In Oregon, for example, the group responsible for coordinating regulations around psychedelic-assisted psychotherapy is considering offering an online course as the prerequisite before an individual can administer psychedelics to another person. Reportedly, the proposed level of necessary education would be high school graduation. This care model would be inappropriate for psychedelic-assisted psychotherapy in any context. If an individual is solely required to take an online course before administering psychedelics, then there would be limited or no professional oversight and no standard of care for their provision. Non-professionals administering psychedelics, then, will likely face civil lawsuits of battery and the negligent infliction of emotional distress, if they restrain patients or if their patients have a bad trip with lasting emotional harm, respectively. Furthermore, psychedelics have the potential to completely incapacitate individuals, raising the risk of homicide, physical assault, sexual assault, and theft by an allegedly qualified guide.
Colleen: What are the main pearls from your recently published update on sexsomnia, and where do we stand in terms of evaluation and management?
Dr. Holoyda: Sexsomnia refers to sexual behavior that occurs during sleep. Its use in court as a potential exculpatory condition for individuals charged with sexual offenses has made it a controversial diagnosis. Sexual acts performed during sleep include masturbation, spontaneous orgasm, sexual vocalization, oral sex, anal sex, fondling, attempted intercourse, and completed sexual intercourse. Men are affected more than women. The diagnosis of sexsomnia requires a thorough clinical history, sleep history, and collateral history. Individuals with sexsomnia often have a history of other parasomnic behaviors, such as sleepwalking or sleep talking. Video polysomnography, or the “sleep study,” may assist in diagnosing sexsomnia; however, research studies have not yet recorded sexual behavior in sleep in individuals presenting with a complaint of sexsomnia. The treatment of sexsomnia includes sleep hygiene, stress management, avoidance of alcohol and other drugs, and optimizing the sleep environment to reduce the recurrence of potentially unwanted sexual activity. Some reports indicate that benzodiazepines may be helpful to reduce its recurrence. In forensic contexts, evaluators should conduct a complete psychosexual assessment, potentially including psychophysiologic measures like virtual reaction time (VRT) and penile plethysmography (PPG), to assess for paraphilic disorders that an individual may attempt to obfuscate with a claim of sexsomnia.

References

  1. Holoyda. 2020. The psychedelic renaissance and its forensic implications. Journal of the American Academy of Psychiatry and the Law.
  2. Holoyda. 2020. Psychedelic psychiatry: Preparing for novel treatments involving altered states of consciousness. Psychiatric Services.
  3. Holoyda et al. 2021. The forensic evaluation of sexsomnia. Journal of the American Academy of Psychiatry and the Law. [online ahead of print] 

 
Psychiatry Resource Section

JAMA Psychiatry Original Investigation Article: Functional Connectivity in Antipsychotic-Treated and Antipsychotic-Naive Patients with First-Episode Psychosis and Low Risk of Self-harm or Aggression
A Secondary Analysis of a Randomized Clinical Trial
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2781373

MDEdge Current Psychiatry Article: Pharmacogenetic testing: Navigating through the confusion
https://www.mdedge.com

AGENDA: 2021 Psychiatry Update CME/CE Virtual Event (June 15-19): Solving Clinical Challenges -- Improving Patient Care:
https://na.eventscloud.com/website/21668/agenda/

Current Psychiatry Article: 4 tips for working with caregivers of children with somatic disorders
https://www.mdedge.com

APA Learning Center Free Members May Course of the Month: Correctional Psychiatry: Improving Access, Safety, and Efficacy—Credits CME: 1.0, Participation:1.0
https://www.psychiatry.org

Clinical Psychiatry News Article: Depression remains common among dystonia patients
https://www.mdedge.com/

 

MAY 2021

Hot Topics in Psychiatry: Dr. Diana Martinez on Her Latest Research 

Introduction

We are back again this month with a candid interview with Dr. Diana M. Martinez, Professor of Psychiatry at the Columbia University Medical Center, and Director of the Martinez Lab at New York State Psychiatric Institute, where she directs research on novel uses for existing therapies. 
Dr. Martinez specializes in addiction research and basic brain mechanisms of addiction studied with brain imaging methods, including PET scanning and MRI. She also conducts studies using established treatments for new indications. Some of her current research includes investigating ketamine for tinnitus, a clinical trial of cannabinoids for neuropathy, and transcranial magnetic stimulation for alcohol use disorder and chronic pain.
Dr. Martinez and I covered several current topics regarding her research, including the latest research on efficacy and application of cannabis, new findings in cocaine addiction treatment, advances in the study of transcranial magnetic stimulation for alcohol use disorder and also chronic pain, and the issue women being underrepresented in academic research in the field of psychiatry.
Read on for an inside look at some of her recent research and perspective to keep current on treatment strategies!
Last issue included insights from Dr. Jon E. Grant, including recent advances in neuropsychopharmacology, trichotillomania and excoriation disorders, and his publications on impulsive and compulsive behaviors, including measurement via self-report tools, firearm ownership, and brain micro-architecture and disinhibition. If you missed it, you can find that interview here.
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, and JAMA Psychiatry—check them out below. 
Don’t forget to check out details for Medscape’s upcoming virtual conference, Psychiatry Update 2021: Solving Clinical Challenges, Improving Patient Care, a MedscapeLIVE! event. It’s right around the corner and you don’t want to miss it!
Thank you to Dr. Martinez for her participation this month. Please contact me at [email protected] with any comments and/or suggestions.

–Colleen Hutchinson

 
Interview

Hot Topics in Psychiatry: Dr. Diana Martinez on Her Latest Research
Dr. Diana M. Martinez, Professor of Psychiatry at the Columbia University Medical Center, and Director of the Martinez Lab at New York State Psychiatric Institute, New York, New York.

Colleen: What is some of the latest research on efficacy and application of cannabis that is applicable to the current psychiatrist’s practice?
Dr. Martinez:
There’s a lack of research when it comes to medical uses for cannabis, due to its status as a schedule I drug (cannabis researchers must abide by federal regulations, even if they work in a state with legalized cannabis). Nonetheless, there is data supporting medical uses for delta-9 THC, whether it’s from the plant or the FDA-approved drug dronabinol. The strongest support for delta-9 THC is for the following conditions: chronic pain, spasticity due to MS (multiple sclerosis), chemotherapy-induced nausea/vomiting, and weight gain in HIV.

When it comes to psychiatric disorders, we have some early evidence suggesting that delta-9 THC can help with sleep disorders, Tourette’s syndrome, PTSD, and OCD. Studies in medically ill patients (chronic pain and MS) indicate that THC helps to reduce anxiety, although there is a lack of large studies in patients with a primary diagnosis of an anxiety disorder. Notably, studies in medically ill patients show no difference between THC and placebo when it comes to symptoms of depression. 

On the other hand, there is data showing that cannabis use in psychiatric patients can worsen the course of illness, especially bipolar disorder and the early phase of psychosis. Furthermore, cannabis use can lead to a substance use disorder, and patients with an underlying psychiatric disorder are at a greater risk compared to the general population. This raises the question: at what point should the clinician worry about their patients’ cannabis use? In my mind, this is similar to alcohol: cannabis use that meets criteria for a substance use disorder or cannabis use in a refractory patient. It’s key to review the 11 criteria for substance use disorder, which are available online, and to intervene when criteria are met for even a mild disorder. In a patient who is refractory to treatment, it’s worth looking into their cannabis use to see if this is a factor. However, it’s key to know why the patient is using cannabis, since this is unlikely to change if their reason for using is not addressed by other means. Common reasons for patients’ cannabis use include: to ameliorate pain and anxiety, to improve sleep, and to increase social interaction. These factors would need to be addressed by other treatments or interventions in order to reduce or stop cannabis use. 
 
Lastly, there is data showing that heavy, regular cannabis use is associated with an increased risk of suicidal thoughts and attempts. However, it’s key to recognize that this risk is not specific to cannabis: drug use, especially alcohol and opioids, is associated with an increased risk of suicide. Nonetheless, this information indicates that suicide prevention must include addressing drug use with an open and frank conversation with our patients.

Colleen: You are involved in research in cocaine addiction. What is new in this area of study that you feel is going to be most rewarding to the practicing psychiatrist?
Dr. Martinez:
Finding pharmacologic treatments for cocaine addiction has been tough. Many clinical trials have been performed, but we still lack a formally FDA-approved medication for this disorder. Nonetheless, there are promising data. A recent meta-analysis showed that prescription psychostimulants can help patients with a cocaine use disorder achieve sustained abstinence. The most consistent positive results were seen with long-acting dextroamphetamine and long-acting mixed amphetamine salts. There is also data indicating that combining prescription psychostimulants with topiramate, a GABA agonist/glutamate antagonist, is effective in promoting sustained abstinence. 

Additional studies have also shown positive results with ketamine and transcranial magnetic stimulation (TMS). Ketamine was shown to reduce craving and improve abstinence from cocaine in a study that administered a single intravenous infusion combined with mindfulness-based behavioral modification. Early studies indicate that transcranial magnetic stimulation (TMS) might help with cocaine use disorder. These studies have included imaging studies, small trials, and observational studies, but the results are promising. Additional clinical trials are now being done to look into this question.

Lastly, a number of studies support the use of behavioral therapies, including cognitive behavioral therapy (CBT), community reinforcement approach (CRA), and contingency management (CM). While CBT emphasizes the use of cognitive control to counteract the impulse to use drugs, CRA focuses on replacing the positives of drug use with positives from the person’s environment, like family, friends, work or school. CM uses rewards to deter drug use, like vouchers or gift cards that are used for non-drug social activities. Research studies show that CM is effective for treating addiction especially when combined with CRA.

References

  1. Tardelli VS, Bisaga A, Arcadepani FB, Gerra G, Levin FR, Fidalgo; Prescription psychostimulants for the treatment of stimulant use disorder: a systematic review and meta-analysis..Psychopharmacology (Berl). 2020 Aug;237(8):2233-2255. doi: 10.1007/s00213-020-05563-3. 
  2. Dakwar E, Nunes EV, Hart CL, Foltin RW, Mathew SJ, Carpenter KM, Choi CJJ, Basaraba CN, Pavlicova M, Levin FR. A Single Ketamine Infusion Combined With Mindfulness-Based Behavioral Modification to Treat Cocaine Dependence: A Randomized Clinical Trial. Am J Psychiatry. 2019 Nov 1;176(11):923-930.
  3. Hanlon CA, Kearney-Ramos T, Dowdle LT, Hamilton S, DeVries W, Mithoefer O, Austelle C, Lench DH, Correia B, Canterberry M, Smith JP, Brady KT, George MS. Developing Repetitive Transcranial Magnetic Stimulation (rTMS) as a Treatment Tool for Cocaine Use Disorder: a Series of Six Translational Studies. Curr Behav Neurosci Rep. 2017 Dec;4(4):341-352. doi: 10.1007/s40473-017-0135-4. Epub 2017 Oct 23.

Colleen: You’ve become a known researcher in the area of transcranial magnetic stimulation for alcohol use disorder and also chronic pain. What have you discovered that is most promising?
Dr. Martinez:
Transcranial magnetic stimulation (TMS) has been used to treat depression for some time. More recently, TMS has been FDA-cleared for obsessive compulsive disorder (OCD) and tobacco use disorder. Thus, it’s an exciting time for TMS research, because there’s a lot of interesting work to be done. In my lab, we are looking into TMS for alcohol use disorder and chronic pain. We are targeting the medial prefrontal cortex and anterior cingulate because imaging studies show that these brain regions are implicated in these disorders. Our study in alcohol addiction is well under way, although we don’t have results yet because it is a sham-controlled and double-blind study. We have begun a study in chronic pain, although we are doing only pilot work right now because we need to find funding to move this along.

Colleen: While potentially more pronounced in other disciplines of medicine, it is fair to say women are underrepresented in academic research in the field of psychiatry. Why do you think this is, and do you see improvement on the horizon?
Dr. Martinez: Overall, women are underrepresented in academic medicine. According to a recent AAMC report, women make up half of medical school students but represent just 25% of full professors at academic centers and only 18% of department chairs. While psychiatry usually has more even distribution of men and women in residency, there’s still a disparity when it comes to careers in academic research. There are a number of reasons behind this, including work-life issues, salary differences, and the need for improved mentorship.

At my institution, we are working to address this issue. We have a fellowship program, funded by the National Institute on Drug Abuse and our department of psychiatry, that provides both research and clinical training in addiction psychiatry. However, we realized that we can’t expect to enroll more women in our fellowship if we wait until they’ve almost completed residency. Thus, we are developing a program where we connect with medical students in order to foster mentorship at this early stage. This will include introducing students to research design and helping them get published early in their careers. Our goal is to improve the recruitment and retention of women in academic research by improving early mentorship.

We are using this same approach to recruit fellows from under-represented minority (URM) groups. We are working with a program that’s funded by the National Institute on Drug Abuse to encourage URM students to think about pursuing a career in academic addiction research. Through this program, we pair students attending the City College of New York with researchers to develop early and productive mentoring relationships. Our goal is to expand this plan to additional medical schools, in order to reduce the disparity that exists in academic research.

 

Psychiatry Resource Section

JAMA Psychiatry Original Investigation Article: Continuation of Antidepressants vs Sequential Psychological Interventions to Prevent Relapse in Depression—An Individual Participant Data Meta-analysis
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2780290

MDEdge Current Psychiatry Article: Cannabinoid-based medications for pain
https://www.mdedge.com/psychiatry/article/239193/pain/cannabinoid-based-medications-pain

AGENDA: 2021 Psychiatry Update CME/CE Virtual Event (June 15-19): Solving Clinical Challenges -- Improving Patient Care:
https://na.eventscloud.com/website/21668/agenda/

Current Psychiatry Article: A clinical approach to pharmacotherapy for personality disorders
https://www.mdedge.com

JAMA Psychiatry Original Investigation Article: Suicide Risk in Medicare Patients with Schizophrenia Across the Life Span
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2780429

APA Learning Center Free Members May Course of the Month: "Doctor, Are You Sure I Am Bipolar?" Challenges in the Differential Diagnosis of Bipolar Disorder
https://www.psychiatry.org

Clinical Psychiatry News Article: The end of happy hour? No safe level of alcohol for the brain
https://www.mdedge.com

 

April 2021

Hot Topics in Psychiatry: Dr. Jon Grant Weighs in on New Advances in Neuropsychopharmacology and Other New Research in Addictive, Compulsive, and Impulsive Disorders

Introduction

We are back again this month with a candid interview with Dr. Jon E. Grant. Dr. Grant is a Professor of Psychiatry & Behavioral Neuroscience at the University of Chicago, where he directs a clinic and research lab on addictive, compulsive, and impulsive disorders. Dr. Grant’s research has focused on various aspects of obsessive-compulsive disorder (OCD) and related disorders, such as neurocognition, neuroimaging, and pharmacological treatment of these problems. Dr. Grant and I covered several current topics, including the most recent meaningful advances in neuropsychopharmacology, the evolution of understanding of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorders and advances in treatment options, and his publications on impulsive and compulsive behaviors, including measurement via self-report tools, firearm ownership, and brain micro-architecture and disinhibition.

Last issue we gave you key insights from George Grossberg, MD, on several current topics, including the link between antidepressants and Alzheimer’s, the utility and safety profile of cholinesterase inhibitors for treatment of Alzheimer’s and the role of rivastigmine, dietary restrictions to prevent or delay Alzheimer’s, the issue of polypharmacy and deprescribing, and defining psychosis in major and mild neurocognitive disorders. If you missed it, you can find that interview here.

Make sure to check out the Suggested Reading from Dr. Grant on identifying subtypes of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder. 

This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, and JAMA Psychiatry, as well as April’s free learning course from the APA. 

Don’t forget to check out details for the Medscape’s upcoming virtual conference, Psychiatry Update 2021: Solving Clinical Challenges, Improving Patient Care, a MedscapeLIVE! event. 

Thank you to Dr. Grossberg for his critical contribution and candor. Please contact me at [email protected] with any comments and/or suggestions. 

–Colleen Hutchinson

 

Interview

Hot Topics in Psychiatry: A Candid Chat with Jon E. Grant, MD
Dr. Grant is a Professor of Psychiatry & Behavioral Neuroscience at the University of Chicago where he directs a clinic and research lab on addictive, compulsive and impulsive disorders.  Dr. Grant’s research has been funded by the NIMH, NIDA, the Wellcome Trust, and private foundations. His research has focused on various aspects of OCD and Related Disorders, such as neurocognition, neuroimaging, and pharmacological treatment of these problems. Dr. Grant is the author of over 400 peer-reviewed scientific articles, 15 books, and is on the editorial board of 10 journals.

Colleen: What are the most recent advances in neuropsychopharmacology that you believe will be most meaningful to your patient population?
Dr. Grant:
In the case of OCD and related disorders, such as trichotillomania and skin picking, the field of neuropsychopharmacology moves extremely slowly. We still have nothing FDA approved for trichotillomania and skin picking, and have really had nothing new for OCD for decades. Having said that, there is some potential promise in glutamate modulators for OCD, and we are almost finished with a new study of a cannabinoid agonist in trichotillomania and skin picking. So there might be potentially promising new options, but we need more.

Colleen: Trichotillomania (hair pulling disorder) and excoriation (skin picking) disorders have been the subject of research and publication for two decades. How would you characterize the evolution of understanding of these disorders and advances in treatment options?
Dr. Grant: Our understanding of these two disorders continues to advance, albeit slower than many other mental health disorders, due to the passionate research of a small number of folks around the world. Although we have developed fairly detailed knowledge about trichotillomania and skin picking disorder, our treatments options have lagged behind largely due to lack of funding for well-powered treatment studies. This is a shame, in my opinion, because understanding how to treat trichotillomania and skin picking disorder could provide a window into managing not only these two disorders but habit/compulsivity more broadly.

Colleen: You have recently published on several aspects of impulsive and compulsive behaviors, including measurement via self-report tools, firearm ownership, and brain micro-architecture and disinhibition. Among these, what have you found most surprising in findings of this body of research?
Dr. Grant: When we set out to examine self-report tools on impulsivity and compulsivity, I was struck by how little there is available to assess compulsive behaviors and how virtually none of the instruments are trans-diagnostic. If we really want to determine pathophysiology of psychiatric disorders, I think we need to be continuously aware of the potential overlap of these illnesses and how we measure that overlap.

 

Suggested Reading

Article: Identifying subtypes of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder using mixture modeling in a multicenter sample. Grant JE, Peris TS, Ricketts EJ, Lochner C, Stein DJ, Stochl J, Chamberlain SR, Scharf JM, Dougherty DD, Woods DW, Piacentini J, Keuthen NJ. J Psychiatr Res. 2020:S0022-3956(20)31057-8. PMID: 33172654.
https://pubmed.ncbi.nlm.nih.gov/33172654/
Dr. Grant: This article is important for two reasons, I believe. First, on a scientific level, it is the first article to demonstrate that trichotillomania and skin picking disorder have subtypes that may necessitate different treatment approaches. And second, on a social/public health level, the article reflects the end result of years of fundraising by a non-profit organization for a multi-center research project. Because research funds in this area have largely not been available from the NIH, the TLC Foundation for Body-Focused Repetitive Behaviors undertook fundraising at the grass roots level and raised almost 3 million dollars for a research project that took place at the University of Chicago, UCLA, MGH/Harvard, and the University of Stellenbosch South Africa. The money was raised from people with these disorders or their loved ones. That is a success story in research, independent of the actual scientific findings.

 

Psychiatry Resource Section

MDedge Current Psychiatry Article: Switching antipsychotics: A guide to dose equivalents
https://www.mdedge.com/

AGENDA: 2021 Psychiatry Update CME/CE Virtual Event (June 15-19): Solving Clinical Challenges -- Improving Patient Care:
https://na.eventscloud.com/website/21668/agenda/

Current Psychiatry Article: Steroid-induced psychiatric symptoms: What you need to know
https://www.mdedge.com

JAMA Psychiatry Original Investigation Article: Association of Age, Antipsychotic Medication, and Symptom Severity in Schizophrenia with Proton Magnetic Resonance Spectroscopy Brain Glutamate Level—A Mega-analysis of Individual Participant-Level Data
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2778479

APA Learning Center Free Members April Course of the Month: Pharmacological Approaches to Treatment-Resistant Depression
https://www.psychiatry.org

Clinical Psychiatry News Article: Psilocybin matches SSRI for moderate to severe depression in phase 2 study
https://www.mdedge.com

Current Psychiatry Article: A clinical approach to pharmacotherapy for personality disorders
https://www.mdedge.com

 

 

March 2021

Hot Topics in Psychiatry: Dr. George T. Grossberg Weighs in on Alzheimer’s, Polypharmacy, and Defining Psychosis in Major and Mild Neurocognitive Disorders

Introduction

We are back again this month with a candid interview with Dr. George T. Grossberg, Director of the Division of Geriatric Psychiatry at St. Louis University School of Medicine. Dr. Grossberg and I covered several current topics, including between antidepressants and Alzheimer’s, the utility and safety profile of cholinesterase inhibitors for treatment of Alzheimer’s and the role of rivastigmine, dietary restrictions to prevent or delay Alzheimer’s, the issue of polypharmacy and deprescribing, and defining psychosis in major and mild neurocognitive disorders.
Last issue we gave you key insights from Craig Chepke, MD, FAPA, on 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. If you missed it, you can find that interview here.
Make sure to check out the Suggested Readings from Dr. Grossberg in the areas of polypharmacy, antidepressant use and Alzheimer’s, cholinergic drugs as a standard pharmacological approach in Alzheimer's, and diet interventions to prevent Alzheimer’s in this issue. 
This month’s Psych Resource section will keep you updated with articles from Clinical Psychiatry News, Current Psychiatry, MDedge Psychiatry, and JAMA Psychiatry, as well as a free learning course from the APA. 
Don’t forget to check out details for the Medscape’s upcoming virtual conference, Psychiatry Update 2021: Solving Clinical Challenges, Improving Patient Care, a MedscapeLIVE! event. 
Thank you to Dr. Grossberg for his critical contribution and candor. Please contact me at [email protected] with any comments and/or suggestions.

–Colleen Hutchinson

 

Interview

Hot Topics in Psychiatry: A Candid Chat with George Grossberg, MD, FAPA
George T. Grossberg, MD, is the Samuel W Fordyce Professor and Director of the Division of Geriatric Psychiatry at St Louis University School of Medicine. He has edited and authored 15 textbooks and contributed more than 500 scholarly papers, abstracts, and chapters to the geriatric medical literature.

Colleen: What is the state of polypharmacy in the geriatric population? Is enough deprescribing going on?
Dr. Grossberg:
Polypharmacy, or taking multiple prescribed and or over-the-counter (OTC) medications, is a particular problem among those over the age of 65 (older adults).
Older adults often take 4 to 6 different prescription and OTC medications daily. In the long-term-care (LTC) environment, they may take 8 to 10 or more medications daily.
The risk of side effects or drug-drug interactions is nearly 100% in patients taking 6 or more medications daily. Health care providers need to emphasize the importance of deprescribing. Communicate the notion that “less is more.” Communicate that taking less medication often improves quality of life and functional abilities of older adults by diminishing the risk of often disabling side effects and of adverse drug-drug interactions.

Colleen: What is the utility and safety profile of cholinesterase inhibitors for treatment of Alzheimer’s? What about for use in non-Alzheimer’s dementia patients? What about the role of rivastigmine?
Dr. Grossberg:
Cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine are still the mainstays of FDA-approved symptomatic therapies for Alzheimer’s disease (AD). When started early in the course of AD and continued over time, they can improve functions in some AD patients for short periods of time and possible slow their rate of decline.
Cholinesterase inhibitors are mostly associated with gastrointestinal (GI) side effects such as nausea, dyspepsia, and diarrhea. The rivastigmine skin patch was developed to minimize GI side effects versus the oral preparation. This agent is also FDA-approved for dementia in Parkinson’s disease. The cholinesterase inhibitors are not approved for other common dementias, such as vascular dementia, Lewy body dementia, or frontotemporal dementia.

Colleen: Where do we stand with regard to current research on dietary restrictions to prevent or delay Alzheimer’s?
Dr. Grossberg:
Lifestyle modification, including exercise, control of hypertension, diabetes, and other cardiovascular risk factors, avoiding smoking, quality sleep, avoiding excessive stress, keeping mentally active (challenging the brain), social and spiritual activity, as well as proper dietary habits may delay the onset of AD in at-risk individuals and slow progression in those diagnosed with AD. Relative to dietary recommendations, the strongest evidence to date is for the Mediterranean diet. This is not a restrictive diet, but one which emphasizes fresh fruits and vegetables, whole grains, fish, extra virgin olive oil as the shortening of choice, some poultry, less red meat, minimally processed foods, and mild alcohol intake.
Obviously, fast foods are not part of the Mediterranean diet.

Colleen: The literature is conflicting. What is the relationship, as you see it, between antidepressants and Alzheimer’s?
Dr. Grossberg:
Yes—the literature is complex. There is evidence that some antidepressants, particularly the older tricyclics that are anticholinergic, may increase the risk of AD. However, there is also growing evidence that depression may be a risk factor for AD and treating depression, in particular with the newer SSRI’s, may be protective. These antidepressants may not only have mood-elevating effects but may also have anti-inflammatory effects in the brain and may decrease amyloid plaque formation. Both are associated with AD and neuronal death.
What is non-controversial is the notion that depression is quite common in AD patients and is a source of excess disability. Consequently, it is important to diagnose and treat depression in AD patients. Prompt recognition and effective treatment improve quality of life in AD patients and may slow disease progression.

Colleen: What was the most critical thing that came out of the 2020 IPA Consensus?
Dr. Grossberg:
Last year, the International Psychogeriatric Association (IPA) published criteria for psychosis in dementia. This recent update of the Jeste and Finkel criteria for psychosis in AD (year 2000) broadens the criteria to apply to all major and minor neurocognitive disorders. Examples are provided of psychosis in these disorders as well as differential diagnoses to consider, a timeline of symptom emergence, and exclusionary criteria.
The IPA revised criteria to also serve as a template for further research in the field.

 
Suggested Readings

Article: The cholinergic system in the pathophysiology and treatment of Alzheimer’s disease. Hampel H, Mesulam MM, Cuello AC, et al. Brain 2018;141(7):1917-1933.
https://pubmed.ncbi.nlm.nih.gov/29850777/
Dr. Grossberg: This is a thorough review by international experts on the topic.

Text: Psychiatric consultation in long-term care. Desai A, Grossberg GT. Cambridge University Press, 2017.
Dr. Grossberg: This text contains extensive materials on polypharmacy and deprescribing. 

Article: Dietary interventions to prevent or delay AD: What the evidence shows. Bartochowski Z, Conway J, Wallach Y, et al. Curr Nutr Rep. 2020 Sep;9(3):210-225.
https://pubmed.ncbi.nlm.nih.gov/32681411/
Dr. Grossberg: Recent review of interventions, including the Mediterranean diet.

Article: Impact of Antidepressant Use on the Trajectory of AD: Evidence, Mechanisms, and Therapeutic Implications. Khoury R, et al. CNS Drugs 2019; Jan;33(1):17-29
https://pubmed.ncbi.nlm.nih.gov/30456746/
Dr. Grossberg: This is an up-to-date relevant review.

 

Psychiatry Resource Section

MDedge Psychiatry Article: JAMA editor resigns over controversial podcast
https://www.mdedge.com

AGENDA: 2021 Psychiatry Update CME/CE Virtual Event (June 15-19): Solving Clinical Challenges -- Improving Patient Care:
https://na.eventscloud.com/website/21668/agenda/

Current Psychiatry Article: The lasting effects of childhood trauma
https://www.mdedge.com

JAMA Psychiatry Article: Association of Antihypertensive Drug Target Genes With Psychiatric Disorders
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2777005

APA Learning Center Free Members Course of the Month: Buprenorphine Update and Evolving Standards of Care
https://www.psychiatry.org

Current Psychiatry Article: The ABCs of successful vaccinations: A role for psychiatry
https://www.mdedge.com

 

 

February 2021

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.

–Colleen Hutchinson

 

Interview

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.

 

Suggested Readings

Personalized Medicine

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.
https://pubmed.ncbi.nlm.nih.gov/32857933/
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.

Bioethics

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).
https://pubmed.ncbi.nlm.nih.gov/33234427/
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.
https://pubmed.ncbi.nlm.nih.gov/31965072/
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
https://www.mdedge.com/psychiatry/article/234890/obstetrics/reproductive-psychiatry-2021-old-questions-and-new-challenges

NEJM Audio Interview: An International Look at Covid-19:
https://www.nejm.org/contact-nejm?query=footer

Annals of Clinical Psychiatry Article: Obsessive Compulsive Personality Disorder and Obsessive-Compulsive Disorder: Clinical Characteristics, Diagnostic Difficulties, and Treatment
https://www.tandfonline.com/doi/abs/10.3109/10401230500295305

Current Psychiatry Article: COVID-19 drives physician burnout for some specialties
https://www.mdedge.com/psychiatry/article/234969/coronavirus-updates/covid-19-drives-physician-burnout-some-specialties

JAMA Psychiatry Article: Suicide Prevention in the COVID-19 Era—Transforming Threat Into Opportunity
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2772135

APA Child & Adolescent Telepsychiatry Toolkit:
https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/child-adolescent

 

 

January 2021

Inaugural Issue

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.

Colleen Hutchinson

 

Interview

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. 

 
Suggested Readings

Pediatric Psychiatry

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.
https://pubmed.ncbi.nlm.nih.gov/32504808
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.

Self-care

Article: Well-being, burnout, and depression among North American psychiatrists. Summers RF, et al. Am J Psychiatry 2020; 177: 955-964.
https://pubmed.ncbi.nlm.nih.gov/32660300/
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
https://www.mdedge.com/psychiatry/article/233919/depression/rebirth-psyc...

Annals of Clinical Psychiatry Article: Validity of Pilot Adult ADHD Self- Report Scale (ASRS) to Rate Adult ADHD Symptoms
https://www.tandfonline.com/doi/abs/10.3109/10401230600801077

Clinical Psychiatry News Article: APA apologizes for past support of racism in psychiatry
https://jamanetwork.com/journals/jamadermatology/fullarticle/2768252

Managing Depression in Primary Care: A Collaborative Care Approach (CME/CE Certified Supplement)
https://globalacademycme.realcme.com/learner/course/2586

NEJM Perspective: Testing in a Pandemic — Improving Access, Coordination, and Prioritization:
https://www.nejm.org/doi/full/10.1056/NEJMp2025173?query=featured_home