MDedge Psychcast

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

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

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

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

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

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

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

Guest host Vicki L. Ellingrod, PharmD, talks with Kristen M. Ward, PharmD, and Amy Pasternak, PharmD, about integrating pharmacogenomic testing into psychiatric practice. Dr. Ellingrod is senior associate dean at the University of Michigan College of Pharmacy, Ann Arbor, and professor of psychiatry in the medical school. She is also section editor of the savvy psychopharmacology department in Current Psychiatry. Dr. Ellingrod has no relevant financial relationships to disclose. Dr. Ward and Dr. Pasternak are clinical assistant professors of pharmacy at the University of Michigan.  Dr. Ward and Dr. Pasternak report no relevant disclosures. Dr. Ward and Dr. Pasternak are team leads in the University of Michigan’s Precision Health Implementation Workgroup. Take-home points Pharmacogenomics is defined as the study of the relationship between genetic variations and how our body responds to medications. Two common reasons for ordering pharmacogenomic testing are that a patient or clinician wants testing completed before starting the trial of a psychotropic medication and that there are concerns about nonresponse or loss of response to medications. Common insurance criteria used to justify such testing include at least one failed medical trial; future use of a medication likely to be affected by genetic variants, such as metabolism through CYP2D6 or CYP2C19; or identification of human leukocyte antigen (HLA) variants before starting carbamazepine or oxcarbazepine. Quality improvement and usability campaigns around pharmacogenomic testing include ensuring that testing results are readily available in the medical record. Results should be searchable. Alerts can be created for prescribers when they order a medication for which a patient has a relevant genetic variant. After ordering testing, clinicians should document the patient’s medication response genotype and phenotype in the medical record so the information can be used for medications other than psychotropics. Summary Pharmacogenomic testing may be ordered for several reasons, including cases in which a patient or clinician wants information before switching to another medication or there are questions about failed medication trials. For approximately 50% of individuals who undergo pharmacogenomic testing, there may not be a change in treatment plans, or the results might not be conclusive enough to affect treatment. However, pharmacogenomic testing is useful in reassuring and improving adherence in patients who experience somatic adverse effects to psychotropic medications and want to know whether those effects are related to their metabolism. Getting insurance companies to cover pharmacogenetic testing can be tricky, and clinicians should be familiar with the criteria requested by insurers before ordering the tests. Many of the genetic-testing companies include a patient-assistance program to cover payment when insurance companies do not. In the medical record, it’s important to document the patient's genotype and phenotype. The patient’s genotype affects their metabolism of medications beyond psychotropics. Pharmacogenomic testing results can prevent serious adverse drug reactions. If testing comments on a patient’s carrier status for specific HLA subtypes implicated in drug metabolism, carbamazepine or other related medications should be added to the patient’s drug allergy list. States requirements about informed consent for genetic testing vary, so any clinicians who order such tests should be informed about their local laws. References Ellingrod VL. Current Psychiatry. 2019 Apr;18(4):29-33. Deardorff OG et al. Current Psychiatry. 2018 Jul;17(7):41-5. Ellingrod VL and Ward KM. Current Psychiatry. 2018 Jan;17(1):43-6. Bishop JR. Current Psychiatry. 2010 Sep;9(9):32-5. Maruf AA et al. Can J Psychiatry. 2020 Aug;65(8):521-30. National Institutes of Health. National Human Genome Research Institute. Genome Statute and Legislative Database. Clinical Pharmacogenetics Implementation Consortium. CPIC guidelines.. Pharmacogenetics Knowledge Base. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Lorenzo Norris, MD, speaks with Tonya Cross Hansel, PhD, about processing incidents such as the Jan. 6, 2021, siege on the Capitol, and determining how to foster recovery. Dr. Hansel is an associate professor with the Tulane University School of Social Work in New Orleans. She has no conflicts of interest. Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Hansel’s research focuses on measuring traumatic experiences and implementing systematic recovery initiatives that address negative symptoms by emphasizing individual and community strengths. The tendency to come together in times of vulnerability is a human instinct. The Jan. 6 Capitol siege was a traumatic and polarizing event; in a Pew survey 1 week later, 37% of respondents expressed a strong negative emotion in response to the riot. The unpreparedness of the U.S. Capitol Police and other law enforcement agencies led to fear and shock as much of the nation watched the breach unfold in real time on television. A variety of groups attended the protest. Some groups were involved in domestic terrorism, and others were part of political groups who came protest their grievances against the government. Those who attended the event with the intent of engaging in violence and instilling fear are considered domestic terrorists. Dr. Hansel said an event such as the insurrection wears on society by causing chronic stress, and one-time events such as the insurrection can lead to a prolonged state of anxiety. Terrorism and violence are sometimes triggered by disenfranchisement when violence seems like the only way to make one’s voice heard. Disasters with an economic fallout, such as natural disasters or the ongoing COVID-19 pandemic, can result in greater disenfranchisement. Prevention of future attacks and domestic terrorism must balance people’s ability to speak out and protest with an effort to avoid disenfranchisement. The way forward must also include addressing chronic fear. Dr. Hansel suggests that building community over shared values is a powerful way to foster resilience after disaster. In the pandemic, we have all experienced sacrifice and hardship. When society moves beyond survival mode, efforts must be made to connect over our shared sense of loss. References Hartig H. In their own words: How Americans reacted to the rioting at the U.S. Capitol. Pew Research Center. 2021 Jan 15. Pape RA and Ruby K. The Capitol rioters aren’t like other extremists. The Atlantic. 2021 Feb 2. Ellis BH et al. Studies in Conflict & Terrorism. 2019 May 31. doi: 10.1080/1057610X.2019.1616929. Hansel T et al. Traumatology. 2020;26(3):278-84. Saltzman LY et al. Curr Psychiatry Rep. 2017 Jun 19. doi: 10.1007/s/1920-017-0786-6. Hall BJ et al. PLoS One. 2015 Apr 24. doi 10.1371/journal.pone.0124782. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

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

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

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

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

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

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

We are still experiencing the direct hit in addition to the aftermath of the SARS-2 Corona Virus, especially it's devastating psychiatric impact.  It's always darkest before dawn, isn't it?  Let's lighten the path, shall we in episode 12 of Clinical Correlation.

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

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

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

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

Ruth S. Shim, MD, MPH, joins Carol A. Bernstein, MD, to discuss how to understand systemic racism within psychiatric institutions and the implications for patient care. Dr. Shim is the Luke & Grace Kim Professor in Cultural Psychiatry in the department of psychiatry and behavioral sciences at the University of California, Davis. She has no disclosures. Dr. Bernstein, a past president of the American Psychiatric Association, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures. Take-home points Dr. Shim discusses her editorial published by statnews about why she left the APA, and describes her frustration about what she sees as the APA’s failure to prioritize mental health inequity and structural racism within the organization. Dr. Shim describes systemic racism and oppression as generational traumas that must be recognized and processed if our professional organizations and country are to move forward with equity. Psychiatry plays a role in healing societal trauma, so psychiatrists need to understand and address the damage of structural racism in our own system. Summary After psychiatry training, Dr. Shim became faculty at Morehouse School of Medicine, one of the few historically Black medical schools. During her clinical work in Atlanta, Dr. Shim noted the difference in health outcomes of inpatients at Emory University Hospital, which treated majority White patients, compared with those of Grady Memorial Hospital, which treated majority Black patients. This observation propelled her research into health disparities, which continues to inform her academic work. Dr. Shim’s decision to leave the APA occurred during the presidential term of Altha J. Stewart, MD, who, even as the first African American president of the organization, was thwarted in her attempt to push the APA to focus attention and resources on addressing mental health disparities, inequity, and systemic racism within the organization and psychiatry, according to Dr. Shim. Dr. Shim observes that systemic racism occurs when the structures of an organization, not individuals, perpetuate the inequity. An example within the APA is the disconnect and power disparity between the group’s executive leadership structure and its elected officials. This disconnect and power disparity stymie progressive voices and interventions, Dr. Shim said. Addressing systemic racism within an organization is challenging because it may not be considered a problem by all members, and usually the leadership of an organization caters to its majority. As an example, Dr. Shim discussed the APA’s systematic attempt to reduce resources and cancel the Mental Health Services Conference (formerly Institute for Psychiatric Services, or IPS meeting), which focuses on health care delivery to the most vulnerable populations. As observed by Dr. Bernstein, the IPS meeting might have incurred financial losses, but investment in such a meeting demonstrated the APA’s concern for mental health equity. (The Mental Health Services Conference was not held in 2020 but is scheduled to be held virtually Oct. 7-8, 2021). References Shim RS and Vinson SY, eds. Social (In)Justice and Mental Health. Washington, D.C.: American Psychiatric Association Publishing, 2021. Shim RS. Structural racism is why I’m leaving organized psychiatry. Statnews.com. 2020 Jul 1. Marmot M et al.  Lancet. 2008 Nov 8;372(9650):1661-9. Okun T. White supremacy culture. Dismantlingracism.org. APA apologizes for its support of racism in psychiatry. psychiatry.org. 2021 Jan 18. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

The Beatles aren't the first group to write about sleep and surely won't be the last. In these next two programs, Dr. Kohanski shares some of her pearls, pharmacologic and nonpharmacologic, on those gymnastic, jumping sheep. Clinical Correlation is a bimonthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

In this episode, Dr. Rakesh Jain and Dr. Andrew Cutler review the pathophysiology and comorbidities in patients with schizophrenia and explore how serious mental illnesses (SMIs) may affect the whole patient. They also discuss the potential dysfunction that may be present across multiple symptoms in patients with schizophrenia based on evidence from antipsychotic-naïve patients. TAKE HOME POINTS – When considering physical comorbidities—including infectious, respiratory, metabolic, and cardiovascular diseases—in patients with SMI, including schizophrenia and bipolar disorder, multiple studies have reported an increased prevalence compared with the general population. There may be dysfunction across cardiometabolic, immune, and endocrine systems in patients with schizophrenia—whether we see elevation of certain blood cytokines or an imbalance between adiponectin and pro-inflammatory cytokines, this may contribute to a persistent cycle of obesity and inflammation. There are opportunities to improve whole patient care through comprehensive management of comorbidities and behavioral risk factors that may be present in patients living with SMIs like schizophrenia. For example, efforts to enhance tobacco smoking cessation, given over half of people with schizophrenia smoke and smoking is a known risk factor for cardiovascular disease, may involve behavioral interventions and cognitive behavioral therapy that have shown promise for smokers with SMIs. References ADA, APA, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Diabetes Care. 2004;27:596-601. APA. Practice Guideline for the Treatment of Patients with Schizophrenia (September 2020). https://doi.org/10.1176/appi.books.9780890424841. Accessed September 17, 2020. Cohn TA et al. Can J Psychiatry. 2006;51(6):382-386. Bahorik AL et al. J Psychosom Res. 2017;100:35-45. Balu DT. Adv Pharmacol. 2016;76:351-382. Brisch R et al. Front Psychiatry. 2014;5:47. De Hert M et al. Eur Psychiatry. 2009;24(6):412-424. De Hert M et al. World Psychiatry. 2011;10(1):52-77. Di Chiara T et al. J Nutr Metab. 2012;2012:175245. Diez JJ et al. Eur J Endocrinol. 2003;148(3):293-300. Fernandes BS et al. Mol Psychiatry. 2016;21(4):554-564. Freyberg Z et al. Front Neurosci. 2017;11:432. Gonzalez-Blanco L et al. Schizophr Res. 2016;174(1-3):156-160. Grimm O et al. Neurosci Biobehav Rev. 2017;75:91-103. Hayes JF et al. Br J Psychiatry. 2017;211(3):175-181. Helleberg M et al. Lancet HIV. 2015;2(8):e344-350. Huckans MS et al. Psychiatr Serv. 2006;57(3):403-406. Khokha JY et al. Schizophr Res. 2018;194:78-85. Leonard BE et al. J Psychopharmacol. 2012;26(5 Suppl):33-41. Lucatch AM et al. Front Psychiatry. 2018;9:672. Mangurian C et al. J Gen Intern Med. 2016;31(9):1083-1091. Menzaghi C. Diabetes. 2007 May;56(5):1198-1209. Myles N et al. J Clin Psychiatry. 2012;73(4):468-475. Nakamizo S et al. Trends in Immunotherapy. 2017;1(2):67-74. NIMH. Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154788. Accessed May 8, 2019. NIMH. Schizophrenia. https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml. Accessed August 26, 2020. Pillinger T et al. Mol Psychiatry. 2018;24(6):776-794. Ringen PA et al. Front Psychiatry. 2014;5:137. Sokal J et al. J Nerv Ment Dis. 2004;192(6):421-427. Stahl SM. Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge University Press; 2013. Toda M et al. Curr Psychiatry Rep. 2007;9(4):329-336 Yang AC et al. Int J Mol Sci. 2017;18(8). © 2020 Alkermes, Inc. All rights reserved. UNB-003069

David H. Rosmarin, PhD, joins Lorenzo Norris, MD, to discuss how to think about the concept of denial and its role in the sociopolitical challenges of our society. Dr. Rosmarin is a clinical psychologist and director of the spirituality and mental health program at McLean Hospital in Belmont, Mass. He also is an assistant professor of psychiatry at Harvard Medical School, Boston. Dr. Rosmarin has no disclosures. Dr. Norris has no disclosures. Take-home points Denial is defined as a cognitive and emotional process by which a person avoids facing aspects of reality, especially when it is difficult to assimilate the details of reality into one’s current thinking. Arguably, denial is a coping or defense mechanism meant to address the tension that arises from trying to change an individual’s current way of thinking and understanding of reality. Another form of denial is choosing to focus only on one’s perception of reality and struggling to see the other side of an argument. We can see this form of denial play out in COVID-19 pandemic denial and in certain political narratives. Denial in its most potent form causes individuals to disconnect from any conversation around the salient topic, which can make denial even worse. Summary Denial can be adaptive in its role of protecting a person's psyche. When the midbrain and limbic system are activated, the frontal lobe needs time to process and integrate the information. For example, people will deny the presence of an event they regret or fear until they have enough emotional capacity to integrate new facts into their current model of reality. Yet, denial can be harmful when there are “side effects.” The classic example of pathologic denial is an individual who has experienced trauma, and through continued denial of its impact and poor integration of the event, starts to experience somatic symptoms. Dr. Rosmarin says the problem with denial is that people who are experiencing denial are often the last to recognize their need for treatment or an intervention. Dr. Rosmarin discusses how, with certain topics, we must value and preserve relationships over persuading certain social contacts, such as family and friends, to overcome their denial. Validating emotions and finding the validity in a person's beliefs and grievances can go a long way toward preserving relationships that are challenged by denial of certain facts. References Rosmarin DH et al.  Lancet Psychiatry. 2021 Feb;8(2):92-3. Hall C and Pick D.  Hist Workshop J. 2017 Oct;84(1):1-23. Miller BL. JAMA. 2020 Dec 8;324(22):2255-6. Rosmarin DH. Spirituality, Religion and Cognitive-Behavioral Therapy: A Guide for Clinicians. New York: Guilford Press, 2018. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Guest host Eva Ritvo, MD, interviews Dorothy Otnow Lewis, MD, about her more than 40-year career in studying death row inmates as examined in the HBO documentary “Crazy, Not Insane.” Dr. Lewis is clinical professor of psychiatry at Yale University, New Haven, Conn. She has no disclosures. Dr. Ritvo is a psychiatrist in private practice in Miami Beach, Fla. She has no disclosures. Take-home points Dr. Lewis has an extensive archive of taped interviews with death row inmates that she has used to inform her work as an expert witness. While doing her child psychiatry training at the Yale Child Study Center and sitting in at the juvenile court, she began to see that some of the children had psychiatric and neurologic problems that had not been addressed. The parents of these children sometimes had psychotic or bipolar disorders. After seeing these themes, Dr. Lewis started a clinic at the court. Dr. Lewis and her team were able to study approximately 15 inmates in four states, including Texas and Florida, both of which had the greatest number of condemned juveniles. One key theme that emerged is that all of the inmates had been sentenced to death as juveniles. Eventually, the Supreme Court ended the death penalty for convicted killers who committed their crimes before age 18. Digging deeper and asking more questions of child and adolescent patients who commit violent acts can help clinicians identify environmental stressors that might underlie behavior that is aggressive and antisocial. In some cases, the psychiatric and neurologic impairments identified are treatable. Dr. Lewis would like to study whether identifying child abuse early might prevent future violence. References Yaeger CA, Lewis DO. Mental illness, neuropsychologic deficits, child abuse and violence. Child Adolesc Psychiatr Clin N Am. 2009;(4):793-813. Lewis DO. Ethical Implications of what we know about violence. Child Adolesc Psychiatr Clin N Am. 2000 Oct 9(4):833-91. Lewis DO et al. Ethics questions raised by the neuropsychiatric, neuropsychological, educational, developmental, and family characteristics of 18 juveniles awaiting execution in Texas. J Am Acad Psychiatry Law. 2004;32(4):408-29. Griffith EEH et al. Re: Ethics questions raised by characteristics of 18 juveniles awaiting execution in Texas.     J Am Acad Psychiatry Law. 2006;34(2):143-4. Lewis DO et al. Some evidence of race bias in the diagnosis and treatment of the juvenile offender. Am J Orthopsychiatry. 1979 Jan;49(1):53-61. Lewis DO. Guilty by Reason of Insanity: A Psychiatrist Explores the Minds of Killers. New York: Fawcett Columbine, 1998. Roper v. Simmons, 543 U.S. 551 (2005). Thompson v. Oklahoma, 487 U.S. 815 (1988) .   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com  

In this week's installment, Dr. Renee Kohanski explores the identity crisis facing many physicians today. Clinical Correlation is a bimonthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Regina James, MD, tells her personal story and discusses how to understand health equity with guest host Carol A. Bernstein, MD. Dr. James is deputy medical director and chief of the division of diversity and health equity at the American Psychiatric Association. She also serves on the advisory board of The PACT group (Pan African Clinical Trials) and receives no income from the group. Dr. Bernstein, a past president of the APA, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures. Take-home points The Robert Wood Johnson Foundation defines health equity as: “Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Equity embraces the idea of inclusiveness and evaluates a whole health care system instead of focusing only on individual marginalized communities. For example, it is essential to understand the social determinants that lead to groups being medically underserved and then to understand the impact of the medically underserved on the entire system. Dr. James led a 20-year career in research and leadership within the National Institutes of Health, including the National Institute of Mental Health, the National Institute on Minority Health and Health Disparities, and the Eunice Shriver National Institute of Child Health and Human Development. She later transitioned to 2M, a research consulting agency, and then to the APA. Within the APA, Dr. James has developed a 5-point strategic plan with the vision that all APA members will be culturally competent and sensitive, and able to provide mental health care for any individual regardless of age, race, gender, or sexual orientation. The strategic plan focuses on raising awareness about mental health equity and destigmatization and leveraging the expertise of the APA membership in their communities. A cornerstone of the plan is an educational agenda, including materials on health equity in psychiatry and outreach to APA members and their community partners. In addition, Dr. James and her office partner with APA leadership to lobby the government for mental health equity and inclusion. Dr. James describes structural racism as current policies within an organization that lead to racial inequalities. Separate from the Office of Diversity and Health Equity, the APA established a Presidential Task Force to Address Structural Racism Throughout Psychiatry to identify the scope and targets of structural racism within organized psychiatry, including the APA. It also seeks to identify how structural racism affects practicing psychiatrists and their patients. References Braveman P et al. What is health equity? Robert Wood Johnson Foundation. 2017 May 1. American Psychiatric Association. Diversity and health equity. American Psychiatric Association. Mental health disparities: Diverse populations. APA Presidential Task Force to Address Structural Racism Throughout Psychiatry. https://www.psychiatry.org/psychiatrists/structural-racism-task-force Rosenkranz KM et al. J Surg Education. 2020. doi: 10.1016/j.surg.2020.11.013. Simonsen KA and Shim RS. Psychiatr Clin North Am. 2019 Sep;42(3):463-71. Alves-Bradford J-M et al. Psychiatr Clin North Am. 2020 Sep;43(3):415-28. Aggarwal NK et al. Patient Educ Couns. 2016 Feb;99(2):198-209. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

As we begin 2021, Renee Kohanski, MD, muses about the roller coaster journey she and her listeners have been on during the challenging times of 2020. Clinical Correlation is a bimonthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Bradford L. Frank, MD, MPH, MBA, conducts a Masterclass on how to provide nursing home consultations for psychiatrists. The documents Dr. Frank refers to during this Masterclass are available at (https://bit.ly/3rWqfcK) Dr. Frank is a board-certified geriatric psychiatrist who provides consultations for more than 30 nursing homes in North Dakota. He has no disclosures. Take-home points Dr. Frank reviews practical information about documentation, prescribing, and diagnoses for psychiatric clinicians who treat individuals living in nursing homes. The Centers for Medicare & Medicaid Services has many rules and regulations governing the psychiatric treatment of individuals in nursing homes, including special mental status testing, a policy of gradual dose reduction, and restrictions on how long certain medications can be used. Documentation Even for geriatric patients who live in nursing homes, a full past psychiatric history, including substance abuse and social history, is essential to diagnosis and treatment. To obtain these histories, Dr. Frank sends documents to the nursing home to be completed ahead of time, and then, while he starts to make his differential diagnoses, he talks with the nursing staff about why they want the consultation. The Brief Interview for Mental Status (BIMS) is a 15-item mental status exam mandated by the CMS during nursing home evaluations. A score of 13-15 indicates that a patient is cognitively intact, 8-12 indicates moderately impaired, and

Three of our favorite masterclasses back-to-back-to-back. The Psychcast will return with new content in 2021.  Bulimia nervosa (01:53) Episode 104  Telepsychiatry (12:58) Episode 111 Cannabis (39:17) Episode 137 Email the show at podcasts@mdedge.com

Richa Bhatia, MD, conducts a Masterclass on how to identify medical and neurologic illnesses that present with psychiatric symptoms and mimic psychiatric diagnoses. Dr. Bhatia is a board-certified general and child and adolescent psychiatrist in private practice. She has no disclosures. Take-home points Psychiatric diagnoses are diagnoses of exclusion. Psychiatric clinicians must maintain a high level of clinical suspicion for medical and neurologic illnesses that present with psychiatric symptoms and mimic psychiatric diagnoses. When patients have a “strange” presentation of their psychiatric illness, including being out of the usual age range, a fast progression, or an unusual constellation of symptoms, clinicians should pursue a medical work-up and think broadly about other diagnoses that might mimic the psychiatric diagnosis. Dr. Bhatia provides an overview of common medical and neurologic illnesses that mimic psychiatric diagnoses, including hypothyroidism, delirium, HIV/AIDS, Addison disease, autoimmune encephalitis, temporal lobe epilepsy, frontotemporal dementia, Wilson’s disease, and Parkinson’s disease. Summary Hypothyroidism is an endocrine disease that can mimic depression. The physical symptoms include constipation, edema, dry skin, hair loss, weight gain, and cold intolerance. Individuals with comorbid hypothyroidism and depression report inadequate response to antidepressants, so psychiatrists should check the patient’s thyroid-stimulating hormone or refer them to their primary care physician if they suspect hypothyroidism with elevated TSH. Delirium is a common yet underdiagnosed syndrome that occurs secondary to medical illness and can produce an array of neuropsychiatric symptoms, including psychosis, irritability, and disorganized behaviors, which can lead to misdiagnosis as schizophrenia or mania. Delirium presents as an abrupt change in cognition with disorientation and significantly impaired attention. Hypoactive delirium presents with lethargy, apathy, and decreased alertness, and is often mistaken for depression in the hospital setting. Simple beside tests such as the Confusion Assessment Method can be used to quickly aid in diagnosing delirium. HIV/AIDS can mimic psychiatric disease through direct effect on the nervous system, opportunistic disease, intracranial tumors, cerebral vascular disease, and medication adverse effects. HIV can mimic depression by causing neurovegetative symptoms; apathy, psychomotor slowing, and working memory deficits are more characteristic of the neuropsychiatric impairment from HIV rather than a primary depressive disorder. In late-stage HIV/AIDS, dementia can cause bizarre behaviors, delusions, and mood disturbance such as euphoria and irritability. Addison disease is characterized by low blood pressure, hyperpigmentation, nausea, vomiting, weakness, fatigue, hypokalemia, and hyponatremia. Addisonian crisis can present with neuropsychiatric symptoms of delirium, anxiety, agitation, cognitive impairment, and auditory and visual hallucinations. Autoimmune encephalitis, with anti–N-methyl-D-aspartate receptor encephalitis as the most common type, often masquerades as a primary psychotic symptom. Notable symptoms include subacute onset with fast progression and no clear prodrome, working memory impairment, agitation, or lethargy. Other presenting symptoms include focal neurologic deficits, new-onset or rapidly developing catatonia, fever, headaches, flu-like illness, and autonomic disturbance. Temporal lobe epilepsy also can mimic a primary psychiatric disorder. The symptoms of seizure-like staring, blinking, lip-smacking, and behavioral arrest are precipitated by a sensation of fear or epigastric sensation and depersonalization, which can lead to misdiagnosis as a panic attack. Frontotemporal dementia (FTD) can be mistaken for a primary psychiatric diagnosis in the initial stages. Hallmark symptoms include progressive behavioral change with disinhibition and a decline in executive functioning and language skills such as verbal learning and reasoning. FTD is the second most common dementia in people aged younger than 65 years. Patients with FTD struggle to give a history, and often lack a psychiatric history or exposure to psychotropic drugs. Clinicians should maintain a high degree of clinical suspicion for FTD in new-onset psychiatric syndromes in older individuals. Stroke can lead to poststroke depression and anxiety, apathy, emotional lability, and personality changes. Depression after stroke, occurring hours to days after the insult, is associated with greater cognitive impairment and increased mortality. The diagnosis of poststroke depression is challenging because of impairments in language and cognition after stroke. Apathy can occur separately from depression and diminish recovery. Wilson’s disease results in copper deposits in the brain and liver. The psychiatric symptoms, including psychosis, occur before neurologic changes. Parkinson’s disease also can result in depression-like symptoms, given the motor and neurovegetative symptoms from the neurodegeneration. Fatigue, psychomotor slowing with diminished facial expression, postural changes, and sleep disturbance are common conditions that can mimic depression. References  Carroll VK. Current Psychiatry. 2009 Aug;8(8):43-54. Welch KA and Carson AJ. Clin Med (Lond). 2018 Feb;18(1):80-7. Scarioni M et al. Ann Neurol. 2020;87(6):950-61. Evans DL et al. Neuropsychiatric manifestations of HIV-1 infection and AIDS, in “Neuropsychopharmacology: 5th Generation of Progress.” Philadelphia: Lippincott Williams & Wilkins, 2002, pp. 1281-99. Deng P and Yeshokumar A. Psychiatric Times. 2020 Jan. (37):1. Kumar A and Sharma S. Complex partial seizure, in “StatPearls [Internet].” Treasure Island, Fla.: StatPearls Publishing, 2020 Jan. (Updated 2020 Nov 20). Rao V. Neuropsychiatry of stroke. Geriatric Workforce Program. Johns Hopkins Medicine. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com        

In this week's installment of Clinical Correlation, Dr. Renee Kohanski reminds listeners of our inherent desire to help one another and problem solve while cautioning against those who would place our most vulnerable populations at risk. Clinical Correlation is a bimonthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Eliza W. Menninger, MD, spoke with Psychcast host Lorenzo Norris, MD, about how to help patients deal with anxiety related to the COVID-19 pandemic. Dr. Menninger is medical director of the behavioral health partial hospital program at McLean Hospital in Belmont, Mass. She treats patients with major depression, bipolar disorder, schizophrenia, and schizoaffective disorder. Dr. Menninger also treats patients in McLean’s Schizophrenia and Bipolar Disorder Outpatient Clinic. She has no disclosures. Dr. Norris has no disclosures. Take-home points Anxiety related to stress, fear, worry, and grief has spiked in all phases of the pandemic. Initially, we faced uncertainty not knowing how to adapt to restrictions, and we assumed that the adaptations would be short term. Six months into the pandemic, we’ve moved into questions about maintaining these adaptive processes over the long term. As the medical director of a partial hospitalization program, Dr. Menninger created an acronym, “MASK,” to help people cope with the stress of the pandemic. MASK stands for Make boundaries, Avoid the virus, Stay connected, Keep the faith. Summary Making boundaries refers to encouraging people to use similar behaviors from their past routines to maintain normalcy. For example, for people who work from home, Dr. Menninger suggests getting dressed and ready for work as though you’re actually going, and taking breaks from screens to reduce virtual platform fatigue. People are feeling socially and physically restricted by the pandemic, and she emphasizes going outside regularly. Boundaries that help delineate physical spaces and emotional responsibilities can alleviate the physical and mental clutter that compounds stress. Avoiding the virus is a constant chore, so Dr. Menninger came up with a humorous song aimed at helping her patients remember their role in avoiding exposure to the coronavirus. Staying connected means focusing on the social connection and feeling the presence of the other person instead of just sensing the temporary connection provided through the virtual platform. Dr. Menninger suggests imagining that the person with whom you’re connecting is in the room with you. Self-care through maintaining routines; exercising; maintaining healthy nutrition; seeking out humor; and enjoying art, music, and other stimuli helps people connect with themselves and others. Keeping the faith means remembering that the pandemic will end, and we have the tools to build resilience in ourselves and patients. Dr. Menninger finds hope in the way her clinical staff has been creative to make a difference in the patients’ life amid the constant changes. She and Dr. Norris cite examples of patients using creativity to overcome overwhelming life circumstances, build on their strengths, and reframe the pandemic to find the silver lining. Reference Marcus PH et al. Current Psychiatry. 2020 Dec;19(12):28-33. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Oliver Freudenreich, MD, talks with Lorenzo Norris, MD, about principles of pandemic management among patients with serious mental illness. Dr. Freudenreich reported receiving grant or research support from Alkermes, Avanir, Janssen, and Otsuka. He has served as a consultant to the American Psychiatric Association, Alkermes, Janssen, Neurocrine, Novartis, and Roche. Dr. Norris has no disclosures. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com  

In this week's installment of Clinical Correlation, Dr. Renee Kohanski tackles the very difficult and painful realities of a postelection country. Clinical Correlation is a bimonthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

This week, we revisit four shows that offer guidance to clinicians for addressing the mental health fallout from COVID-19. Lisa W. Coyne, PhD, founder of the McLean OCD Institute for Children and Adolescents in Belmont, Mass., focuses on helping children and adolescents with anxiety and obsessive-compulsive disorder. She disclosed receiving royalties from New Harbinger and Little Brown Publishing. Christine Moutier, MD, describes interventions that can prevent patients from ending their lives by suicide. She is chief medical officer of the American Foundation for Suicide Prevention. Dr. Moutier reported no disclosures. Sanjay Gupta, MD, offers a Masterclass on how to determine which medication works best for geriatric patients with symptoms of dementia. Dr. Gupta, chief medical officer at BryLin Hospital in Buffalo, N.Y., disclosed serving on the speakers’ bureaus of AbbVie, Acadia, Alkermes, Intra-Cellular Therapies, Janssen, and Otsuka. Peter Yellowlees, MBBS, MD, wraps up the podcast with perspective about permanent changes that could be in the offing to the practice of psychiatry because of the pandemic. He is a professor of psychiatry at the University of California, Davis. Dr. Yellowlees has no disclosures. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Diana M. Martinez, MD, conducts a Masterclass on marijuana’s effects on psychiatric disorders. Dr. Martinez, a professor of psychiatry at Columbia University, New York, specializes in addiction research. She disclosed receiving medication (cannabis) from Tilray for one study and has no other financial relationships with this company. Take-home points The use of cannabis, recreationally and medically, has been a controversial topic for ages, and the classification of cannabis as a schedule I controlled substance has made it all the more difficult to research and meaningfully understand its harms and benefits. Based on information from the National Academies of Sciences publication Health Effects of Marijuana: An Evidence Review and Research Agenda, Dr. Martinez presents a sweeping overview of the role of cannabis in two domains: Its ability to worsen psychiatric symptoms, and its role in causing psychiatric disorders. The cannabis plant has 100 cannabinoids. The two most commonly studied are tetrahydrocannabinol (THC), which creates the "high," and cannabidiol (CBD), which does not create a high and has many subjective effects. Cannabis is researched and used in several forms, including the smoked plant or flower form, and prescription cannabinoids based on THC – namely dronabinol (Marinol), nabilone (Cesamet), and CBD. Research suggests that both benefits and risks are tied to using cannabis and cannabinoids. Clinicians should have rational discussions with their patients about the use of cannabis. If patients are no longer responding to psychiatric treatment, and the clinician wants to talk about their cannabis use, it is important to understand the common reasons patients use cannabis, including for chronic pain, anxiety, and insomnia. Benefits There is substantial evidence supporting the use of cannabis and cannabinoids for the treatment of chronic pain. Most studies evaluated the smoked or vaporized form. Research suggests a dose of 5-20 mg of oral THC is about as effective as 50-120 mg of codeine, although there are few head-to-head studies to reinforce this finding. Cannabis will likely have a role in the pain treatment armamentarium. The risks of use include intoxication and development of an addiction. Cannabinoids may have a role in achieving abstinence from addiction to cannabis and other substances. THC in the form of cannabinoids shows some promise for its use in disorders such as PTSD and obsessive-compulsive disorder, but larger controlled studies are needed. In addition, cannabinoids have an effect when combined with other behavioral interventions, such as exposure therapy. Risks There is substantial evidence that cannabis has a moderate to large association with increased risk of developing psychotic spectrum disorders in a dose-dependent fashion, particularly in patients who are genetically vulnerable. Moderate evidence suggests that cannabis causes increased symptoms of mania and hypomania in people with bipolar disorder who use it regularly. Cannabis can cause addiction. About 9% of people who use it will develop a substance use disorder, and the risk of developing a substance use disorder increases to 17% in people who start using cannabis in their teenage years. Frequent cannabis use is associated with withdrawal symptoms, such as irritability, sleep problems, cravings, decreased appetite, and restlessness. References National Academies of Sciences, Engineering, and Medicine. Health Effects of Marijuana: An Evidence Review and Research Agenda. Washington, DC: National Academies Press, 2017. Whiting PF et al. JAMA. 2015;313(24):2456-73. Fischer B et al. Am J Public Health. 2017 Jul 12. doi: 10.2105/AJPH.2017.303818. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com  

In this week's installment of Clinical Correlation, Renée Kohanski, MD, ponders the loss of professional courtesy and the larger implications of medicine-shifting paradigms. Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Lisa W. Coyne, PhD, spoke with Psychcast host Lorenzo Norris, MD, about strategies that can be used to help children and adolescents deal with anxiety and obsessive-compulsive disorder amid COVID-19. Dr. Coyne, a clinical psychologist, is founder of the McLean OCD Institute for Children and Adolescents in Belmont, Mass. She also is director with the New England Center for OCD and Anxiety in Cambridge, Mass. Dr. Coyne disclosed receiving royalties from New Harbinger and Little Brown Publishing. Dr. Norris has no disclosures. Take-home points Much of the anxiety experienced by some children and adolescents is caused by uncertainty about the future. Some children and adolescents also are watching cases of COVID-19 tick up across the country and are concerned about the mixed messages they are receiving from adults. Different cultures exist around belief in science. Rates of anxiety in general are on the rise as are demands for more mental health services. Clinicians are supporting each other to support their patients. Anxiety in young patients might present as disruptions in sleep and appetite. Look for an increase in oppositional behavior. Young patients with anxiety also might resist going to bed. Clinicians also are seeing increases in depressed mood and nonsuicidal self-injury. Acceptance and commitment therapy, a type of cognitive-behavioral therapy that is exposure based, is a strategy that can be used to help patients develop psychological flexibility and put distance between themselves and their thoughts. References Mazza MT with foreword by Coyne LW. The ACT Workbook for OCD: Mindfulness, Acceptance, and Exposure Skills to Live Well With Obsessive-Compulsive Disorder. Oakland, Calif.: New Harbinger Publications, 2020. Allmann AE et al. Acceptance and commitment therapy-enhanced exposures for children and adolescents. Exposure Therapy for Children and Adolescents with Obsessive-Compulsive Disorder: Clinician’s Guide to Integrated Treatment. Academic Press, 2020. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Yuan Chang Leong, PhD, spoke with Psychcast host Lorenzo Norris, MD, about his research into the neural underpinnings of right- and left-leaning individuals. Dr. Leong is a postdoctoral scholar in cognitive neuroscience at the University of California, Berkeley. He has no disclosures. Dr. Norris has no disclosures. Take-home points Dr. Leong and colleagues looked for further evidence of “neural polarization,” which is defined as divergent brain activity based on conversative versus liberal political attitudes. The prefrontal cortex is the part of the frontal lobe responsible for executive and higher-order brain function that makes sense and organizes what a person is seeing, hearing, and experiencing. Participants were shown news clips about immigration policy and their brain activity showed differences in activity of their dorsomedial prefrontal cortex (DMPFC), which is active in interpreting narrative content. The findings suggest there is a neural basis for the way in which individuals with different political attitudes interpret political information and news. The research suggests that words related to threat, morality, emotions, anger, and differentiation/community drive neural polarization. Summary Dr. Leong and colleagues asked participants to watch news clips about immigration policy while undergoing functional MRI with the goal of identifying the neural correlates of neural polarization, which is thought to parallel the behavioral aspects of political polarization. Dr. Leong and colleagues identified an association of divergence in connectivity to the DMPFC to the ventral striatum, a structure involved in reward processing and sensing the valence and tone of information. Their study, published in the Proceeding of the National Academy of Sciences, suggests that information from the ventral striatum is transmitted differently to the DMPFC between groups. The findings suggest that our political beliefs might influence our interpretation of other information, as the DMPFC helps humans interpret narrative content. Dr. Leong pointed out that this study provides evidence about why it is so difficult to bridge the partisan divide. He also discussed the psychology of social identity theory and how any categorization of people makes individuals think along the lines of in-group and out-group, and how the human drive is to protect the in-group. References Leong YC et al. PNAS. 2020 Oct 20. doi: 10.1073/pnas.2008530117. McLeod S. Social identity theory. Simply Psychology. Updated 2019. University of Texas, Austin. Ethics unwrapped. In-group/out-group (video). Brooks M. Brain imaging reveals a neural basis for partisan politics. Medscape.com. 2020 Oct 27. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Renee Kohanski, MD, discusses managing difficult referrals from trusted colleagues. Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com, and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.  

Christine Moutier, MD, joins Lorenzo Norris, MD, to discuss how clinicians can scale up interventions to reduce suicide rates amid the pandemic. Dr. Moutier is chief medical officer of the American Foundation for Suicide Prevention. She reported no disclosures. Dr. Norris also reported no disclosures. Take-home points Death by suicide is a health outcome, which means that there is always a place to intervene, whether clinically, socially, or through research. Risks for suicide during the pandemic are known to increase; however, it is not a foregone conclusion that suicide deaths will rise during or afterward. Mental health diagnoses are a risk factor for suicide, and there will be interplay with stressors such as unemployment, financial stress, grief, and socioeconomic disparities. The basics of suicide prevention include screening for suicidal ideation at behavioral health appointments. If a change in risk is identified, clinicians should use a patient-centered intervention, such as a safety plan. Summary The U.S. suicide rate has risen by 35% from 1999 to 2018, and the rates of suicide are particularly increasing in middle-aged populations as well as among youths of color. Evidence-based efforts are underway to mitigate suicide deaths through national suicide prevention plans. Yet, everyone has a role to play in suicide prevention, since part of prevention includes reducing stigma related to conversations about mental health and asking about crises and suicidal thoughts. In behavioral health settings, routine screening should be implemented for suicidal ideation and deterioration in any aspect of mental health. Asking about suicidal ideation is the bare minimum, and not all patients will admit to suicidal ideation when asked. Other risk factors for suicide include acute stressors such as decompensation and losses of relationships and employment. Most individuals with suicidal thoughts do not need to be psychiatrically hospitalized. Suicidal thoughts, as symptoms of a mental illness, can be treated with interventions other than hospitalization. The goal is to maintain safety and respond appropriately. In-office interventions include creating a safety plan or adding to an existing plan. As a silver lining, the pandemic has normalized conversations about mental health and reduced stigma around mental health experiences. Dr. Moutier discusses how, as the pandemic set in, the AFSP experienced a notable increase in requests for education about mental health and suicide prevention. References Moutier C. JAMA Psychiatry. 2020 Oct 16. https://bit.ly/34AF0Zq. Chung DT et al. https://bit.ly/31RYxm9. American Foundation for Suicide Prevention:  https://bit.ly/2HK3S8j Policy priorities: https://bit.ly/37IvO78 Safety plan worksheet: https://bit.ly/2HK3Vkv Centers for Disease Control and Prevention suicide risk factors: https://bit.ly/3jyMu3i *  *  * Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.  Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Philip Resnik, PhD, returns to the Psychcast, this time with his research partner and wife, Rebecca Resnik, PsyD, to discuss the interface between language, psychiatry, psychology, and health. Dr. Philip Resnik appeared on the show previously to discuss artificial intelligence, natural language processing, and mental illness. He is a professor in the department of linguistics at the University of Maryland, College Park, and has a joint appointment with the university’s Institute for Advanced Computer Studies. Dr. Philip Resnik has disclosed being an adviser for Converseon, a social media analysis firm; FiscalNote, a government relationship management platform; and SoloSegment, which specializes in enterprise website optimization. Some of the work Dr. Philip Resnik discusses has been supported by an Amazon AWS Machine Learning Research Award. Dr. Rebecca Resnik is a licensed psychologist in private practice who specializes in neuropsychological assessment. In 2014, she served as cofounder of the Computational Linguistics and Clinical Psychology workshop at the North American Association for Computational Linguistics. She continues to serve as a workshop organizer and clinical consultant to the cross-disciplinary community. She has no disclosures. Dr. Norris disclosed having no conflicts of interest. Take-home points Dr. Rebecca Resnik and Dr. Philip Resnik are interested in finding measurable, observable features to apply to the assessment of psychological and psychiatric diagnoses. They point out that finding an objective measure is essential for scaling up mental health evaluations and treatment. Natural language processing (NLP) is focused on analyzing language content. NLP technology has generated tools such as Siri, Alexa, and Google Translate, and NLP allows computers to do things more intelligently with human language. Individuals are using machine learning and NLP to analyze language data sets to evaluate diagnostic criteria. The goal is to create or use language sets that can be analyzed outside of the clinic. Dr. Rebecca Resnik imagines a world where a patient gives a “language sample” to an app or an avatar that would be evaluated by NLP that would, in turn, offer some overarching hypotheses about the person. So much of evaluations is trying to home in on the correct signal, explicit and implicit, from the patient. In addition, neuropsychiatric tests/scales are standardized against a limited scope of the population, so NLP would be matched to the individual. Dr. Philip Resnik looks at signals in text and speech content, acoustics, microexpressions, and even biometric data. Machine learning can process and distill a huge amount of data with various signals more easily than any human. Dr. Rebecca Resnik revisits the idea of clinical white space, which is the “space” or the time between clinical encounters, and this is where decompensation and high-risk suicidal behaviors occur. She suggests that NLP software could be used to fill this white space by using apps to collect text samples from patients, and the software would analyze the samples and warn of patients who are at risk of decompensation or suicide. If clinicians were to use text or speech samples from people’s smart technology, we could assess an individual's risk in the moment and use nudge-type interventions to prevent suicide. Finally, Dr. Philip Resnik emphasizes that there are technologists who have the skills and technology that is on the verge of helping clinicians, but the key to progress is collaborating with clinicians. References Resnik P et al. J Analytical Psychol. 2020 Sep 10. doi: 10.111/sltb.12674. Coppersmith G et al. Biomed Inform Insights. 2018;10:1178222618792860. Zirikly A et al. CLPsych 2019 shared task: Predicting the degree of suicide risk in Reddit posts. Proceedings of the Sixth Workshop on Computational Linguistics and Clinical Psychology. 2019 Jun 16. Yoo DW et al. JMIR Mental Health. 2020;7(8):e16969. American Medical Informatics Association and Mental Health: https://www.amia.org/mental-health-informatics-working-group Selanikio J. The big-data revolution in health care.  TEDxAustin. 2013 Feb. CLPsych: Computational Linguistics and Clinical Psychology Workshop. 2019 Program. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Dr. Renee Kohanski discusses how important personal and professional development is among physicians in the workplace. Is your current job worth it? Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast  

Sanjay Gupta, MD, conducts a Masterclass on treating geriatric patients with symptoms of dementia, particularly amid the restrictions tied to COVID-19. Dr. Gupta is chief medical officer at BryLin Hospital in Buffalo, N.Y. He is also is a clinical professor in the department of psychiatry at the State University of New York, Syracuse, and is affiliated with SUNY at Buffalo. Dr. Gupta attends at 8-10 nursing homes. He disclosed serving on the speakers’ bureaus of AbbVie, Acadia, Alkermes, Intra-Cellular Therapies, Janssen, and Otsuka. Take-home points Common neuropsychiatric symptoms in patients with dementia include agitation, aggression, delusions, insomnia, anxiety, and depression. One-third of community-dwelling elders and between 60%-80% of nursing facility patients have these neuropsychiatric symptoms. The most common medication class Dr. Gupta uses is antipsychotics. The use of these medications in individuals with dementia is off label. The Food and Drug Administration maintains a black-box warning on the use of antipsychotics for geriatric patients because of the increased risk of sudden death. Risperidone is supported by the most data, then olanzapine, then aripiprazole, and finally quetiapine. Quetiapine has very limited data to support its efficacy. Most antipsychotics have modest efficacy data for their use in this population. The riskiest adverse effects are cardiovascular adverse events, which are higher in risperidone. Dr. Gupta starts risperidone at a low dose of 0.25 mg taken by mouth b.i.d. and titrates to a maximum dose of 2 mg/24 hours. The starting dose for olanzapine is 2.5 mg up to a maximum dose of 10 mg. The starting dose of aripiprazole is 1 mg, and maximum dose 5 mg or less. Selective serotonin reuptake inhibitors (most commonly sertraline or citalopram), the atypical antidepressant mirtazapine, and anticonvulsants (valproic acid) are also used for agitation in dementia but there is limited evidence for their efficacy. Melatonin and trazodone have a positive effect on sleep that can have downstream improvement on aggressive behaviors. Summary To choose an effective treatment, it’s essential to obtain a detailed history of the symptoms from patients and collateral, such as relatives and staff members from the facility. Staff members can be educated about what information is most important to the clinician, or they may provide vague information, such as “the patient is confused.” Specific symptoms that can be used guide treatment include the presence of disorganized thoughts, delusions and paranoia, or visual and/or auditory hallucinations; the timing of the behavior (day vs. night); and patterns of aggressive behaviors. Dr. Gupta emphasizes that it’s important to rule out delirium as the cause of agitation by evaluating underlying medical issues with laboratory evaluations, and when possible, a physical exam. Antipsychotics work best in the context of aggression driven by paranoia and/or delusions of persecution. Antipsychotics seem to work less well for general agitation that may be driven by triggers that need to be uncovered through investigation of the history and environment. Reasons for agitation and aggression might include sensory or activity deprivation, difficulty emptying bladder or bowels, or depression and loneliness, both of which are prevalent during the pandemic. Adverse effects of antipsychotics will be greater in older adults, and include sedation, gait problems that increase the risk of falls, and extrapyramidal or Parkinsonian symptoms. In a geriatric patient, tardive dyskinesia can occur with as little as 1 month of exposure to an antipsychotic, compared with 3 months in younger adults. Before starting an antipsychotic, the clinician must obtain informed consent from the health-care proxy and inform them that using antipsychotics in a patient with dementia is a non–FDA-approved treatment with a black-box warning. Gradual dose reduction, a Medicare policy about the use of psychotropic medications within nursing homes, is defined as “stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.” Dr. Gupta addresses this policy by assessing which medications are essential and often stopping some medications once the patient is started on antipsychotics. References Steinberg M, Lyketsos CG. Am J Psychiatry. 2012 Sep;169(9):900-6. Maher AR et al. JAMA. 2011 Sep 28;306(12):1359-69. Schneider LS et al. JAMA. 2005 Oct 19;294(15):1934-43. Seitz DP et al. Cochrane Database Sys Rev. 2001 Feb 16;(12):CD0089. Ballard C et al. Cochrane Database Sys Rev. 2006 Jan 25. doi: 10.1002/14651858. Ballard C, Waite J. Cochrane Database Sys Rev. 2006 Jan 25;(1):CD003476. Department of Health & Human Services. State Operations Manual Surveyor Guidance Revisions Related to Psychosocial Harm in Nursing Homes. CMS.gov. 2016 Mar 25. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

David Henry, MD, host of the Blood & Cancer podcast, joins Psychcast host Lorenzo Norris, MD, to discuss steps clinicians can take to alleviate the distress associated with receiving a diagnosis of cancer. Dr. Henry is clinical professor of medicine at the University of Pennsylvania, Philadelphia. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures. Take-home points Cancer patients have always been susceptible to developing depression and anxiety after receiving their distressing diagnoses. During the COVID-19 pandemic, the risk for depression and anxiety are even greater because patients face separation from their oncology treatment teams and for some, delays in treatment. Major depressive disorder (MDD) occurs in up to one-third of cancer patients, and any depressive disorder can be seen in about half. Another concern is how to screen for depression in the context of cancer. Dr. Norris suggests using the Patient Health Questionnaire–2 (PHQ-2) screener, or the question: “Are you sad or depressed?” Answering those questions can give patients the opportunity to open up about their emotions. Signs of depression in cancer include nonadherence to treatment, changes in mood and anxiety affecting daily functioning at home or work, and demoralization, which is defined as helplessness, isolation, and despair in the face of overwhelming stressors. Summary An emotional upset, such as disbelief, despair, or even denial, might occur immediately after receiving a cancer diagnosis. A depressive disorder, however, is a persistently depressed, sad mood with changes in functioning that affect the patient, his/her family, and even engagement with treatment. Findings of studies about the prevalence of depression in patients with cancer vary depending on the type of screening and/or diagnostic tool used. In general, the prevalence of MDD is up to 38%, and the prevalence of any depressive disorder is up to 58%. The prevalence of depression is even greater in patients with advanced cancer. In the general population, the 12-month prevalence of MDD is 6%, and the lifetime prevalence is 16%. It’s useful to think about stress along a continuum of diagnoses ranging from a normal expected stress syndrome, an adjustment disorder, MDD triggered by the event, depression secondary to a general medical condition as can occur in central nervous system and pancreatic cancer, or even a substance-induced mood disorder from either prescribed medications or perhaps a form of coping that has turned maladaptive. Cognitive-behavioral therapy (CBT) can be explained as examining the way thoughts influence emotions and behavior. When using CBT with cancer patients, a good place to start is checking in on their understanding of their diagnosis, their prognosis, and current and future treatments. The goal is to see whether they have unnecessary cognitive distortions that may be affecting their emotions and behaviors. During periods of extreme stress, CBT can help patients by emphasizing the use of adaptive thoughts, and identifying maladaptive thoughts and behaviors as opportunities for intervention. To screen for depression, it may be enough to ask: “Are you depressed?” As a screening tool, the PHQ-2 asks only two questions: “Over the last 2 weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things, or been feeling down, depressed or hopeless? The PHQ-2 score ranges from 1 to 6, and even at the lowest score, it has a sensitivity and specificity of 90.6% and 65.4%, respectively, in detecting any depressive disorder. References Krebber AMH et al. Psycho-oncology. 2014 Feb;23(2)121-30. Walker J et al. Ann Oncol. 2013 Apr 1;24(4):895-900. Trinidad AC et al. Psychiatr Ann. 2011;4(9):439-42. Daniels S. J Adv Pract Oncol. 2015 Jan-Feb;6(1):54-6. Other resources PHQ-2: https://www.hiv.uw.edu/page/mental-health-screening/phq-2 National Cancer Institute: Depression–Health Professional Version: https://www.cancer.gov/about-cancer/coping/feelings/depression-hp-pdq

Dr. Renee Kohanski, MD, uses a proverb to discuss how she talks to patients about facemasks, and how she talks to patients with face masks on. What's hiding behind the mask? *  *  * Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at podcasts@mdedge.com and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast  

Psychcast host Lorenzo Norris, MD, talks with members of the Group for the Advancement of Psychiatry’s Media Committee about how to help patients navigate the uncertainties associated with educating K-12 and college students during the pandemic. The discussion is moderated by Jack Drescher, MD. Dr. Norris is assistant professor of psychiatry and behavioral sciences and assistant dean of student affairs at George Washington University in Washington. He also serves as medical director of psychiatric and behavioral sciences at George Washington University Hospital. Dr. Norris has no conflicts of interest. Dr. Drescher is clinical professor of psychiatry at Columbia University in New York, adjunct professor at New York University, and a training and supervising psychoanalyst at the William Alanson White Institute. He has no conflicts of interest.  Joining Dr. Norris and Dr. Drescher are Carol Bernstein, MD; Jeffrey Freedman, MD; Gail Saltz, MD; and Peter Kramer, MD. None of the guests have a conflict of interest. Summary Questions about school reopenings are fraught with uncertainty for children, parents, and teachers, with concerns for safety as well as the quality of the school experience. Constant communication between parents and schools with families is warranted; however, without a clear plan, too much communication can generate anxiety. The pandemic and school reopenings affect most sectors of society, including the economy, and vulnerable and elderly populations. The pandemic puts pressure on families because the distribution of work often is in the home. Women in particular are struggling with the ongoing need to manage work demands with those tied to their children’s school schedules. School reopening plans have ramifications for the workplace as parents struggle to meet their usual schedule and productivity standards. School reopening is another aspect of the pandemic that underscores class and financial disparities, because some school systems can afford widespread testing to keep children in school. These decisions, in turn, have a ripple effect on parents' ability to return to work. School reopenings also affect young adults at colleges and universities. The social milieu of college targets the development of young adults as they accomplish social and emotional milestones by interacting with peers. Yet, to reopen safely, colleges have been forced to change their structure and limit social interactions between students and faculty. In addition, college is a common time and place for mental illnesses to surface or be exacerbated in young people; it’s unclear whether there will be enough mental health services for this group, which is now under even more stress. Colleges are trying to fill the mental health gap by using adjunctive tools, such as apps, and broader telehealth and virtual psychotherapy services. Children at every age are facing developmental challenges, including a "failure to launch." Presently, 52% of young adults reside with one or both of their parents, the largest proportion since the Great Depression.   References Bushwick S. Schools have no good options for reopening during COVID-19. Scientific American. 2020 Sep 5. Simpson BW. The important and elusive science behind safely reopening schools. https://www.jhsph.edu/covid-19/articles/the-important-and-elusive-science-behind-safely-reopening-schools.html. Johns Hopkins School of Public Health. 2020 Aug 14. Johns Hopkins School Reopening Plan Tracker. https://bioethics.jhu.edu/research-and-outreach/projects/eschool-initiative/school-policy-tracker/. Fry R et al. A majority of young adults in the United States live with their parents for the first time since the Great Depression. Pew Research Center. FACTTANK: News in the Numbers. 2020 Sep 4. Marcus J and Gold J. Colleges are getting ready to blame their students: As campuses reopen without adequate testing, universities fault young people for a lack of personal responsibility. The Atlantic. 2020 Jul 21. Will M. Keeping COVID-19 rates low in schools: Advice from an expert. Education Week. 2020 Sep 28. *** Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com  

Richard Balon, MD, returns to the Psychcast, this time to conduct a Masterclass on the impact of marijuana use on patients, particularly adolescents. Dr. Balon is professor of clinical psychiatry and anesthesiology and associate chair of education at Wayne State University in Detroit. He has no disclosures. Take-home points Marijuana remains a controversial topic as potential legalization looms large in public policy and various groups espouse the positive benefits of marijuana. Current marijuana formulations are more potent than formulations used in previous years. Formulations used today have a higher tetrahydrocannabinol content, with up to 80% THC content achieved through artificial selection. Clinicians are rightly concerned about the well-established negative effects of marijuana on specific populations, particularly adolescents. They also worry about the effect of marijuana on brain development, which could affect educational outcomes, and the significant risk of developing psychosis and/or schizophrenia after using marijuana. Newer research on marijuana use is also suggesting other negative health outcomes, including a potential link between marijuana use and an increased risk of developing various types of cancer. Summary Research over the past 20 years has elucidated the negative effects of marijuana on brain health and development. Marijuana use undermines cognitive function, including executive function and educational outcomes. Longitudinal and twin studies show a decline in the IQ of adolescents who have used marijuana. This is congruent with other established research and public health guidelines urging individuals to avoid the use of psychoactive drugs before the brain finishes maturing at approximately age 25 years. In 2016, Nora D. Volkow, MD, director of the National Institute on Drug Abuse, and other leading investigators in the field published a review of the literature discussing the impact of marijuana cognitive capacity, amotivational syndrome, and the risk of psychosis. Ample evidence based on neuropsychological testing demonstrates a negative impact of marijuana on learning and working memory. Cannabis amotivational syndrome manifests as apathy, reduced concentration, and an inability to follow routines or master new material. Evidence demonstrates that long-term heavy cannabis use is associated with educational underachievement and impaired motivation. Marijuana use is considered a preventable risk factor for the development of psychosis and schizophrenia. Any use of marijuana is estimated to double the risk of schizophrenia, accounting for 8%-14% of cases, and those at greatest risk include adolescents who start at an early age, engage in heavy use, and use high-potency THC. There is limited evidence about the effect of marijuana on PTSD, and a study using a large Veterans Affairs database suggests that marijuana may worsen PTSD symptoms and increase the risk of violence. A well-established physical outcome of heavy cannabis use is cannabis hyperemesis, defined as recurrent nausea, vomiting, and cramping abdominal pain tied to marijuana use. The symptoms may improve temporarily by taking a hot shower or bath. Though more research is required, low-strength evidence suggests that regular marijuana use may be associated with development of testicular germ cell tumors. The association of marijuana use with lung and oral cancer is unclear, partly because marijuana smokers often also smoke cigarettes. Given that we know the smoke in cigarettes is a major risk factor for heart disease, the same concerns must be investigated for individuals who smoke only marijuana. References Fischer B et al. Am J Public Health. 2017 Jul 12;107(8):e1-12. Volkow ND et al. JAMA Psychiatry. 2016;73(3):292-7. Lorenzetti V et al. Eur Neuropsychopharmacol. 2020 Jul;36:169-80. Fried P et al. CMAJ. 2002 Apr 2;166(7):887-91. Meier MH et al. Addiction. 2017 Jul;113:257-65. McAlaney J et al. Eur Addict Res. 2020 May 6;1-8. Ben Amar M, Potvin S. J Psychoactive Drugs. 2007;39:131-42. Wilkinson ST et al. J Clin Psychiatry. 2015 Sep;76(9):1174-80. Steenkamp MM et al. Depress Anxiety. 2017 Mar;34(3):207-16. Chocron Y et al. BMJ. 2019;366:l4336. Ghasemiesfe M et al. JAMA Netw Open. 2019;2(11):e1916318. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Introducing Clinical Correlation, a new podcast drop from the Psychcast. Renee Kohanski, MD, began producing observational segments for the Psychcast since its inception in April 2018. Clinical Correlation episodes will be published on Mondays twice per month. In this first edition, Dr. Kohanski recalls a poignant moment during her training when her mentor and then director, Donald Morgan, MD (https://bit.ly/35PAqY6), reconsidered his opinion prior to testifying in a court of law based on a simple question from a trainee. For Dr. Kohanski, this moment emphasized the importance of honest and open conversations.  You can email the show at podcasts@mdedge.com and you can learn more about the show at https://www.mdedge.com/podcasts/psychcast   

Jeffrey R. Strawn, MD, talks with host Lorenzo Norris, MD, about assisting children and adolescents with anxiety and anxiety disorders, particularly during the COVID-19 pandemic. Dr. Strawn, a previous Psychcast guest, discusses ways for mental health clinicians to think about proportionate anxiety versus anxiety that is severe, continual, and persistent. He is director of the anxiety disorders research program at Cincinnati Children’s Hospital Medical Center and an associate professor of psychiatry at the University of Cincinnati. Dr. Strawn has received research support from several pharmaceutical companies and from the National Institute of Mental Health. He also has received royalties from Springer. Dr. Norris is assistant dean of student affairs, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He has no conflicts of interest. Take-home points Anxiety is a normal emotional reaction critical to survival. Yet, when the emotions become extreme, anxiety can negatively affect day-to-day functioning. With any event that may cause stress, the anxiety should be expected and proportional to the event. Clinicians and parents can support children and adolescents by pointing out different emotional reactions and discussing them to promote self-awareness, as well as maintaining routines while also acknowledging the loss of normalcy. Clinicians should keep in mind several dimensions of the child-parent relationship and how they interact with the ever-changing home and schooling environment. The dimensions to be considered include: Flexibility versus control, which is a spectrum that ranges from rigid to chaotic, and cohesion and support, which ranges from disengaged to enmeshed. Summary If the triggering event is severe, persistent, and uncertain, such as the COVID-19 pandemic, the anxiety may last and become an anxiety disorder, which results in functional impairment. Anxiety (not yet a disorder) may provoke changes in emotions and behaviors, such as irritability, frustration, poor sleep, and so on, that are proportional and expected to the major changes produced by the pandemic. So, parents and clinicians need to monitor for impact on functioning. Clinicians and parents can support children by pointing out different emotional reactions and discussing them to promote self-awareness. Adults should acknowledge that children are going through loss and trauma and be open to discussing how life is different now but not lose sight of the future. Parents will have to balance trying to keep normalcy in place where possible and discussing when life feels far from the norm. In his clinical practice, Dr. Strawn has noticed more reports of irritability and frustration. These emotions need to be evaluated but not necessarily pathologized. Those emotions likely arise from the drastic changes in home environment. Also parents now have more opportunity to observe their children in the learning environment. The pandemic has come with certain benefits, such as more time at home together allowing families time to slow down and engage in different, more fulfilling activities. Yet, the pandemic has created chronic and variable stressors that can negatively affect physical and mental health. This combination of the dark and light has the potential to foster resilience as we reflect on our vulnerabilities and strengths. But we must also think about how to inoculate ourselves against loneliness, and the risks of how social distancing and societal discord may fray our social fabric. References Strawn JR. Current Psychiatry. 2020 May;19(5):9-10. Brooks D. The pandemic of fear and agony. New York Times. 2020 Apr 9. Delgado SV, Strawn JR. Difficult Psychiatric Consultations: An Integrated Approach. New York: Springer, 2013. Strawn JR et al. Depress Anxiety. 2012;29(11):939-47. Strawn JR et al. Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-39. Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com