Podcasts about mdedge psychcast

Lorenzo Norris, MD, host of MDedge Psychcast, talks with Scott A. Norton, MD, MPH, MSc, and John Koo, MD, about delusions of infestation, weighing in on the diagnosis and management of patients with this challenging disorder, and more. Dr. Norton is a dermatologist and preventive medicine specialist at the Uniformed Services University of the Health Sciences in Bethesda, Md. Dr. Koo is professor of dermatology at the University of California, San Francisco, and is a dermatologist and board-certified psychiatrist. Dr. Norton and Dr. Koo had no relevant disclosures.  Reference Delusional infestation surges during COVID-19 pandemic     

Lorenzo Norris, MD, touches base with Nick Andrews to discuss COVID-19 and to welcome Jacqueline Posada, MD, as an occasional cohost of the MDedge Psychcast. Dr. Posada, associate producer, interviews Lynne S. Gots, PhD, about treating anxiety, obsessive-compulsive disorder, and other disorders in the midst of the COVID-19 pandemic. Dr. Gots is an assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington. She has a private psychotherapy practice and has no financial relationships to disclosure.   Take-home points Anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. Anxiety is an adaptive response to a threat, and COVID-19 and its repercussions makes this a threatening time. In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety. Consider the following suggestions for working with anxious patients and clinicians: Acknowledge that social media has the potential for shaming and worsening social anxiety. Limit exposure to news and social media as much as possible. Monitor patients for excessive reassurance-seeking behaviors, and enact ERP plans. Establish a regular but flexible routine with boundaries between work, home, and rest. Practice self-compassion by lowering expectations and even using formal self-compassion practices. Summary Cognitive-behavioral therapy is an evidence-based therapy for obsessive-compulsive disorder (OCD) and many forms of anxiety and depression. Acceptance and commitment therapy (ACT) is considered a third-wave modality of CBT. The acceptance component is based on mindfulness and acceptance of “what is.” The commitment component involves identifying core values and actions so that a person can use his/her values as a guide to behaviors. The goal is not to eliminate anxious or obsessional thoughts but to accept they are there and work alongside them. Clinicians should be aware that anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. For example, a person’s OCD rituals may not be worsened, but an underlying tendency for perfectionism could be triggered as he/she tries to practice “the perfect quarantine.” Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety. Clinicians can look for reassurance-seeking behaviors that have cropped up with increased anxiety. For example, for a person with contamination anxiety, it might be tempting to wash for longer than 20 seconds or to wipe things down compulsively. Advise patients to pick a routine, such as washing for 20 seconds and no more. Individuals can choose a reputable source and follow its guidelines. The key is to avoid falling into the trap that more reassurance-seeking behaviors will alleviate anxiety. Using excessive reassurance-seeking behaviors can lead to increased anxiety through the conditional learning mechanism of negative reinforcement.   Other helpful suggestions Social media contains a potential for shaming based on comparing oneself and behaviors to others, so individuals should limit exposure to it. News intake should be limited to 1 hour a day, and only reputable sources should be used. Video calls also can trigger social anxiety because individuals literally have to see themselves more often than usual. Ways to minimize this anxiety include minimizing your personal image or covering the image with a Post-it note. For people who are at home all day, establish a routine with a regular wake and sleep time and scheduled breaks. Some type of boundary between home and work life should be created. Self-compassion should be practiced. The first step is to lower expectations and live according to your values and what is realistically possible given the extensive changes in the past month. Professionals need to seek support from other professionals going through the same thing, so connect with a colleague who can relate to your situation. Remember that, as mental health professionals, we are a repository for everyone else’s anxiety and suffering, so we need to be kind to ourselves. Consider using a self-compassion practice. Recognize that you are suffering. Connect with the community: Everyone is suffering. Hold that suffering and offer yourself words of compassion and loving kindness. References and resources Dr. Gots’s website: https://cognitivebehavioralstrategies.com/ Blog post by Dr. Gots that summarizes her clinical advice: https://www.nami.org/Blogs/NAMI-Blog/March-2020/How-to-Protect-Your-Mental-Health-during-the-Coronavirus-Outbreak Suggestions for when and how to decontaminate groceries: https://www.seriouseats.com/2020/03/food-safety-and-coronavirus-a-comprehensive-guide.html Self-compassion practice suggestion: https://self-compassion.org/exercise-2-self-compassion-break/ Supportive touch practice for times of stress and vulnerability: https://self-compassion.org/exercise-4-supportive-touch/ Self-compassion evidence-based resources: https://self-compassion.org/the-research/ International OCD Foundation: https://iocdf.org/ *  *  *   Show notes by Dr. Posada, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com  

MDedge Psychcast host Lorenzo Norris, MD, interviews Steven Wengel, MD, about the challenges of loneliness in geriatric populations in nursing homes, especially during the current COVID-19 pandemic. Dr. Norris also discusses potential interventions with Dr. Wengel, who is a geriatric psychiatrist at the University of Nebraska Medical Center in Omaha. And later, in the “Dr. RK” segment, Renee Kohanski, MD, talks about how, in the midst of the pandemic, we are slowing down while we’re speeding up … and are learning how to use – and not abuse – technology. Take-home points Loneliness has been defined as a form of social pain; it is more than sadness or a “state of mind.” Loneliness and being alone are separate issues suggesting that loneliness is more of an emotional state and being alone is often a choice. Loneliness can be characterized as deficits in authentic interactions and connection because you can be surrounded by people and still feel lonely. Loneliness has been studied as a predictor of health problems and is identified as a risk factor for early mortality and dementia and as a predictor of chronic illnesses such as depression. When it comes to treating loneliness in the geriatric population, favor any type of intervention over none and avoid chalking up symptoms as “just loneliness.” Basic interventions include providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive type symptoms with an SSRI. Summary In a study of nursing-home patients, 9% report loneliness often or always and 25% report loneliness sometimes; older adults are more susceptible to loneliness secondary to frailty and limited transport options. Loneliness is an independent risk factor for early mortality and a predictor for other chronic diseases including dementia, hypertension, depression, and overall poor health. During the COVID-19 pandemic, most nursing homes are under lockdown, and all visitors are barred to minimize the introduction of COVID-19 to the facilities. This means residents are unable to see family and loved ones. This necessary intervention brings up the question of quality of life over quantity of life for older individuals. Isolation and social distancing have also taken away group activities like communal meals and games with socializing. Children of institutionalized patients might also feel a sense of loss and guilt as they are not allowed to see their loved ones. Particular to geriatrics, physical touch is essential to healing emotional pain, for example, a gentle touch or massage to relieve anxiety or physical redirection to ease agitation secondary to dementia. Two primary means of addressing loneliness for the geriatric population include providing structure and finding opportunities for volunteerism such as helping other residents or completing simple tasks within the institution. Loneliness and major depressive disorder are difficult to differentiate in the older population. Dr. Wengel recommends favoring intervention over none. This means using basic interventions like providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive symptoms with an SSRI. References Jansson AH et al. Loneliness in nursing homes and assisted living facilities: Prevalence, associated factors and prognosis. Jour Nursing Home Res. 2017;3:43-9. Social isolation, loneliness in older people pose health risks. National Institute on Aging. https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks. Cacioppo JT. Loneliness: Human Nature and the Need for Social Connection. New York: W.W. Norton and Company, 2008. *  *  *   Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

MDedge Psychcast host Lorenzo Norris, MD, interviews Sy Atezaz Saeed, MD, MS, about his annual analysis of the key studies that could change day-to-day psychiatric practice. Dr. Norris’s conversation with Dr. Saeed is based on a two-part evidence-based review that identified the top 12 research findings for clinical practice from July 2018 to June 2019. Part 1, which Dr. Saeed wrote with Jennifer B. Stanley, MD, and Part 2 were published in Current Psychiatry. Take-home points Each year, Dr. Saeed identifies 10-20 high-quality journal articles with direct impact on clinical practice that, if used appropriately, can generate better outcomes for psychiatric patients. The goal of the list is to close the gap between cutting-edge science and clinical practice. Secondary literature (for example, Cochrane Reviews, NEJM Journal Watch, and so on) is used to differentiate the clinically relevant “signal” from the noise of all the research produced. Knowledge changes over time, so it’s important to be up to date but flexible in how the knowledge is applied. Summary The methodology used to generate the list is aimed at identifying 10-20 useful articles. Dr. Saeed took a three-pronged approach that reviewed research findings suggesting readiness for clinical utilization published between July 1, 2018, and June 30, 2019; asked several professional organizations and colleagues: “Among the papers published from July 1, 2018, to June 30, 2019, which ones in your opinion have (or are likely to have or should have) impacted/changed the clinical practice of psychiatry?”; and looked for appraisals in postpublication reviews such as NEJM Journal Watch, F1000 Prime, Evidence-Based Mental Health; commentaries in peer-reviewed journals; and other sources that suggest an article is of high quality and clinically useful. This approach generated a solid list of articles to consider presenting at journal clubs or a topic to present at grand rounds. Studies on this list also might overlap with research covered in popular media, so the list is a tool that clinicians can use to answer questions patients raise. The secondary literature is used to differentiate the clinically relevant “signal” from the noise of all the research produced. Those secondary sources include Cochrane Reviews, BMJ Best Practice, NEJM Journal Watch, Evidence-Based Mental Health, and commentaries in peer-reviewed journals to help distill the clinically useful articles for a busy clinician. Four of the 12 articles that affected Dr. Saeed’s practice covered the risk of death associated with antipsychotic medication usage in children, the role of antipsychotic polypharmacy in schizophrenia to decrease inpatient hospitalizations, the outcomes associated with prescribing different adjunctive medications in combination with antipsychotics, and the use of prazosin for nightmares in PTSD. References Saeed SA et al. Top research findings of 2018-2019 for clinical practice. Part 1. Current Psychiatry. 2020 January;19(1):12-8. Saeed SA. Top research findings of 2018-2019 for clinical practice. Part 2. Current Psychiatry. 2020 February;19(2):22-8. Ray WA et al. Association of antipsychotic treatment with risk of unexpected death among children and youths. JAMA Psychiatry. 2019;76(2):162-71. Tijhonen J et al. Association of antipsychotic polypharmacy vs. monotherapy with psychiatric rehospitalization among adults with schizophrenia. JAMA Psychiatry. 2019;76(5):499-507. Stroup TS et al. Comparative effectiveness of adjunctive psychotropic medications in patients with schizophrenia. JAMA Psychiatry. 2019;76(5):508-15. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507-17. Show notes by Jacqueline Posada, MD, associate producer of the MDedge Psychcast. Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Dr. Lorenzo Norris is an Associate Professor of Psychiatry and Behavioral Sciences at George Washington University, and the host and creator of the MDEdge Psychcast podcast. Palliative psychiatry for patients with Amyotrophic Lateral Sclerosis (ALS). Finding meaning in endings. “End of life does not result in a lack of meaning.” How maintaining the spirit of curiosity prevents mistakes and prevents a doctor from falling into simple pattern recognition. "Back then the idea of a black male wanting to be a physician . . . that's just a moonshot."Transcript

Dr. Lorenzo Norris is an Associate Professor of Psychiatry and Behavioral Sciences at George Washington University, and the host and creator of the MDEdge Psychcast podcast. Consult and Liason Psychiatry; Who is suited to become a psychiatrist? "A high level of emotional intelligence awareness, pristine boundaries, and the ability to recognize, contain or transform pain your own or someone else's."Transcript

In this episode of the MDedge Psychcast, we revisit an interview that Lorenzo Norris, MD, MDedge Psychiatry editor in chief, conducted earlier this year by phone with two psychiatrists working in New Mexico. Dr. Norris spoke with Caroline Bonham, MD, and Avi Kriechman, MD, about enhancing resilience in rural communities. Dr. Bonham is vice chair in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is assistant professor in that department, and a pediatrician who works on youth suicide prevention and school mental health.   Understanding risks of suicide in rural communities Nationally, suicide rates have been going up across the United States, including in rural communities. Paucity of mental health clinicians supporting youth and their families has implications for youth suicide. Impact of structural poverty and the opioid epidemic also have implications for these rising rates.  Identifying resources within small, rural communities Communities have resources that are not tapped into enough by clinicians, such as churches, teachers, and community health workers. Recent studies show that most communities have members who know people at risk and want to help. It is important for clinicians to think outside of the box so that they help facilitate the use of natural resources/strengths that exist within small communities, such as food pantries that operate out of mental health centers, spiritual organizations, and aftercare programs in schools.  Building resilience among individuals The literature shows that engaging people in a collaborative, transparent process of care is effective. If community members who do not have problems, such as suicidality, physical ailments, or a severe mental illness, are taught to reach out, destigmatize, and facilitate treatment, the mental health outcomes of patients are better. Concrete, feasible intervention would be to work with gun store owners about the risk factors for suicide, how to encourage people to seek help. Some police departments provide education about the safe storage of firearms. References Curtin SC and Heron M. Death rates due to suicide and homicide among persons aged 10-24: United States, 2000-2017. NCHS Data Brief. 2019 Oct;(352):1-8. Altschul DB et al. State legislative approach to enumerating behavioral health workforce shortages: Lessons learned in New Mexico. Am J Prev Med. 2018 Jun;54(6 suppl 3):S220-9. Bonham C et al. Training psychiatrists for rural practice: A 20-year follow-up. Acad Psychiatry. 2014 Oct;38(5):623-6. Kriechman A et al. Expanding the vision: The strength-based, community-oriented child and adolescent psychiatrist working in schools. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):149-62. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych

 Roberto Lewis-Fernández, MD, returns to the MDedge Psychcast, this time to discuss ways to approach pharmacotherapy for Latino patients with depression. Previously, on episode 36 of the Psychcast, Dr. Lewis-Fernández discussed the role of cultural assessments in providing person-centered mental health care. Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University and director of the New York state Center of Excellence for Cultural Competence and the Hispanic Treatment Program at the New York Psychiatric Institute, spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP. And later, in the “Dr. RK” segment, Renee Kohanski, MD, asks whether some euphemisms that are becoming more common in society keep us from finding real solutions to problems. *  *  *   Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *   How Latino patients typically think of illness and medications Commonly, patients of Latino descent seek mental health treatment after trying other interventions, such as talking with family, clergy, and primary care clinicians. Latino patients, similar to other patient populations, sometimes present with ambivalence about medications and concerns that the medications might be “fairly strong” or addictive. The need to take medications is seen as an admission of sorts that the presenting problem of depression or anxiety is serious. Specifically, Latino patients are concerned about medications and risk of physical and psychological addiction and being reliant on a crutch. For example, a Latino patient might worry that by taking an antidepressant medication, they will lose their innate ability to improve on their own. This belief plays out when Latino patients stop medication prematurely, just as it begins to be effective, in order to “poner de mi parte,” which translates to “do my share.” The Latino culture puts weight on self-reliance. Latino patients often look for flexibility in medications and express concern about their effect on the body. For example, some patients might want to take medication only on days in which they feel sick. Others might ask for days off from the medication to ensure that the body does not weaken from being dependent on medications. Natural remedies often are favored by Latino patients. In some Latino communities, there might be natural pharmacies and “botanicas,” which provide herbal and vitamin remedies. Natural medicines are viewed as “gentle” and more in line with what the body needs. Psychotherapy for the treatment of mild depression often is favored by patients who want to use therapy before medications. Latino patients usually prefer more "advice"-driven psychotherapy that focuses on problem solving. Possible structural barriers to treating Latino patients Common structural barriers to accessing care include limited time to make appointments because of work and family obligations as well as a fragmented health care system with ever changing clinicians. Stigma and concerns about “harm to the body” can prove to be barriers.  How clinicians might work with Latino patients Be open to being flexible to patients’ requests, such as the desire to perhaps skip a day each week or even stop medications. Exerting clinical authority based on biological understanding of the medication and diagnosis can backfire and can result in patients stopping the medication altogether. Understand different conceptions in the Latino community about how and when emotions should be expressed. The “ataque de nervios” (“attack of nerves”) presented in the DSM-5 as a culture-bound syndrome is indicative of the Latino attitude that emotions are meant to be expressed but also controlled. So “un ataque de nervios” represents a situation that is so overwhelming that emotions take over, such as an attack and cannot be controlled. Know that warmth is more important than expertise in the eyes of some Latino patients. References Vargas SM et al. Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy. Transcult Psychiatry. 2015 Apr;52(2):244-73. Lewis-Fernández R et al. Impact of motivational pharmacotherapy on treatment retention among depressed Latinos. Psychiatry. 2013 Fall; 76(3):210-2. Moitra E et al. Examination of ataque de nervios and ataque de nervios like events in a diverse sample of adults with anxiety disorders. Depress Anxiety. 2018 Dec;35(12):1190-7. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

Jack Drescher, MD, returns to the MDedge Psychcast, this time to discuss ethical issues raised by the treatment of gender-variant prepubescent children with MDedge Psychiatry editor in chief Lorenzo Norris, MD. The two spoke at the 2019 Group for Advancement in Psychiatry (GAP) meeting in White Plains, N.Y. Dr. Drescher is a Distinguished Life Fellow of the American Psychiatric Association, past president of GAP, and a past president of the APA’s New York County Psychiatric Society. He has a private practice in New York. And later, in the “Dr. RK” segment, Renee Kohanski, MD, says artificial intelligence is much more powerful than we imagined. *  *  *   Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *   Three approaches used to address gender-variant children Despite the acceptance of gender dysphoria as a diagnosis with standardized treatments, the treatment of gender-variant prepubescent children remains a controversial area. There are several treatment approaches regarding how and when a child should have a social transition to their desired gender.  The oldest treatment approach is based on research that shows that most children will grow out of their gender dysphoria when the therapies applied help the children get used to living in the body of their assigned gender. Essentially, this approach discourages public or private social transition.  The Dutch Protocol is based on research that shows the difficulty in predicting which children will continue to have gender dysphoria and which will not. Some children will have persistent gender dysphoria and become transgender; some may become homosexual; and others may identify with their own biological sex. The Dutch approach encourages children to have cross-gender interests and to privately identify with their desired gender, but there is not a public social transition. Families and clinicians use watchful waiting to see whether the gender dysphoria persists. It’s based on the idea that one cannot predict the future and so parents accept the child wherever they are.  The final approach focuses on social transition without a medical or surgical treatment. Therefore, if the child’s gender dysphoria desists, they can “detransition,” since there was no medical intervention. The gender-affirmative approach, mostly found in the United States, presupposes that it is possible to identify which children will persist in their transgender presentations and encourages a public, social transition to living as their identified gender. In case the child “makes a mistake,” they can transition back to their biological sex. A social transition occurs when a child, with the help of clinicians, explains to the family that they believe the gender dysphoria is going to last and that the child should be allowed to present publicly as their desired gender. This includes communicating with the school, family, and friends to help the child to be treated respectfully in the gender they desire.  Treatments for gender-variant children Puberty suppression is a medical treatment used by physicians in all three approaches. These medications block sex hormone action and are used to delay puberty and prevent the development of undesired secondary sex characteristics of the biologic sex. Adolescents frequently experience anxiety, depression, even suicidal ideation during this period because they feel pressured to choose their gender and avoid developing the secondary sexual characteristics of their biological sex.  Social changes are outpacing the science. More frequently, children show up at gender clinics already socially transitioned by their parents; these children outnumber the subjects in the persist and desist literature. Regardless of the approach used, parents and clinicians should try to act on the exigent circumstances to relieve the distress of the child.  Patients who are transitioning should be referred to a specialist, because this is a sensitive topic and treatment requires expertise.  References  Shumer DE et al. Advances in the care of transgender children and adolescents. Adv Pediatr. 2016 Aug;63(1):79-102. Reed GM et al. Disorders related to sexuality and gender identity in the ICD-11: Revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21. Zraick K. Texas father says 7-year-old isn’t transgender, igniting a political outcry. New York Times. 2019 Oct 28. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych

  Mark S. Gold, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to discuss the intersection between the rise in suicide and the opioid crisis in the United States. Dr. Gold is adjunct professor of psychiatry at Washington University in St. Louis. He also serves on the editorial advisory board of MDedge Psychiatry. Previously, Dr. Gold served as distinguished professor and chairman of the psychiatry department at the University of Florida, Gainesville. * * *  Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * Timestamps: This week in Psychiatry (01:11) Interview with Dr. Gold (03:40) This week in Psychiatry Demeaning patient behavior takes an emotional toll on physicians by Steve Cimino Suicide and the opioid crisis In 2017, more than 70,000 people died from overdose, and 47,600 of those deaths involved prescription or illicit opioids. Most coroners list the deaths as “accidental” unless there is a suicide note or the deceased spoke about an intent to die. Chronic opioid self-administration changes the brain. The person becomes less high and more depressed over time. The prevalence of depression is at least 50% in those with opioid use disorder. Some experts estimate that up to 30% of opioid overdoses are intentional and count as suicide. A person with opioid use disorder has 13 times the risk of attempting and completing suicide, compared with the general population. Until recently, psychiatric evaluations and suicide assessments were not routine in the chain of events from opioid use to overdose to transition to medication-assisted treatment (MAT). People whose overdoses are reversed by naloxone are prime candidates to ask whether an overdose was accidental. In an emergency department in Flint, Mich., 30% of overdose patients rescued with naloxone described their overdose as a suicide attempt. Although some people revived with naloxone are angry, it is important to consider irritability and anhedonia that come from giving an opioid antagonist during a high. Future of treatments in the opioid crisis Much is still unknown. For example, there are no MAT options for either stimulant or cannabis use disorders, which are implicated in the morbidity and mortality of the overdose crisis. More research is needed to determine how long patients should be on MAT and when their brains “reset” after addiction. Also, in the pipeline is advanced imaging showing how drug use changes a person’s neurocircuitry and genetics. The OPRM1 gene, for example, is a polymorphism whose presence predicts whether a person is more likely to become addicted after their first use of opiates and determines treatment resistance to recovery. In the next year, efforts aimed at preventing overdoses and investigating the risk and rates of suicide are likely to continue. If every patient with a high-dose opioid prescription were offered naloxone, nearly 9 million more naloxone prescriptions could have been dispensed in 2018. So, we might see state-level policies that seek to increase naloxone prescriptions to patients based on morphine equivalents. Looking beyond overdoses and relapse prevention, the National Institute on Drug Abuse (NIDA) has identified novel targets focused on regenerating the reward system in order to return the brains of people with addictions to premorbid function after years of abuse.   References Volkow N and Gordon J. Suicide deaths are a major component of the opioid crisis. NIDA. 2019 Sep 19. Oquendo MA and Volkow ND. Suicide: A silent contributor to opioid-overdose deaths. New Engl J Med. 2018;378:1567-9. 5-point strategy to combat the opioid crisis. U.S. Department of Health & Human Services. Still not enough naloxone where it’s most needed. Centers for Disease Control and Prevention. 2019 Aug 6.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

  Dinah Miller, MD, returns to the MDedge Psychcast, this time to do a Masterclass lecture on involuntary commitment. Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care.” She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. In addition, Dr. Miller is a columnist for Clinical Psychiatry News and serves on the editorial advisory boards of CPN and MDedge Psychiatry. Timestamps: This week in Psychiatry (00:37) Masterclass lecture (02:00) Dr. RK (40:50) This week in Psychiatry: Duloxetine 'sprinkle' launches for patients with difficulty swallowing by Christopher Palmer Drizalma Sprinkle (duloxetine delayed-release capsule) has launched for the treatment of various neuropsychiatric and pain disorders in patients with difficulty swallowing. Overview of the involuntary commitment debate Four main controversies surround involuntary treatment First, standards for involuntary commitment vary by state; most states require that a person be diagnosed with a mental illness and is imminently dangerous to self or others. Some states extend their parameters to include those who are “gravely disabled” or need of psychiatric treatment. Second, as involuntary beds decrease, there is no place for involuntary treatment. Third, involuntary treatment includes outpatient civil commitment (OCC), and policy groups differ in their opinions of involuntary inpatient and outpatient treatments. Laws defining the need and amount of mandated outpatient services vary, based on geographical area. Also, outpatient commitment is difficult to enforce. The final controversy addresses a patient’s right to refuse treatment with medication. Groups hold wide-ranging positions along policy spectrum The Treatment Advocacy Center is a strong proponent of involuntary hospitalization. The group advocates for more state hospital beds in the United States, monitors the number of state hospital beds, proposes an involuntary standard of based on need for treatment, and argues that anosognosia justifies involuntary hospitalization. The National Alliance on Mental Illness (NAMI) is a grassroots organization founded by parents of individuals with serious mental illness (SMI) and initially represented a view in favor of involuntary hospitalization based on protecting those with SMI. However, as NAMI has grown to represent a broad swath of people with mental illness, the organization has struggled with whether it represents the interests of people with SMI only or a broader group of people with any mental illness. The American Psychiatric Association holds the middle ground, identifying dangerousness as the standard of involuntary care. In 2015, the APA released a carefully worded stance in support of outpatient commitment on a limited basis. Organizations strongly against involuntary treatment include the Bazelon Center for Mental Health Law, whose mission is to protect and advance the rights of adults and children with mental illness. The Bazelon Center opposes anything that restricts the rights of people with mental illness. The recovery movement, which developed as a backlash against the perceived paternalism of psychiatry, prioritizes the mental health consumer’s autonomy with an emphasis on peer support and being proactive in health care choices. On the antipsychiatry spectrum are the groups MindFreedom International and the Citizens Commission on Human Rights. Both of those groups oppose involuntary treatment. Violence and mental illness In the community, psychiatric illness is thought to be responsible for 4% of total violence and 7%-10% of murders. The MacArthur Foundation investigated rates of violence in people with mental illness 10 weeks after an inpatient hospitalization. It found that, compared with community samples, people with mental illness following hospitalization have higher rates of violence. The rate of violence was 8% for people with schizophrenia, 15% for bipolar disorder, 18% for depression, and 23% for personality disorder. Twenty weeks after discharge, patients with more treatment contacts were less likely to be violent. Mental illness does not belong in conversations about violence prevention because violence is more strongly correlated with substance use, anger, and early exposure to violence. Thus, mass murder cannot be prevented with forced care or institutionalization. The case is less clear for involuntary treatment for suicide prevention. For example, we know that two-thirds of gun deaths are suicides; however, we do not have statistics to elucidate whether involuntary hospitalization would prevent suicides. Final thoughts Involuntary hospitalization should be the treatment choice of last resort. A psychiatrist should pursue careful assessment with as many sources as possible and strongly suggest alternatives, such as voluntary hospitalization. Involuntary hospitalization could be less traumatizing by implementing steps such as reducing forced treatments, minimizing seclusion and restraints, asking patients for feedback at the end of their stays, and acknowledging that involuntary treatment is difficult. Involuntary care would be less necessary if voluntary care were easier to access earlier in an illness to avoid crisis and hospitalization.   References Miller D and Hanson A. “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). Torrey EF et al. The MacArthur Violence Risk Study revisited: Two views ten years after its initial publication. Psychiatr Serv. 2008 Feb 1;59(2):147-52. Testa M and West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010 Oct;7(10):30-40. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

Kent A. Kiehl, PhD, joins host Lorenzo Norris, MD on the MDedge Psychcast to discuss the use of MRI scans to provide information about the brains of people who exhibit antisocial behaviors. The goals are to use the information to treat patients and prevent violent crimes.  Timestamps: This week in Psychiatry (00:33) Meet the guest (03:35) Interview (04:25) Credits (54:10) Dr. Kiehl is professor of psychology, neuroscience, and law at the University of New Mexico, Albuquerque. He also codirects a nonprofit mental health research institute called the Mind Research Network, also in Albuquerque. He also helps run a for-profit consulting firm that helps attorneys do better science, called MINDSET. This week in Psychiatry: Suicide attempts up in black U.S. teens by Randy Dotinga Overall rates of suicide dipped from 1991 to 2017, according to research published in Pediatrics. However, the rate of suicide attempts grew slightly in black adolescents during that time.  SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI: 10.1542/peds.2019-1187.   Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Brain imaging can support diagnoses Dr. Kiehl works with cutting-edge technology using noninvasive structural and functional brain imaging; machine learning, such as artificial intelligence; and algorithms to evaluate forensic patients and understand psychopathology, predict outcomes, and measure the impact of interventions. Dr. Kiehl and his team travel to prisons across the country with two mobile MRI units imaging incarcerated individuals and forensic patients. More and more, brain imaging is considered in capital cases, because MRI provides valuable information for defense attorneys and prosecutors. For example, a man was charged with murder and his MRI supported a diagnosis of frontotemporal dementia with a behavioral variant, so he was able to plead not criminally responsible based on his illness – and was sent to a state mental hospital rather than to death row. The case of John W. Hinckley Jr., who shot former President Ronald Reagan and his press secretary, James Brady in 1981, was an initial case in which neuroscience and imaging influenced the verdict. The shooter’s brain imaging showed enlarged ventricles and cortical atrophy, which supported a diagnosis of schizophrenia – particularly when compared with the imaging of age-matched controls. Structural and functional MRI is an adjunct to neuropsychological tests. Neuroscientists are elucidating patterns through artificial intelligence and algorithms that can be useful to civil and criminal cases. For example, age is considered a strong predictor of antisocial behaviors. To enhance accuracy, Dr. Kiehl’s team has developed a neuroprediction model in which MRI quantifies brain age, which correlates closely with cognitive testing scores. So, brain age might be more useful for predicting behavior than chronological age. This study used more than 1,000 imaging studies of inmates. The data were analyzed using an algorithm called independent component analysis, which evaluates distinct neural circuits to identify components that predict age. In the next step of analysis, the algorithm identifies patterns associated with reoffending. Younger brain age in the anterior temporal lobe and orbitofrontal cortex – brain areas associated with decision making – accurately estimates the risk of reoffending better than just chronological age. Based on an understanding of brain plasticity, dogma suggesting that people who commit violent crimes cannot be changed should be challenged. A group at the University of Wisconsin, Madison, was asked to create an evidence-based, multimodal treatment program for the hardest-to-treat violent juvenile offenders. The program, which includes interventions such as multisystemic family therapy and positive reinforcement contingency treatment, resulted in a decrease in reoffending and violent crimes in participants who received 10 months of treatment. Dr. Kiehl’s group followed up with those juvenile boys using MRI to evaluate what had changed in their brains, how much treatment is required, and how or whether those brain changes can be reinforced. Reduction in incarceration costs is a return on investment for the states that fund those types of programs. Take-home points If scientists can identify useful interventions and identify brain changes though imaging, perhaps science can affect outcomes such as societal violence and incarceration rates. Implementation is the primary short-term obstacle. This type of research needs more funding and institutional change to identify programs that work. The brain has an incredible amount of plasticity, which translates into opportunities for change.   References  The Mind Research Network Kiehl KA. The Psychopath Whisperer: The Science of Those Without Conscience. Random House, 2014. Kiehl KA et al. Age of gray matters: Neuroprediction of recidivism. Neuroimage Clin. 2018;19:813-23. Steele VR et al. Machine learning of structural magnetic resonance imaging predicts psychopathic traits in adolescent offenders. Neuroimage. 2017 Jan 15;145(Pt B);265-73.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych        

Susan Hatters Friedman, MD, returns to the MDedge Psychcast  to join host Lorenzo Norris, MD,  to discuss postpartum psychosis. Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman and colleagues recently wrote an article published in Current Psychiatry examining this topic, Postpartum psychosis: Protecting mother and infant. Timestamps: This week in psychiatry (01:09) Interview (05:07) Dr. RK (22:07) Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.   Overview of postpartum psychosis   Postpartum psychosis is a medical emergency with a fulminant development occurring within 1-4 weeks after delivery. Onset is usually 3-10 days postpartum, and women experience a spectrum of symptoms from psychosis to dysphoric mania and confusion. Many women who experience postpartum psychosis do not have a past psychiatric history, although they might go on to develop bipolar disorder. Symptoms change quickly, with risks of devastating consequences. A woman with postpartum psychosis might minimize or even conceal her symptoms to avoid being separated from her child or out of fear that her child will be taken away. Collateral information is extremely important. A woman is at the greatest risk of developing a mental illness in the period around childbirth. The rate of postpartum depression is 1 in 9, and the baseline rate of postpartum psychosis is 1/500. Women with bipolar disorder (which may be undiagnosed until the postpartum psychosis) or a previous episode of postpartum psychosis are at highest risk of postpartum psychosis. Prevention and intervention Clinicians must be proactive with their psychoeducation about pregnancy, contraception, and the natural course of mental disorders during pregnancy and postpartum. If a patient with bipolar disorder is of childbearing age, the clinician should consider having her on medications that are relatively safe during pregnancy. In 2011, 45% of pregnancies in the United States were unintended; thus, preconception counseling is necessary. Medications for bipolar disorder can help prevent postpartum psychosis. Other preventive measures include using sleep strategies after childbirth, such as arranging support to assist at night and weighing the risks of breastfeeding. Breastfeeding can lead to sleep deprivation, which in turn, increases the risk of decompensation. If a woman wants to breastfeed, the psychiatrist should be in touch with the pediatrician and plan for breastfeeding by having the mother on medications that are safe for breastfeeding. Involuntary hospitalization might be required if the postpartum psychosis puts the mother or child at imminent risk of harm. Family and nonpsychiatrists on the health care team might be resistant to psychiatric hospitalization because it would mean separating the mother from the child. Psychiatrists can broach resistance by explaining the details of a thorough risk assessment and emphasizing that, while bonding is important, the hospitalization is meant to prevent the worst outcomes of suicide or infanticide. Review of key points Postpartum psychosis can present with mood symptoms or delirium, so those signs should make a clinician vigilant for postpartum psychosis. The symptoms of postpartum psychosis change rapidly with escalating danger, such as infanticide and suicide, so collateral from family and speedy treatment are essential. Focused early collaboration and education with team member such as ob.gyns. and pediatricians help make future interventions go more smoothly.   References Friedman SH et al. Postpartum psychosis: Protecting mother and infant. Curr Psychiatr. 2019 Apr 1;18(4):13-21. Sit D et al. A review of postpartum psychosis. J Womens Health (Larchmt). 2006 May;15(4):352-68. Harlow BL et al. Incidence of hospitalization for postpartum psychosis and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry. 2007;64(1):42-8.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

Susan Hatters Friedman, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about family murder.  Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman is editor of Family Murder: Pathologies of Love and Hate, which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Overview of family murder  Family murder is defined as situations in which any member of a family kills another family member. It encompasses a wide scope of violence that includes intimate partner homicide; infanticide, including purposeful feticide; neonaticide (murder in first day of life); siblicide; and parricide (a child killing a parent).  The book, Family Murder: Pathologies of Love and Hate, discusses the epidemiology and public health implications of family murder, various motivations, and pertinent psychiatric assessments, including risk assessments and sanity evaluations. It was written to prompt better screening and risk assessments, with the goal of prevention.  Motivating factors leading to murder  Phillip J. Resnick, MD, who also works in forensic psychiatry at Case Western, identified five main motives of parent-child violence.  Fatal maltreatment is the result of fatal neglect or abuse by a parent. This type of family murder is common and is most likely to be prevented, especially with intervention by Child Protective Services. Altruistic murder occurs in three categories in which a parent wants to spare a child from perceived suffering: Psychotic parents with delusions about their children being harmed. Murder-suicide, such as when a severely depressed and suicidal parent kills their child to avoid leaving them without a parent after their suicide. Parents who kill a child with serious, chronic physical illness as a means of “saving” the child from a “worse” fate. Acutely psychotic murder occurs in the context of serious mental illness such as schizophrenia, bipolar disorder, or postpartum psychosis. Preventing this type of murder means monitoring the content of delusions and hallucinations related to family members. The Andrea Yates murders are a prime example of this type of murder. Unwanted child motive is most common in neonaticide cases. The child is considered a hindrance to something the parent wants, such as a relationship. To screen for this risk, physicians can ask whether the pregnancy was planned and observe the interaction between child and parent, especially during the first hours to days of life. Partner revenge is rare but is most likely to occur in context of a custody battle, with one partner seeing murder as a means of revenge. Psychiatrists can observe interactions between partners and inquire about threats from partners. Screening and preventing violence  Psychiatrists can screen for violence by asking: “How are disagreements handled in your family?” This broad, neutral question elucidates family dynamics about partner violence, anger, and negative parental practices. It can generate information aimed at preventing fatal outcomes. Strong human emotions, such as anger, jealousy, and pride, combined with risk factors such as a history of violence and access to weapons, drive family murder. Psychoeducation about childhood development can decrease the risk of violence, especially in the fatal maltreatment category. Addressing countertransference issues  Family murder stimulates strong countertransference in response to the perpetrator. Working as a team can diffuse these emotions and allows a venue for processing. Building rapport with patients and recognizing their humanity by using phrases such as “When he died,” rather than “When you killed him.”   References  Family Murder: Pathologies of Love and Hate. Group for the Advancement of Psychiatry, 2018. Hatters Friedman S. Filicide-suicide: Common factors in parents who kill their children and themselves. J Am Acad Psychiatry Law. 2005 Jan. 33(4):496-504.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych

Judith R. Milner, MD, MEd, SpecEd, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about steps psychiatrists can take to address the mental health needs of people traumatized by a natural disaster, such as Hurricane Dorian survivors.  In This Week in Psychiatry, Katherine Epstein, MD, and Helen M. Farrell, MD, write about miracle cures in psychiatry. You can read the article online by clicking here or you can access the downloadable PDF by clicking here.  Time Stamps: This Week in Psychiatry (02:37) Interview with Dr. Milner (06:33) Dr. RK with Dr. Renee Kohanski (39:31) Dr. Milner is a general and child and adolescent psychiatrist in private practice in Everett, Wash. She has traveled across the globe with various groups in an effort to alleviate some of the suffering caused by war and natural disaster. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses the extent to which people choose what is important and meaningful. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.   STAGES OF NATURAL DISASTERS Devastation stage During the devastation stage, the primary objectives are giving basic first aid and attending to the sick, searching for those who are missing, and getting people safely into shelters. Psychological first aid (PFA) is the primary form of mental health treatment. PFA addresses basic needs by helping people find shelter, food, water; assisting with communication; reuniting families; and conducting case management to address acute needs. Normalization stage The normalization stage continues for several months after the disaster and includes the honeymoon phase, in which people are grateful to have survived and the community unites to rebuild; and then the disillusionment phase, during which frustrations and hopelessness arise as communities and individuals realize the limits of disaster assistance. Psychiatric disorders are likely to develop during the normalization stage. Acute stress disorder (ASD) typically occurs 3-30 days after the event with cardinal symptoms such as hyperarousal, hypervigilance, and negative cognitions that affect relationships. Medical professionals should monitor for development of chronic disorders such as PTSD, major depressive disorder, and anxiety disorders. Prolonged stressors, such as living in a damaged home, increase the risk of depression and anxiety. Those with preexisting vulnerabilities – such as past traumatic experiences from physical, sexual, or emotional abuse; previous natural disasters; or other chronic stressors of poverty and medical illness – are at greatest risk of developing a trauma-related disorder after a natural disaster. The normalization stage is a critical period to use the “training the trainer” model. Because many locations do not have a surplus of mental health clinicians, psychiatrist volunteers can train local individuals to provide services. For example, mental health professionals can train the trainers to recognize symptoms of common psychiatric conditions and to provide basic treatment. Manualized therapies are useful but require in-depth training. Other simple modalities, such as deep breathing, visualization, and relaxation techniques, can be useful. Acceptance stage During the acceptance stage, rates of persistent PTSD range from 25% to 40%. Ongoing therapy is helpful, especially group therapy, which is an effective use of resources. Facilitation of group therapy can be taught while training the trainers. If a mental health professional volunteers and participates in the training the trainers’ model, there must be follow-up, which should include providing intellectual support and refresher courses, evaluating how training is being used, and checking up on patients/clients who have received services. Predisaster advice: Do not go it alone. Affiliate with a group that has a plan, so that your presence on the scene does not add to the chaos. Postdisaster advice: Be aware of compassion fatigue and take time away from volunteerism. Recognize signs of secondary traumatic stress. Counsel volunteers upon their return from the disaster site.   References Substance Abuse and Mental Health Services Administration. Phases of disaster. Last updated 2018 Oct 1. Pfefferbaum B et al. Practice parameter on disaster preparedness. J Am Acad Child Adolesc Psychiatry. 2013 Nov;52(11):1224-38. World Health Organization. Psychological first aid: Guide for field workers. 2011. National Child and Traumatic Stress Network. Psychological first aid online. International Institute for Psychosocial Trauma. Clinical assessment of survivors of trauma. U.S. Department of Veterans Affairs. PTSD: National Center on PTSD. Compassion Fatigue Awareness Project. Disaster Psychiatry Outreach.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

Show Notes J. John Mann, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about the need for medicine to shift its approaches to preventing suicide. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education. Dr. Mann is professor of translational neuroscience at Columbia University in New York.  For a complete video of this interview, see this vodcast. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how a religious wedding she attended made her think about the distinction between cults and cultures. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.   Why are suicide rates on the rise? In the United States, between 2001-2017, the suicide rate increased by 33%, making suicide the second-leading cause of death for people aged 15-34 years. Why the suicide rate has increased is unclear. Factors influencing rising suicide rates include the 2008 recession and the opioid crisis; however, these events cannot fully explain the trend because they occurred in the middle of the rising rates. As suicide rates increase, the medical community missed opportunities for prevention at both primary care and psychiatry visits. A Centers for Disease Control and Prevention study that examined suicide rates and psychiatric illness found approximately half of suicide decedents did not have a known mental health condition. Connections to untreated psychiatric illness Only 22% of people with psychiatric illness who die by suicide had their mental illness treated. The age of onset for major depressive disorder has been occurring earlier and indicates a greater pool of individuals is at risk of suicide. For example, during 2005-2014, major depressive episodes in adolescents increased by nearly one-third. Individuals who attempt and die by suicide have a predisposition to respond to their mental illness with suicidal behaviors. This trait poses a challenge in the face of rising rates of mental illness in the United States.  Role of treatment by primary care physicians 45% of individuals who die from suicide see their primary care clinician within a month of their death. If nonpsychiatrist doctors or primary care physicians are trained to recognize depression and suicide, the rates of death and disability from depression can be decreased. Most people who die by suicide are seeking help by going to a health care professional. How should the clinician respond? If a person presents with somatic complaints with no clear causes (for example, normal lab values), this is a time for the primary care physicians to ask about depression and suicide. What steps can be taken to prevent suicide? Medicine needs an updated approach in education about depression and suicide that is similar to the changes that have taken place during the opioid crisis. Now all clinicians must complete continuing medical education about pain management and opioid prescribing, which has led to a decrease in deaths from prescription pain medications. All clinicians must be able to recognize and treat depression, because it is becoming a leading cause of death and disability. Clinicians need to do a better job of making connections between somatic complaints and mood disorders. References U.S. Department of Health and Human Services, National Institutes of Health. Mental health information: Suicide. Updated August 2019. Stene-Larsen K and A Reneflot. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019 Feb;47(1):9-17. Reed J. Primary care: A crucial setting for suicide prevention. SAMHSA-HRSA Center for Integrated Solutions. U.S. Department of Health and Human Services. Adolescent mental health basics. Rising rates of MDD in adolescents. Bruce ML et al. Reducing suicidal ideation and depressive symptoms in depressed older patients. JAMA. 2004 Mar 3;291(9):1081-91. DA Brent and N Melhem. Familial transmission of suicidal behavior. Psychiatr Clin North Am. 2008 Jun;31(2):157-77. Mohatt NV et al. A menu of options: Resources for preventing veteran suicide in rural communities. Psychol Serv. 2018 Aug;15(3):262-9.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

  Show Notes Roger McIntyre, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about obesity, inflammation, and treatment implications for mental health conditions. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education.  Dr. McIntyre is a professor of psychiatry and pharmacology at the University of Toronto, and head of the mood disorders psychopharmacology unit at the University Health Network, also in Toronto. For a complete video of this interview, please visit the vodcast. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how to think through whether sharing personal information with patients helps move their therapy forward. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.   Reconceptualizing mental illness by looking at inflammation Mental illness should be viewed as a disease involving many organs – including the brain – and psychiatry should expand its understanding of the etiology of mental illness. Increasingly, research suggests that a subgroup of people with mental disorders, including those with a variety of diagnoses, have symptoms related to alterations in their immune system and inflammation. Inflammation plays a role in disparate psychiatric diagnoses, including childhood disorders such as obsessive-compulsive disorder, ADHD, and autism, and adult disorders such as schizophrenia, depression, and Alzheimer’s disease. Currently, psychiatry uses the monoamine paradigm to explain psychiatric diagnosis, and most medications were developed using that paradigm. A subgroup of people is not sufficiently helped by current medications, so looking at inflammation as a driver of mental illness provides another biological avenue to pursue drug development. Role of obesity and chronic health conditions in worsening inflammation Obesity, particularly abdominal obesity, is overrepresented in people with mental illness and is not fully explained by either social determinants of health or medication side effects. Obesity and mental illness have a bidirectional relationship; each affects the body as multiorgan system diseases. Mental illness can be conceptualized as a kind of “metastasis to the brain.” Adipose tissue releases a surfeit of neurochemicals hazardous to brain function and that disrupt neurocircuitry. For example, compared with an individual with major depressive disorder (MDD) only, an individual with MDD and obesity is more likely to have symptoms driven by inflammation, such as anhedonia, cognitive impairment, limited motivation, and a dysregulated reward system. Obesity should also be a target symptom worthy of a focused treatment plan. Heart disease is the leading cause of death in schizophrenia, and coronary artery disease is an inflammatory illness. Research is identifying connections between psychiatric illness such as schizophrenia and potentially inflammatory driven symptoms, often called “sickness behaviors,” such as low motivation, anhedonia, and cognitive impairment. Clinical implications of obesity and inflammation Alterations in inflammation and metabolism are not just a consequence of obesity. For example, patients will bipolar disorder who report sexual or physical trauma are more likely to be in a proinflammatory neurochemical state and benefit from anti-inflammatory interventions. Are patients with early trauma who do not respond fully to “traditional” monoamine medications part of the subpopulation who respond to anti-inflammatory interventions because trauma is driving inflammation? The genetics of mental illness already are complicated and will be influenced by the environment and a “proinflammatory milieu.” Which tests show inflammation? Current inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein, are not specific enough to direct treatment of inflammation in mental illness. Elements of a patient’s history, including history of trauma, disrupted sleep and circadian disturbances, cigarette smoking, poverty, housing dislocation, and exposure to racism, can indicate inflammation. We can conceptualize as anti-inflammatory several current treatments, such as mindfulness-based therapy, electroconvulsive therapy, and selective serotonin reuptake inhibitors. Alternative treatments to treat inflammation exist; however, specific anti-inflammatory treatments, such as NSAIDs, cyclooxgenase-2 inhibitors, and minocycline, are not yet recommended for patients with mental illness. Targeting inflammation as prevention of psychiatric illness Clinicians can target drivers of inflammation as a means of treatment and prevention of mental illness. They can also target the basics, such as sleep, diet, exercise, and socializing, as preventive measures that also target inflammation. The incidence of depression can be decreased by targeting lifestyle changes and metabolic illness with treatments such as exercise and statins. Interventions focused on inflammation are being investigated as a means of prevention for people at risk of mental illness. For example, a study in China in which Dr. McIntyre was involved explored whether exercise can decrease the development of bipolar disorder in children who have a genetic predisposition to the illness. Caloric restriction can reduce inflammation and improve cognition.  Inflammation and the absence of ‘meaningful connections’ In social baseline theory, human beings allocate energy in proportion to their social connectivity. People with fewer social connections are more likely to be in a proinflammatory state and more likely to consume high-carbohydrate food. Loneliness can be conceptualized as an epidemic associated with serious health outcomes, such as suicide, addiction, and other chronic mental and physical health problems. We are living in a society of anxious despair. Psychiatry needs to broaden its understanding of mental illness by investigating a variety of underlying causes, from inflammation to the monoamine theory.   References Rosenblat JD et al. Inflamed moods: A review of the interactions between inflammation and mood disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2014 Aug 4;53:23-34. Harvey SB et al. Exercise and prevention of depression: Results of the HUNT cohort study. Am J Psychiatry. 2018 Jan 1;175(1):28-36. Redlich C et al. Statin use and risk of depression: A Swedish national cohort study. BMJ Psychiatry. 2014 Dec 4;14:348. doi: 10.1186/s12888-014.0348-y. Leclerc E et al. The effect of caloric restriction on working memory in healthy non-obese adults. CNS Spectr. 2019 Apr 10:1-7. doi: 10.1017/S1092852918001566. Schwabel D. “Vivek Murthy: How to solve the work loneliness epidemic.” Forbes.com. Oct 7, 2017. Ho RCM et al. Factors associated with risk of developing coronary artery disease in medical patients with major depressive disorder. Int J Environ Res Public Health. 2018 Oct;15 (10): 2073. doi: 10.33901/ijerph1510102073. Dantzer R. Cytokine, sickness behavior, and depression. Immunol Allergy Clin North Am. 2009 May;29(2): 247-64.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych                

  Show Notes Jack Rozel, MD, returns to the MDedge Psychcast to discuss gun violence and a new report from the National Council for Behavioral Health. In episodes 29 and 33, Dr. Rozel talked with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about this topic in the wake of the shooting last year at the Tree of Life synagogue in Pittsburgh.  Dr. Rozel is medical director of resolve Crisis Services at the Western Psychiatric Institute and Clinic of the University of Pittsburgh. He also is president-elect of the American Association for Emergency Psychiatry and a member of the National Council. Dr. Rozel can be found on Twitter @ViolenceWonks. Later, Renee Kohanski, MD, discusses betrayal in the context of Erik Erikson’s conceptualization of trust vs. mistrust. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.   Gun violence in the United States Mass violence with guns is a distinctly American problem occurring with greater frequency and severity in the United States, compared with other countries. The United States has a broad swath of firearm violence: Deaths by suicide account for 60% of gun deaths, and the remaining 40% are deaths by homicide. 1%-2% of homicides are completed in mass shootings, which are defined as an event in which a gunman indiscriminately shoots four or more people. Firearm homicides have been trending downward, while mass shootings have increased. Mass shootings might be influenced by media coverage; media exposure about mass shootings can incite possible perpetrators. Mass shootings are shown to cluster in ways similar to suicide contagion. Responses to mass shootings/violence The National Council for Behavioral Health addresses mass violence by releasing a new report: The report, called “Mass Violence in America: Causes, Impacts and Solutions,” was written by a group of 30 multidisciplinary experts, including Dr. Rozel. It was released in response to stigma and incorrect messages linking psychiatric diagnoses to mass violence. The report reviews models aimed at preventing violence and understanding threat assessment. Predicting violence and diffusing threats Pathway to violence is a model for predicting mass violence generated by data and analysis of violent acts by the Los Angeles Police Department, U.S. Capitol Police, U.S. Marshals Service, and the U.S. Secret Service. Grievances: Violence often starts with a grievance. Clinicians might be familiar with patients who are “grievance collectors” and do not get along with any person, whether at work, family, or society at large. The pivot: A transition from simply having a grievance to violent ideation and wanting vengeance through violence. Psychiatrists certainly will see people who express violent fantasies. Perpetrators of violence shift from fantasy into research about planning and preparing to attack. Clinicians want to identify the point at which people feel aggrieved and should become most concerned when these people begin to get certain fixations. Preparation: The person will start to acquire weapons and tactical clothing; probe into vulnerabilities of their targets, conduct “test attacks”; and eventually carry out the final attacks. Identification: The grievance stage is the most effective place to intervene, once the identification has been made, and potentially diffuse a violent outcome. The United States holds a unique position when it comes to gun ownership, violence The United States is one of the three countries in the world that allow citizen access to firearms in their constitutions. With 393 million civilian-held firearms, the United States has more civilian-owned firearms than the next 39 countries combined. India, which has 70 million civilian-held firearms, ranks No. 2. Regardless of what happens with gun control following each mass shooting, the guns already are out there in civilian hands. Behavioral health clinicians must talk with patients about firearms safety. A person living in the United States is 10 times more likely to die of firearm-related suicide and 25 times more likely to die of firearm-related homicide, compared with people living in other economically developed countries. Components of proposed legislation that could reduce gun violence: Increasing mental health access: Violent acts can be attenuated through access to mental health with anger-management classes and interventions at emotional regulation. Implementing universal background checks for gun purchases. Currently, this policy varies from state to state. Requiring a background check to obtain a concealed carry permit. Testing competency/shooting ability with guns before giving a permit. Increasing access to gun violence restraining orders, also called gun violence prevention orders. The restraining orders are aimed at temporarily stopping people who pose a threat to themselves or others by buying or possessing a firearm. The number needed to treat to prevent suicide with this type of restraining order is 11-20.  Education and research that could address the problem Research about the pathway to violence model and threat assessment can be used to create training for the array of professions that touch on violence – such as police, gun stores, teachers, and health care professionals. Training can focus on de-escalation and recognition of individuals at risk of perpetuating violence against themselves and others. Training for health care professionals should not be limited to just a psychiatry rotation, but also in emergency medicine and primary care, since gun violence affects patients within every field. Research into firearm violence prevention is incredibly underfunded, primarily because of the restrictions embedded in the Dickey Amendment. Named for the late Rep. Jay Dickey of Arkansas, the provision specifies that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” This amendment remains a huge obstacle to any group seeking to research gun violence. References Lankford A. Do the media unintentionally make mass killers into celebrities? An assessment of free advertising and earned media value. Celebr Stud. 2018;9(3):340-54. Knoll IV JL and GD Annas. Mass shootings and mental illness. In: Gold LH and RI Simon (eds). Gun Violence and Mental Illness. Arlington, Va.: American Psychiatric Association Publishing, 2016. Silver J et al. Foreshadowing targeted violence: Assessing leakage of intent by public mass murderers. Aggress Violent Behav. 2018;38:94-100. Metzl JM and KT MacLeish. Mental illness, mass shootings, and the politics of American firearms. Am J Public Health. 2015;105(2):240-9. Swanson JW et al. Gun violence, mental illness, and laws that prohibit gun possession: Evidence from two Florida counties. Health Aff (Millwood). 2016 Jun 1;35(6):1067-75. Van Dorn R et al. Mental disorder and violence: is there a relationship beyond substance use? Soc Psychiatry Psychiatr Epidemiol. 2012;47(3):487-503. Rahman T et al. Anders Breivik: extreme beliefs mistaken for psychosis. J Am Acad Psychiatry Law. 2016;44(1):28-35. National Council for Behavioral Health. Mass violence in America: Causes, impacts, and solutions. 2019 Aug. Mass shooters and murderers: Motives and paths. National Collaborating Centre for Mental Health. Violence and aggression: Short-term management in mental health, health and community settings.2019 Apr 1. Betz ME and GJ Wintemute. Physician counseling on firearm safety: A new kind of cultural competence. JAMA. 2015;314(5):449-50. District of Columbia v. Heller (2008). Rostron A. The Dickey amendment on federal funding for research on gun violence: A legal dissection. Am J Public Health. 2018 Jul;108(7):865-7. “More research could help prevent gun violence in America.” Rand Review. 2018 Jul 10.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych    

In this episode, Neal Christopher and Badr Raknakaran give an overview of other podcasts that may be of interest to psychiatrists. Links to some resources below: (Not all are discussed in the episode)   Psychopharmacology Updates Practical psychopharmacology updates for mental health clinicians. Useful for psychiatry / mental health professionals. Expert interviews and soundbites from CME presentations. Practical and free of commercial bias. Not sponsored by any pharmaceutical company. https://podcasts.apple.com/us/podcast/psychopharmacology-and-psychiatry-updates/id1425185370   MDedge https://podcasts.apple.com/us/podcast/mdedge-psychcast/id1382898254?mt=2 MDedge Psychcast is a weekly podcast from MDedge Psychiatry, online home of Clinical Psychiatry News and Current Psychiatry. Hosted by Editor in Chief Lorenzo Norris, MD, Psychcast features psychiatric clinicians discussing the issues and concerns that most affect their specialty. The information in this podcast is provided for informational and educational purposes only. The Medical Mind Podcast A podcast about innovation in mental health care from the APA Division of Education. APA Administration host Ann Thomas interviews APA members and other healthcare professionals about new initiatives in psychiatry. https://www.psychiatry.org/psychiatrists/education/podcasts/the-medical-mind-podcast   Psychiatric Services From Pages to Practice Psychiatric Services Editor Lisa Dixon, M.D., M.P.H., and Podcast Editor and co-host Josh Berezin, M.D., M.S., discuss key aspects of research recently published by Psychiatric Services. Tune in to Psychiatric Services From Pages to Practice to learn about the latest mental health services research and why it is relevant. Topics include community-based treatment programs, collaborative care, evidence-based treatment and service delivery, criminal and social justice, policy analysis, and more. https://ps.psychiatryonline.org/podcast   Psychiatry Unbound APA Publishing's Books podcast, hosted by APA Books Editor-in-Chief, Laura Roberts, M.D. Psychiatry Unbound offers the opportunity to hear the voices behind the most prominent psychiatric scholarship in the field today. Subscribe now to learn about important topics in the field of psychiatry and see how our authors are making an impact in clinical settings throughout the world. http://psychiatryunbound.apapublishing.libsynpro.com/   AJP Audio brings you highlights from each issue of The American Journal of Psychiatry. https://ajp.psychiatryonline.org/audio   The Journal of Clinical Psychiatry Publisher's Podcast includes monthly audio updates of the features in each issue of JCP, plus special features added from time to time. https://podcasts.apple.com/us/podcast/the-journal-of-clinical-psychiatry-publishers-podcast/id386299220   Concepts in Psychiatry The premiere podcast for psychiatrists, psychiatry residents, and other mental health professionals interested in strengthening their knowledge of the fundamental concepts of psychiatry and learning the latest news in the treatment of mental health disorders. Hosted by Sarah DeLeon, MD, a third year psychiatry resident. https://podcasts.apple.com/us/podcast/concepts-in-psychiatry/id1257416543   PsychEd: educational psychiatry podcast This podcast is written and produced by psychiatry residents at the University of Toronto and is aimed at medical students and residents. Listeners will learn about fundamental and more advanced topics in psychiatry as our resident team explore these topics with world-class psychiatrists at U of T and abroad. https://podcasts.apple.com/us/podcast/psyched-educational-psychiatry-podcast/id1215646896 Journal of the American Academy of Child and Adolescent Psychiatry Each month JAACAP highlights a selected article found within the pages of the Journal by providing a podcast interview with the author. Tune in regularly to this feature of JAACAP, where we strive for a relaxed 'fireside chat' atmosphere in which authors can share aspects of their science that we are less often privy to. Podcasts are typically 15 to 20 minutes in length. https://podcasts.apple.com/us/podcast/journal-american-academy-child-adolescent-psychiatry/id660778429   Focus on Neurology and Psychiatry by ReachMD New research and clinical trials yield frequent developments in neuroscience and mental health. ReachMD welcomes an array of leading thinkers who lend their focused expertise to these principles, central to human function and ability. https://podcasts.apple.com/us/podcast/focus-on-neurology-and-psychiatry/id913720346 Mad in America podcast Welcome to the Mad in America podcast, a new weekly discussion that searches for the truth about psychiatric prescription drugs and mental health care worldwide. This podcast is part of Mad in America's mission to serve as a catalyst for rethinking psychiatric care. We believe that the current drug-based paradigm of care has failed our society and that scientific research, as well as the lived experience of those who have been diagnosed with a psychiatric disorder, calls for profound change. On the podcast we have interviews with experts and those with lived experience of the psychiatric system. Thank you for joining us as we discuss the many issues around rethinking psychiatric care around the world.   https://podcasts.apple.com/us/podcast/focus-on-neurology-and-psychiatry/id913720346   SAGE Psychology & Psychiatry Welcome to the official free Podcast site from SAGE for Psychology & Psychiatry. SAGE is a leading international publisher of journals, books, and electronic media for academic, educational, and professional markets with principal offices in Los Angeles, London, New Delhi, and Singapore. https://podcasts.apple.com/us/podcast/sage-psychology-psychiatry/id871125966   Mental Health and Psychiatry (Video & Audio) Guest speakers, researchers and University of California faculty explore mental illness and mental health. https://podcasts.apple.com/us/podcast/mental-health-and-psychiatry-video/id522813934 https://podcasts.apple.com/us/podcast/mental-health-and-psychiatry-audio/id522813323 PeerView Neuroscience & Psychiatry CME/CNE/CPE Audio Podcast PeerView is an independent, professional medical publishing company focused on gathering and reporting information pertaining to clinically relevant advances and developments in the science and practice of medicine. As publishers of PeerView Publications, PeerView is solely responsible for the selection of publication topics, the preparation of editorial content and the distribution of all materials it publishes. https://podcasts.apple.com/us/podcast/peerview-neuroscience-psychiatry-cme-cne-cpe-audio/id179489480 Mental Health Book Club Podcast Sydney Timmins - a writer and Becky Lawrence - a secondary school teacher discuss books that contain mental health issues. Sydney and Becky will combine their love of reading and talking, working their way through anything from self-help, fiction and memoirs tackling a range of mental health issues. Trigger warning: this podcast discusses mental health topics that may cause distress to some listeners, we will give a full list of topics in each episodes show notes. https://podcasts.apple.com/us/podcast/mental-health-book-club-podcast/id1279210164 Mental - The Podcast to Destigmatise Mental Health Mental is the brain-child of Bobby Temps, who lives and thrives while managing his own mental health. Each week joined by a special guest Mental is intended to be a safe space to hear honest and open discussion about mental health in the hope listeners will feel more empowered to continue the conversation with others. This podcast is a chance for Bobby to give back for the support he has received and share what he continues to learn in the ongoing journey for optimum mental wellbeing. Covering many, many topics that influence mental health, we focus on identity and the sheer weight of being a human in our modern, technology-filled world. Learn about different conditions from first-hand experience, with statistics you can trust and inspiring guests. Mental health is something to be mindful of just as much as physical health, and Mental strives to let listeners know that they don't have to do so alone. Oh, and remember… you are enough! https://podcasts.apple.com/us/podcast/mental-the-podcast-to-destigmatise-mental-health/id1358920477   MQ Open Mind  MQ: Transforming Mental Health https://www.mqmentalhealth.org/ MQ Open Mind looks at the science behind mental health and its potential to transform lives. The show digs deep into the cutting-edge research taking on mental illness and speaks to the people it could help. Hear conversations on a range of different conditions, from depression and anxiety to schizophrenia and bipolar. Brought to you by MQ: Transforming Mental Health, the new major mental health research charity https://podcasts.apple.com/us/podcast/mq-open-mind/id1271690765 Piece of Mind: Mental Health & Psychiatry We bring you the latest on mental health research at Cardiff University's MRC Centre and the National Centre for Mental Health (NCMH), plus real-life experiences of people affected by mental health problems. We would love to hear your feedback or ideas for future episodes, either comment on our latest episode, message us at info@ncmh.info or Tweet/Insta with #POMpod. https://podcasts.apple.com/us/podcast/piece-of-mind-mental-health-psychiatry/id1326789920 Mental Health Foundation podcast https://podcasts.apple.com/us/podcast/mental-health-foundation-podcast/id665005881   JAMA Psychiatry Author Interviews Interviews with authors of articles from JAMA Psychiatry. JAMA Psychiatry is an international peer-reviewed journal for clinicians, scholars, and research scientists in psychiatry, mental health, behavioral science, and allied fields. JAMA Psychiatry strives to publish original, state-of-the-art studies and commentaries of general interest to clinicians, scholars, and research scientists in the field. The journal seeks to inform and to educate its readers as well as to stimulate debate and further exploration into the nature, causes, treatment, and public health importance of mental illness. https://podcasts.apple.com/us/podcast/jama-psychiatry-author-interviews/id1227007379   ADD Lancet NEI Podcast Neuroscience Education Institute The Neuroscience Education Institute (NEI) is committed to help raise the standard of mental health by providing imaginative medical education that focuses on the highest level of learning. Each episode offers an opportunity to learn about current issues in psychiatry from key opinion leaders in the medical field. NEI's Podcast would be of value to anyone with an interest in neuropsychiatric diseases and psychopharmacology. https://podcasts.apple.com/us/podcast/nei-podcast/id288425495 Therapy We All Wear It Differently A podcast for early career psychologists. If you're looking for inspiration and advice for your psychology career, you're in the right place. Amy Felman interviews working psychologists from diverse fields with all levels of experience as they share their journeys, challenges and career breakthroughs that have lead them to where they are today. Tune in and discover how we all wear it differently. https://podcasts.apple.com/us/podcast/we-all-wear-it-differently-podcast-for-early-career/id992827102 Psychologists Off The Clock: A Psychology Podcast About The Science And Practice Of Living Well Ever wonder what therapists talk about over coffee? We are three clinical psychologists who love to chat about the best ideas from psychology. In this podcast, we explore the psychological principles we use in our clinical work, and bring you ideas from psychology that can help you flourish in your work, parenting, relationships, and health. Thank you for listening to Psychologists Off The Clock! https://podcasts.apple.com/us/podcast/psychologists-off-clock-psychology-podcast-about-science/id1176171178 Shrink Rap Radio David Van Nuys, Ph.D. All the psychology you need to know and just enough to make you dangerous... This podcast features renowned psychologist,Dr. David Van Nuys , brining you in-depth interviews on a broad array of psychological topics including: psychotherapy, dreams, consciousness, depth psychology, business psychology, developmental psychology, mind/body psychology, personal growth, psychology and art, research psychology, social issues, and spirituality. The roster of world-class guests includes: Philip Zimbardo, Charles Tart, Irvin Yalom, Jonathan Haidt, Sara Lazar, Robert Altemeyer, Stanley Krippner, Arnold Mindell, Dacher Keltner, Michael Meade, and David Barlow among others. https://podcasts.apple.com/us/podcast/shrink-rap-radio/id79491957 Speaking of Psychology American Psychological Association "Speaking of Psychology" is an audio podcast series highlighting some of the latest, most important and relevant psychological research being conducted today. Produced by the American Psychological Association, these podcasts will help listeners apply the science of psychology to their everyday lives. https://podcasts.apple.com/us/podcast/speaking-of-psychology/id705934263 Counselor Toolbox Podcast  Dr. Dawn-Elise Snipes Counselors, coaches and sober companions help hundreds of thousands of people affected by Addictions and Mental Health issues each year. Learn about the current research and practical counseling tools to improve your skills and provide the best possible services. Counselor Toolbox targets counselors, coaches and companions, but can also provide useful counseling self-help tools for persons struggling with these issues and their loved ones. AllCEUs is an approved counseling continuing education provider for addiction and mental health counselors in most states. Counseling CEUs are available for each episode. https://podcasts.apple.com/us/podcast/counselor-toolbox-podcast/id1120947649 The Trauma Therapist Guy Macpherson, PhD This is a podcast about people helping people. Bruce Perry, Gabor Mate, Janina Fisher and many other of the world's leading master therapists, thought leaders and game-changers who specialize in PTSD, post-traumatic stress disorder, trauma, complex trauma and related fields join Guy Macpherson, PhD at thetraumatherapistpodcast.com for inspiring interviews about what it takes and what it means to sit with those who've been impacted by trauma. https://podcasts.apple.com/us/podcast/the-trauma-therapist/id899009517 The Thoughtful Counselor The Thoughful Counselor Team The Thoughtful Counselor is a podcast that is dedicated to producing great conversations around current topics in counseling and psychotherapy. We view counseling and psychotherapy as a deeply beautiful and complex process, and strive to incorporate both the art and science of the field in each episode. https://podcasts.apple.com/us/podcast/the-thoughtful-counselor/id1152853871 Between Us: A Psychotherapy Podcast    Psychotherapists John Totten and Mason Neely bring you this psychotherapy podcast that explores what is happening between therapists and patients, from both sides of the relationship. https://podcasts.apple.com/us/podcast/between-us-a-psychotherapy-podcast/id1152775317 The Modern Therapist's Survival Guide with Curt Widhalm and Katie Vernoy Curt Widhalm, LMFT and Katie Vernoy, LMFT The Modern Therapist's Survival Guide: Where Therapists Live, Breathe, and Practice as Human Beings It's time to reimagine therapy and what it means to be a therapist. We are human beings who can now present ourselves as whole people, with authenticity, purpose, and connection. Especially now, when clinicians must develop a personal brand to market their private practices, and are connecting over social media, engaging in social activism, pushing back against mental health stigma, and facing a whole new style of entrepreneurship. To support you as a whole person, a business owner, and a therapist, your hosts, Curt Widhalm and Katie Vernoy talk about how to approach the role of therapist in the modern age. https://podcasts.apple.com/us/podcast/modern-therapists-survival-guide-curt-widhalm-katie/id1310770477   ACT in Context Association for Contextual Behavioral Science ACT in Context is freely available to anyone, and its episodes will take listeners on a journey from the history and development of ACT through its clinical application and the future of the work. This podcast will primarily focus on ACT, but it will often touch upon several related issues such as behavioral principles, the underlying theory of language (Relational Frame Theory) and philosophy of science. We hope that informal learners, potential consumers, researchers and clinicians alike find it useful. https://podcasts.apple.com/us/podcast/act-in-context/id748513885   The Learn Psych Podcast is a monthly educational podcast on topics in psychiatry. It is targeted towards students and trainees, though it is often relevant to a wide variety of healthcare providers. https://podcasts.apple.com/us/podcast/learn-psych-podcast/id1118809594   Psychiatry Today Join Dr. Scot Bay every Wednesday night at 7PM while he discusses Psychiatry and mental health with guests. https://podcasts.apple.com/us/podcast/psychiatry-today/id279601313   Psychiatric videos for teaching Psychiatric interviews created for teaching purposes. https://podcasts.apple.com/us/podcast/psychiatric-videos-for-teaching/id670271700   Psyched??! We answer your call for psychiatry and mental health topics with our new upcoming podcast. We are two psychiatrists, David Carreon, 100%-nerd with a side of philosophy, and Jessi Gold, down-to-earth, empathic and, at times, sarcastic. We're starting a podcast called "Psyched!" aimed to communicate stories in neuroscience and psychiatry to a wider audience. We're targeting psychiatrists as our primary listeners, but hope to have a program that's accessible, entertaining and informative for a broader audience. Basically, we want to be the Economist for psychiatry. We'll cover everything from the foundational to the cutting-edge, from the popular to the weird. We hope to capture and communicate the excitement of psychiatry, and have fun while doing it. https://podcasts.apple.com/us/podcast/psyched-a-psychiatry-blog-episodes/id1299266826   Let's Talk about Borderline Personality Disorder A podcast about Borderline Personality Disorder by the National Education Alliance for Borderline Personality Disorder (NEABPD) https://podcasts.apple.com/us/podcast/lets-talk-about-borderline-personality-disorder/id1310234795   Psychiatry from University of Oxford Psychiatry is a medical discipline seeking to understand and treat mental illness. These podcasts provide an introduction to core topics in psychiatry, and to research undertaken in the Oxford University Department of Psychiatry. This series is relevant to health-care professionals and members of the public. The topic podcasts are particularly relevant to medical students studying psychiatry. https://podcasts.apple.com/us/podcast/psychiatry/id796432735   MGH Psychiatry Academy Podcasts https://player.fm/series/mgh-psychiatry-academy-podcasts  

Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, interviews the psychiatry residents who produce the PsychEd podcast, which as they put it, is “created by medical learners, for medical learners.” Dr. Norris speaks with some of the members of PsychEd podcast team: Sarah Hanafi, MD, a first-year resident in psychiatry at McGill University, Montreal; Alex Raben, MD, a fourth-year resident in psychiatry at the University of Toronto; Lucy Chen, MD, a fourth-year psychiatry resident at the University of Toronto; and Bruce Fage, MD, a fifth-year psychiatry resident at the University of Toronto. And later, in the “Dr. RK” segment, Renee Kohanski, MD, discusses the role of the placebo in the modern setting. Dr. Kohanski is a member of the MDedge Psychiatry Editorial Advisory Board and is a psychiatrist in private practice in Mystic, Conn. Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Why podcasting? The PsychEd podcast originated when the team identified a gap in podcast-mediated learning for psychiatry trainees. In psychiatry, there have been podcasts that reviewed recent publications, but none that examined foundational topics. Other specialties, such as emergency medicine, have several podcasts covering basic topics aimed at trainees. Podcasts are identified as an asynchronous educational material. They are a medium that can be used in “downtime,” especially because many trainees commute or have other time during which they can consume information. At the American Psychiatric Association’s 2019 Annual Meeting, the PsychEd team presented on the integration of podcasting into medical education. Materials should focus on digital natives vs. digital immigrants. In 2015, one research group polled emergency medicine residents and found a differential in the use of podcasts; 90% of users were residents and 45% were program directors. Podcasts are a supplement to other types of learning Podcasts can distill information as well as engage with information and experts in an alternative fashion. Podcasts are efficient in their use of time and broaden listeners’ exposure to information and experts. Podcasts offer one modality of learning and are not meant to replace other sources. Resources should focus on what information is needed and be tailored to where students, residents, and all learners spend their time. PsychEd beginnings After the team identified the need for a psychiatry education–focused podcast, they started meeting to create an environment for collaboration. Learning how to podcast – using the equipment, editing the recording, and uploading to relevant platforms – was the hardest part. All PsychEd podcasting is done “live.” The team takes their recording equipment to the experts they interview. Presently, their guests are located in Toronto. The team has expanded to Montreal with a new team member, Sarah Hanafi, a first-year psychiatry resident at McGill University. Formatting The podcast started with a case-based format, using a composite case presented to an expert, followed by a junior learner asking questions. Now the team does more prep work to create a structured script that includes educational objectives. Using a script allows for the interview to flow in a more organized structure, which makes for easier editing. Meeting and preparing the script with experts demands time and preparation in order to create the milieu for a generative interview. Most often, the “pearls” come from the unscripted questions that elicit reflections. Experts have been willing and excited to participate in the podcast and to disseminate their knowledge in a format that will reach trainees. PsychEd topics So far, PsychEd has covered basic topics of psychiatry, including major depressive disorder, schizophrenia, bipolar disorder, and anxiety, and it is now expanding to more complex topics. An initial idea was to incorporate the patient perspective to add nuance to the foundational-level topics. Listeners were indifferent to this idea since they already encounter the patient experience on a regular basis and incorporating the patient voice did not necessarily target the educational content. This scenario illustrates in difficulty of choosing topics: Subject matter that will draw in listeners but also are creative and add meaning. There is space for societal topics in psychiatry such Big Data, climate change, technology, and loneliness. PsychEd has been awarded a grant through the University of Toronto to expand subject matter focused on clinical skills to target priorities identified by the Royal Board of Canada through its “Competency by Design” initiative. Other challenges in podcasting Choosing topics is a balance of identifying cutting-edge topics vs. issues universal to all psychiatrists. Should popular topics be revisited? Deciding how to identify topics that can enhance learning but are also professionally enriching to the psychiatrist as an individual. What personal growth has come from podcasting? Learning leadership skills: Leading a small team to create a quality podcast and then expanding to research about the impact. Providing a creative outlet both in content and thinking about the scope of scholarship within psychiatry. Enhancing time management and learning how to juggle interests outside of clinical work. Understanding how to access rich local resources, ranging from experts to other trainees who want to podcast and contribute. Broadening one’s vision and perspective by talking with thought leaders: As psychiatrists, our work resonates with similar themes, and it’s inspiring to talk to others about universal themes. References The PsychEd podcast: https://www.psychedpodcast.org/ Mallin M et al. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014 Apr;89(4):598-601. Matava CT et al. eLearning among Canadian anesthesia residents: A survey of podcast use and content needs. BMC Med Educ. 2013 Apr 23;13:59. Riddle J et al. A survey of emergency medicine residents’ use of educational podcasts. West J Emerg Med. 2017 Feb; 18(2): 229-234.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

Welcome to this bonus episode of the MDedge Psychcast. In this episode, as a tribute to the late Carl C. Bell, MD, we would like to replay highlights from the interview that Lorenzo Norris, MD, did with him last year at the annual IPS (Institute on Psychiatric Services) Mental Health Services conference in Chicago. Dr. Norris, host of the MDedge Psychcast, is assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Bell, who died Aug. 1, was a psychiatrist at Jackson Park Hospital in Chicago and an emeritus professor of psychiatry at the University of Illinois at Chicago. He spoke with Dr. Norris in episodes 26 and 27 about identifying and preventing fetal alcohol spectrum disorders. Conceptualizing intellectual disabilities in children In the late 1960s, African American children had twice the rates of mild intellectual disabilities as did white children. Some clinicians thought that the intellectual disabilities they were seeing among African American children were the result of social-cultural mental retardation, but that conclusion did not make sense to Dr. Bell. Julius B. Richmond, MD, former surgeon general, cocreated Head Start as a way to address some of the educational disadvantages faced by low-income children. African American psychologists began to suggest that standardized tests were biased against certain racial and low-income groups. Bell thought some African American and low-income children might have knowledge that their counterparts in other communities might not have. Fetal alcohol exposure emerges as an explanation A few years ago, Dr. Bell was talking with a woman patient with three children in the Illinois Department of Children and Family Services. The children had poor tempers, social/emotional skills. And when he looked at their mother, he saw fetal alcohol facies. After talking with the patient longer, he learned that she had not gotten far in school. She also had problems with simple subtraction. At that point, he thought that the patient might have had fetal alcohol exposure. He then began looking at family medicine patients at Jackson Park Hospital in Chicago. The question at that time was: “Were you drinking while you were pregnant?” That question did not explain why patients had children who could not do basic subtraction and had ADHD, for example. Bell realized that the right question was: When did you realize you were pregnant? In many cases, they would say that they had learned they were pregnant at 4-6 weeks. Choline deficiency and fetal alcohol exposure The Institute of Medicine recommended that pregnant women consume 450 mg/day of choline each day. Robert Freedman, MD, and his colleagues found that higher amounts of choline as a prenatal supplement are tied to more self-regulation among infants who had common maternal infections during gestation. Bell began giving choline to patients. In one example, a patient’s ability to relate to others improved dramatically after taking choline over an 18-month period. The American Medical Association passed a resolution supporting the addition of adequate amounts of choline to prenatal vitamins. References Freedle RO. Correcting the SAT’s ethnic and social-class bias: A method for reestimating SAT scores. Harvard Educ Rev. 2003. 73(1):1-42. Bell CC and J Aujla. Prenatal vitamins deficient in recommended choline intake for pregnant women. J Fam Med Dis Prevent. 2016. 4(2):1-3. Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders: A randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2015 Nov;102(5):1113-25. Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders(FASD)  has high feasibility & tolerability. Nutr Res. 2013. Nov;33(11):897-904. Zeisel SH and KA da Costa. Choline: An essential nutrient for public health. Nutr. Res. 2009. Nov;67(11):615-23. Freedman R et al. Higher gestational choline levels in maternal infection are protective for infant brain development. J Pediatr. 2019 May. 208:198-206. Velazquez R et al. Maternal choline supplementation ameliorates Alzheimer’s disease pathology by reducing brain homocysteine levels across multiple generations. Mol Psychiatry. 2019 Jan 8. doi: 10.1038/s41380-018-0322-z. Wilhoit F et al. Fetal alcohol spectrum disorders: Characteristics, complications, and treatment. Community Ment Health J. 2017 Aug;53(6):711-8.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych

 Show Notes Last week, Igor Galynker, MD, PhD, spoke with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about how to identify suicide crisis syndrome. This week, he explores the kinds of “gut feelings” that clinicians can access to help them identify when a patient might have the syndrome.   Dr. Galynker has been a guest on the Psychcast twice before, once to discuss the impact of suicide on physicians and a second time to talk about his research on the arguments for adding a suicide-specific diagnosis to the DSM-5. He is associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel in New York. In addition, Dr. Galynker is founder and director of the Richard and Cynthia Zirinsky Center for Bipolar Disorder, and professor of psychiatry at the Icahn School of Medicine, both at Mount Sinai. Later, Renee Kohanski, MD, discusses the ability of psychiatrists to help patients realize that they can choose what matters in their lives. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. The “gut feelings” -- emotional reactions to the patient in suicide risk assessment -- also will elicit behaviors from a clinician. Behavioral signs of the four emotions are pertinent for clinicians who are burned out or may have limited emotional awareness. Examples include: Anxious overinvolvement manifested as going above and beyond for a patient; doing things that are out of character, such as answering phone calls/texts on the weekend; reluctance to set boundaries. Dislike and distancing: The patient in suicide crisis syndrome will be the last one the clinician sees on the inpatient unit or the one he/she postpones or forgets to see; the clinician experiences dread tied to the prospect of seeing a patient all day, shortens sessions, or does not answer phone calls. How to combine emotional response and the suicide crisis syndrome. New research from Dr. Galynker and colleagues suggests that the predictive validity for suicide risk doubles if the patient meets criteria for suicide crisis syndrome and the clinician has an emotional response as described above. The emotional response is elicited not just from the suicide crisis syndrome but also from the suicidal narrative. The narrative of a suicidal person describes an intolerable present with no future. This type of aberrant narrative triggers an emotional response in the clinician. One could argue the electronic medical record makes it difficult to understand the patient’s narrative, which can impede the clinician’s ability to have an emotional response to the patient’s suffering. Why has psychiatry not focused on suicide over other mental health diagnoses? As a transdiagnostic phenomenon, one could argue that suicide must be a primary focus of assessment and treatment by psychiatrists. Suicide elicits a variety of cultural responses, ranging from shame, disgust, and a sense of weakness to empathy for the pain and suffering of a suicidal person. It is difficult to connect with someone who is suffering from a desire to die, but this might be what the patient wants. Clinical excellence is the ability to connect with a variety of patients in different settings, and it’s about demonstrating how one cares.   References Olfson M et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-26. Galynker I et al. Prediction of suicidal behavior in high-risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb;34(2):147-58. Cohen LJ et al. The suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav. 2018 Oct;48(5):613-23. Suicide rising across U.S. Centers for Disease Control and Prevention. Vital Signs. 2018 Jun. Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: Advantages outweigh limitations. World Psychiatry. 2014 Jun;13(2):128-30. Fawcett J. “Diagnosis, traits, states and comorbidity in suicide” in The Neurobiological Basis of Suicide. Boca Raton, Fla.: Taylor & Francis, 2012.   For more MDedge Podcasts, go to mdedge.com/podcasts   Email the show: podcasts@mdedge.com   Interact with us on Twitter: @MDedgePsych  

  Show Notes Igor Galynker, MD, PhD, talks with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about suicide crisis syndrome.   Dr. Galynker has been a guest on the Psychcast twice before, once to discuss the impact of suicide on physicians and a second time to talk about his research on the arguments for adding a suicide-specific diagnosis to the DSM-5. He is associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel in New York. In addition, Dr. Galynker is founder and director of the Richard and Cynthia Zirinsky Center for Bipolar Disorder, and professor of psychiatry at the Icahn School of Medicine, both at Mount Sinai. Show Notes by Jacqueline Posada, MD, who is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Later, in the “Dr. RK” segment, Renee Kohanski, MD, tells the story of a patient who found a way to rediscover his value system against great odds. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Suicide crisis syndrome: A suicide-specific mental state Until recently, there was no differentiation between the mental state associated with lifelong suicide risk versus the mental state associated with imminent suicide risk. Jan Fawcett, MD, distinguished these mental states for the first time by differentiating acute risk of imminent death and lifelong risks and traits of suicidal behavior. Lifetime suicide risk factors include mental illness, history of suicide attempts, depression, and substance abuse. Imminent suicidal behavior risk factors include panic, acute anhedonia, agitation, and insomnia. Dr. Galynker and colleagues have identified a condition they call suicide crisis syndrome, which they define as a mental state that predicts imminent suicidal behavior in days to weeks. The predictive validity has been replicated across several cultures and populations. Suicide crisis syndrome: To be identified as having suicide crisis syndrome, the patient must meet both criterion A and two criteria of B. Criterion A: Frantic hopelessness or state of entrapment defined as being stuck in a life situation that is painful and intolerable, and a feeling that all routes of escape are blocked. The risk of suicide within 1 month is 13% for people who meet criteria for suicide crisis syndrome. Criterion B: Affective dyscontrol, including emotional pain or mental pain; severe panic with agitation, and dissociation; rapid mood swings that can include happiness; and acute anhedonia. Cognitive dyscontrol, which can include ruminative flooding associated with headache or head pressure; cognitive rigidity; and inability to suppress the ruminative thoughts. (For example, you might assess by asking: “Do you control the thoughts or do the thoughts control you?”) Overarousal with insomnia and agitation. Social withdrawal and isolation, and evading communication. Why are suicide-specific diagnoses necessary? 75% of people who die by suicide do not report suicidal ideation to a clinician, psychiatrist, or primary care physician. Notably, suicide crisis syndrome does not include suicidal ideation in the criteria, because not all people within imminent risk feel suicidal until the moment strikes. Some patients will hide their suicidal ideation from their clinician to prevent having their plan foiled. Suicide crisis syndrome creates a fuller picture of patient risk. Assessment of the criteria help a clinician consider more risk factors for imminent risk than simply a patient’s self-report about suicidal ideation. Approach suicidality with a different framework Suicide-specific diagnoses represent a profound shift in approach, because suicide is a transdiagnostic phenomenon for depression, bipolar disorder, and schizophrenia. A person can be at imminent risk for suicide without meeting criteria for other DSM diagnoses. Other suicide-specific diagnoses: Maria A. Oquendo, MD, PhD, and colleagues have put forward “suicidal behavior disorder,” which is a diagnosis that captures the propensity of suicidal behavior and urges to kill oneself. Suicidal behavior disorder and suicide crisis syndrome provide clinical targets for treatment of suicide. Without a diagnosis, clinicians cannot test treatment or teach the assessments.   Use emotional reactions to the patient in suicide risk assessment Clinicians can identify “gut feelings” that help hone their assessments. Galynker and colleagues have identified four emotions that can help clinicians identify suicide risk: Distress. Dislike with distancing. Anxious overinvolvement, with a paradoxical combination of hope and distress. Collusion/abandonment/rejection, which includes a type of hopelessness and calm. Clinicians can be trained to identify these emotions, which they may have been taught to suppress. Recognition of these emotions can be cultivated through “emotional awareness rounds.”   Dr. Fawcett is a professor of psychiatry at the University of New Mexico, Albuquerque. Dr. Oquendo is the Ruth Meltzer Professor of Psychiatry at the University of Pennsylvania, Philadelphia.   References Olfson M et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-26. Galynker I et al. Prediction of suicidal behavior in high-risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb;34(2):147-58. Cohen LJ et al. The suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav. 2018 Oct;48(5):613-23. Suicide rising across U.S. Centers for Disease Control and Prevention. Vital Signs. 2018 Jun. Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: advantages outweigh limitations. World Psychiatry. 2014 Jun;13(2):128-30. Fawcett J. “Diagnosis, traits, states and comorbidity in suicide” in The Neurobiological Basis of Suicide. Boca Raton, Fla.: Taylor & Francis, 2012.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

Show Notes Elspeth Cameron Ritchie, MD, MPH, talks with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about averting disruptions in psychiatric medications after short- and long-term disasters. Dr. Ritchie is a psychiatrist who works in Washington. Show Notes by Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Later, in the “Dr. RK” segment, Renee Kohanski, MD, discusses the potential impact of pharmacogenomics on the practice of psychiatry. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.   Dr. Ritchie and disaster psychiatry She entered disaster psychiatry through her many years as a military psychiatrist. She had to think about how to plan and treat psychiatric emergencies during deployments to an austere environment, such as Somalia and Iraq. She was on active duty during Sept. 11, 2001, and helped coordinate the disaster response during that period and then completed a fellowship in disaster psychiatry at the Uniformed Services University in Bethesda, Md. Ritchie says that the field has changed immensely, from the way in which it once handled debriefings to the current use of psychological first aid. Yet, she thinks that psychiatric medications are a neglected area of planning. Minor, major disasters can cause disruptions in psychiatric medications Access/continuity of psychiatric medications is overlooked in planning. Disruption in psychotropic medications will affect many populations, including people with serious mental illness (SMI), first responders, and patients dependent on controlled substances such as methadone, buprenorphine and naloxone, and benzodiazepines. Especially for those with SMI in a disaster that creates increased stress, the absence of medications can have longer negative consequences, such as changes in behavior as hospitalizations or that may lead to contact with the legal system. Plans need to be made in advance with patients to prevent disruption in medications. Small disasters could include a weather event, such as a snow or rainstorm. These can create barriers to medication at the basic level, such as a lack of electricity affecting computer systems, a pharmacist cannot make it to work, etc. Larger disasters, such as hurricanes, can have effects that last months to years, such as loss of psychiatrists or lack of other infrastructure related to mental health.   Population-specific planning during disasters Patients with SMI: Some might be homeless and affected by weather conditions; there often may be a robust citywide response aimed at creating a safety net for these individuals. First responders: It is essential to have medications available for sleep, such as trazodone or zolpidem, to mitigate the effects of long, stressful workdays that make it hard to “turn off” and get rest. Working professionals: Many people balance busy lives on a routine basis, so it’s important to help these patients maintain their medications and functioning. Psychiatrists should make sure that these patients have adequate supplies of medications, such as SSRIs. How can psychiatrists help to prepare? They can ensure that patients can have an adequate supply of medications in several locations in case of disaster or emergency. They can provide a 90-day supply of medication in the event of a large disaster with lasting effects. They can determine that patients have a printed up-to-date list of all their medications in case they need to change pharmacies or have medications refilled by another clinician, such as a primary care physician. Patients and doctors rely on the electronic health records for medication lists, which may fail during a disaster. They can identify at-risk patients, such as those on controlled substances (opiates and benzodiazepines), and refill any medications that, if missed, can result in withdrawal syndromes. Disaster planning has come a long way over the last 30 years Disaster planning often takes into consideration food supply and medications. However, psychiatric medications often are forgotten as being essential to patients. For example, the Centers for Disease Control and Prevention does not stockpile psychotropic medications, other than valium, for emergencies. Psychiatrists can advocate within their cities or states to ensure that disaster plans include a contingency for psychiatric care, such as stockpiles of psychotropic medications. Psychiatrists can help in disaster planning by consulting on formularies for disasters and suggesting versatile psychotropic medications that can be used in multiple settings or for different patient types. Examples of versatile medications include mirtazapine for sleep and depression, bupropion for depression and ADHD, medications for sleep, antipsychotics, and such key SSRIs as fluoxetine. Psychiatrists also must plan for themselves and consider their own self-care as well as emergency planning for their offices and their families.   References Ritchie EC et al. When a disaster disrupts access to psychiatric medications. Current Psychiatry. 2019 May;18(5):22-6. Kenardy J. The current status of psychological debriefing: It may do more harm than good. BMJ. 2000 Oct 28;321(7268):1032-3. Rodriguez JJ and R Kohn. Use of mental health services among disaster survivors. Curr Opin Psychiatry. 2008 Jul;21(4):370-8. Redd SC and TR Frieden. CDC’s evolving approach to emergency response. Health Secur. 2017 Jan/Feb;15(1):41-52.   For more MDedge Podcasts, go to mdedge.com/podcasts   Email the show: podcasts@mdedge.com   Interact with us on Twitter: @MDedgePsych      

Ep. 70 Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. In this episode, Richard Balon, MD, returns to the MDedge Psychcast to discuss benzodiazepines. This time, Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, interviewed Dr. Balon about prescribing benzodiazepines for patients with serious medical illnesses. They also examine some of the controversies around benzodiazepines and common mistakes that some clinicians make when prescribing these drugs. Dr. Balon is professor of psychiatry at Wayne State University in Detroit. And later, in the “Dr. RK” segment, Renee Kohanski, MD, explores the need for psychiatrists to challenge the distorted thinking patterns of patients, particularly in light of the growing influence of social media. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Benzodiazepines can be used for patients with serious mental illness across several areas of medical illness, including those with cardiovascular, gastrointestinal, and sleep disorders, as well as for those with generalized anxiety disorder (GAD) and panic disorder. Cardiovascular illness Patients with cardiovascular illness might have just encountered a near-death experience and present with somatic symptoms of their cardiovascular illness and anxiety. This overlap of symptoms makes cardiovascular illness a reasonable comorbidity in which to use benzodiazepines for anxiety. A naturalistic study of patients with heart failure showed patients on benzodiazepines had a small decrease in mortality. The reason is unknown, but it could be from a decrease in anxiety and stress, both of which affect the heart. Older studies show that some benzodiazepines can be used in addition to antihypertensives. Gastrointestinal illness Benzodiazepines also are useful for such gastrointestinal (GI) illnesses as peptic ulcer disease, inflammatory bowel disease, irritable bowel syndrome, etc. The symptoms of GI illness, such as constipation, diarrhea, and nausea, can complicate the use of SSRIs or tricyclic antidepressants for anxiety. Older studies suggest that adding benzodiazepines to the regimen of these patients, especially those without substance use disorder, can improve outcomes. Sleep disorders Five benzodiazepines have been approved for sleep disorders: triazolam, flurazepam, temazepam, estazolam, and quazepam. These medications are used infrequently despite having a long half-life, which is useful for sleep initiation and maintenance. Quazepam is designed specifically for insomnia and has activity at a different part of the alpha subunit on the GABA receptor. Clonazepam also is useful, especially for patients with comorbid anxiety and sleep issues, because it contributes to sedation, and as a result of its long half-life, it continues to relieve anxiety throughout the day. Generalized anxiety disorder (GAD) and panic disorder Many clinicians are leery about using alprazolam for several reasons. The medication’s short half-life contributes to patients using the drug several times a day. Immediate relief of anxiety has a reinforcing effect, which in turn, increases the risk of abuse. There are no well-designed trials comparing benzodiazepines with SSRIs. Many of the recommendations about how to use benzodiazepines come from clinical experience. Some patients with GAD without substance use benefit from benzodiazepines such as clonazepam. It is possible for some patients to stay on long-term treatment with benzodiazepines and not need higher doses because of tolerance. Clarity is needed about the true impact of benzodiazepines on patients  Benzodiazepines are an integral part of the psychopharmacology armamentarium yet are underused. Their use is increasingly discouraged, and trainees are not getting enough experience with prescribing benzodiazepines. Benzodiazepines are rarely abused on their own. Common mistakes in using benzodiazepines Patients who might need or benefit from treatment with benzodiazepines are not adequately assessed. Dose escalation with benzodiazepines often is avoided. When patients ask for an increase in the dose, this is not necessarily sign of abuse. A dose increase might be a sign that the patient is still anxious. Trainees are not getting proper guidance in prescribing benzodiazepines; they need to be familiar with prescribing all classes of psychotropics. References Slee A et al. Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. Lancet 2019 Feb 23;393(10173):768-77. Guina J, Merrill B. Benzodiazepines I: Upping the care on downers: The evidence of risks, benefits, and alternatives. J Clin Med. 2018 Jan 30. doi: 10.3390/jcm7020017. Salzman C. The APA task force report on benzodiazepine dependence, toxicity, and abuse. Am J Psychiatry. 1991 Feb;148(2):151-2. Fava GA et al. Benzodiazepines in anxiety disorders. JAMA Psychiatry. 2015;72(7):733-4. Tully PJ et al. The anxious heart in whose mind? A systematic review and meta-regression of factors associated with anxiety disorder diagnosis, treatment, and morbidity risk in coronary heart disease. J Psychosom Res. 2014 Dec;77(6):439-48. Colussi GL et al. Benzodiazepines: An old class of new antihypertensive drugs? Am J Hypertension. 2018 Apr;31(4):402-4.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych          

Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. In this episode, Lorenzo Norris, MD, host of the MDedge Psychcast, interviews Jonathan M. Meyer, MD, about prescribing clozapine and understanding barriers of use. Dr. Meyer is clinical professor of psychiatry, University of California, San Diego, and a psychopharmacology consultant with the California Department of State Hospitals. Overview of clozapine Clozapine is an effective medication for treatment-resistant schizophrenia and lethality/suicide. Clozapine is underused by clinicians for many reasons. Clinicians have less comfort with prescribing clozapine. Too few trainees are exposed during residency to prescribing clozapine. Using clozapine during training provides the knowledge and comfort necessary to prescribe it once out in practice. Fear of prescribing clozapine outweighs the benefits to patients who need it. Other barriers include monitoring burdens in confluence with systems issues. Indications for use Treatment-resistant schizophrenia is defined as an inadequate response to two antipsychotic trials, and treatment-resistant schizophrenia occurs in about 30% of patients with schizophrenia. People with treatment-resistant schizophrenia have a 5% chance of responding to other antipsychotic medications, while the response rate to clozapine is about 40%. In light of those statistics, getting patients with schizophrenia on clozapine should be a priority. Everyone benefits when a patient with treatment-resistant schizophrenia is started on clozapine. Clozapine treatment leads to decreased symptoms and suffering, improved quality of life, decreased suicidality and aggression, and lower hospitalization rates, which in turn, lead to decreased health care costs. Barriers to using clozapine Education is key to empowering physicians to start prescribing clozapine and overcoming the initial resistance to prescribing. SMI Adviser is a website sponsored by the American Psychiatric Association (APA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) that provides access to education, data, and consultations for clinicians who treat serious mental illness. SAMHSA also has sponsored “centers of excellence” in New York state and the Netherlands that provide consultation and on-demand answers to questions about prescribing. The Clozapine Handbook, written by Dr. Meyer and Stephen M. Stahl, MD, PhD, is another centralized resource for prescribers. Dr. Meyer and Dr. Stahl wrote the handbook to educate and encourage clinicians to prescribe clozapine and improve patient outcomes.  Adverse events and monitoring Myocarditis: Rate of myocarditis ranges from 0.5% to 3% (most rates from Australia), an adverse event that happens primarily within the first 6 weeks of clozapine therapy. Symptoms suggesting myocarditis include fever and elevated troponin level more than twice the upper limit of normal. Clinicians can order a C-reactive protein test, which can help rule in myocarditis if troponins are elevated but not at twice the upper limit range. In the first 6 weeks of therapy, clinicians are encouraged to order a troponin test during the patients' weekly labs. Isolated fever does not mean myocarditis, because fever is a common side effect during titration, and clinicians can complete the fever work-up. Cigarette smoke can induce cytochrome P450 (CYP) enzyme, including CYP1A2. It is not necessary to have patients stop smoking when they start clozapine. Clinicians can adjust the clozapine dose based on response and clozapine level. Induction of CYP1A2 enzyme happens only when people smoke or burn the actual leaf of tobacco or marijuana. Vaping or e-cigarettes will not induce CYP1A2 and change clozapine levels. Threshold of response is 350 ng/mL, however levels that lead to response differ with each individual and will be influenced by smoking habits. Other common side effects include orthostasis, sedation, and sialorrhea. New technologies are available to reduce barriers of prescribing clozapine and to improve patient adherence to hematologic monitoring. Athelas is a company that manufactures a Food and Drug Administration–cleared point-of-care device to measure neutrophil count by way of a finger stick. Results are dispensed real time. Athelas also will take care of medication dispensing. A point-of-care device is in development for plasma clozapine levels with fingerstick, which will allow clinicians to make titration decisions in real time instead of 1 week after levels. The device already is available in Europe. Creating a system that allows for adherence Using case managers to improve clozapine adherence is cost effective when the amount saved from avoiding hospitalization is taken into account. Clozapine can lead to a functional recovery in terms of how a patient interacts with family, friends, and society at large. Clozapine has the ability to improve productivity leading to employment, which is another way the benefits of creating a system to improve clozapine adherence outweigh financial costs.   References Kane JM et al. Clinical guidance on the identification and management of treatment-resistant schizophrenia. J Clin Psychiatry. 2019 Mar 5;80(2): doi: 10.4088/JCP.18com12123. Suskind D et al. Clozapine response rates among people with treatment-resistant schizophrenia: Data from a systematic review and meta-analysis. Can J Psychiatry. 2017 Nov;62(11):772-7. doi: 10.1177/0706743717718167. Kelly DL et al. Addressing barriers to clozapine underutilization: A national effort. Psychiatr Serv. 2018 Feb 1;69(2):224-7. Bui HN et al. Evaluation of the performance of a point-of-care method for total and differential white blood cell count in clozapine users. Int J Lab Hematol. 2016 Dec;38(6):703-9.   Other resources SMI Adviser: Clozapine Center of Excellence, sponsored by the APA and SAMHSA. The Clozapine Handbook (Cambridge University Press, 2019). Clozapine and smoking cessation (NSW Health, Australia). Point of care neutrophil measurement. https://athelas.com/fda/. https://curesz.org/.   For more MDedge Podcasts, go to mdedge.com/podcasts   Email the show: podcasts@mdedge.com   Interact with us on Twitter: @MDedgePsych              

  Show Notes In this episode, we revisit three of our best episodes on preventing suicide. In episode 46, Lorenzo Norris, MD, host of the MDedge Psychcast, interviewed Igor Galynker, MD, about how to assess suicide crisis syndrome. Dr. Norris is editor in chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Galynker is associate chairman for research in the department of psychiatry at Mount Sinai, New York. In episode 42, Dr. Norris interviewed Caroline Bonham, MD, and Avi Kreichman, MD, about addressing suicidality in rural communities and strategies for enhancing resilience. Dr. Bonham and Dr. Kreichman work together at the University of New Mexico, Albuquerque. She serves as vice chair of the department of psychiatry and behavioral sciences at the university, and he is an assistant professor there. In episode 54, Sidney Zisook, MD, who directs the residency training program at the University of California, San Diego, conducted a Masterclass on the many causes of physician suicide and how this might be prevented.  And stay tuned for our Dr. RK segment, where Renee Kohanski, MD, who talks about making mistakes while caring for patients and granting ourselves full and complete forgiveness. Dr. Kohanski has a private practice in Mystic, Conn.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

  Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Guest George T. Grossberg, MD: Samuel W. Fordyce Professor; director, geriatric psychiatry at Saint Louis University. Dr. Grossberg spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.   New developments in Alzheimer’s research The Systolic Blood Pressure Intervention Trial, also known as the SPRINT MIND Study, showed that tightly controlled systolic blood pressure (SBP) of 120 mm Hg, compared with an SBP of 140 mm Hg, resulted in a 20% reduced risk of developing mild cognitive impairment. The SPRINT study was terminated early at the median follow-up of 3.26 years as its results showed that tightly controlled SBP significantly reduces the risk of stroke and heart disease. The Alzheimer’s Association has agreed to fund an additional 2 years of the SPRINT MIND Study to evaluate whether tightly controlled BP is effective in reducing the risk of Alzheimer’s disease. In the brain, the glymphatic system was discovered in 2012 and is similar to the lymphatic system in its role as a drainage system for removing toxins. Glial cells mediate toxin removal, and the glymphatic system removes toxins that eventually can cause cell death in the brain. Because the glymphatic system is involved in removing the beta-amyloid plaques that contribute to cell death in AD, the glymphatic system is another area of investigation in the pathogenesis of AD. Novel treatment of moderate to advanced AD involves using plasma infusion. Infusion of plasma products from healthy, nonimmunocompromised 18-year-old individuals into older patients with AD is a potential treatment for AD. Precedent for this intervention comes from animal studies investigating parabiosis, a procedure in which two animals are connected so that they share each other’s blood stream. When such a circulatory exchange occurs between a younger mouse and an older mouse with AD, the older AD model mouse regains cognitive abilities and is able to complete mazes that it was unable to complete before. How can this model be adapted to humans? One possibility might involve infusing plasma from young healthy individuals into older adults with advanced AD. A safety proof-of-concept study, published recently, found that plasma products can be safely infused. The next step is an efficacy study. A relationship has been found between AD and periodontal disease. The primary bacteria related to periodontal disease, Porphyromonas gingivalis, is found in close proximity in the brain to the plaques and tangles of AD. One theory posits that the presence of this bacteria is related to inflammation that may contribute to the causality of AD. Could AD be treated with the antibiotics used to treat periodontal disease? The answers remain unclear. Aducanumab, a monoclonal antibody targeting the beta-amyloid plaques of AD, initially showed favorable changes in imaging studies of the brains of people with AD. In March 2019, the study was halted because of futility. An independent data-monitoring committee determined that the early results seen on imaging did not result in clinically meaningful changes, compared with placebo. Some AD researchers consider this drug failure the “final nail in the coffin” of the amyloid hypothesis, and the pathogenesis of AD is most likely related to tau neurofibrillary tangles and other mediators, such as the immune system and inflammation.   References SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 26 Nov 2015;373:2103-16. Jessen NA et al. The glymphatic system: A beginner’s guide. Neurochem Res. 2015 Dec;40(12):2583-99. Dominy SS et al. Porphyromonas gingivalis in Alzheimer’s disease brains: Evidence for disease causation and treatment with small-molecule inhibitors. Science Advances. 23 Jan 2019;5(1): doi: 10.1126//sciadv.aau3333. Conese M et al. The fountain of youth: A tale of parabiosis, stem cells, and rejuvenation. Open Med (Wars). 2017;12:376-83. Phase 3 study of aducanumab in early Alzheimer’s disease. ClinicalTrials.gov Identifier: NCT02477800.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych  

In this masterclass, Charles L. Raison, MD, returns to the MDedge Psychcast to discuss the risks and benefits of antidepressants. He previously appeared on the Psychcast in episodes 15 and 16. Dr. Raison is Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families and professor, School of Human Ecology, and professor, department of psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison. Later, Renee Kohanski, MD, discusses the need for psychiatrists to take care of and nourish their communities. Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Treatment with antidepressants The STAR-D trial, a large effectiveness trial (n = 4,000), looked at the effect of SSRIs and other medications for the treatment of depression. As an effectiveness trial, STAR-D looked at “real” patients with comorbidities (as opposed to efficacy trials, which use “perfect patients” with no comorbidities to minimize confounding effects). Only 30% of patients went into complete remission with first step of treatment with an SSRI (citalopram) at the highest tolerated dose. Almost 50% experienced a response (a 50% reduction in symptoms of depression on standardized scale). Cynicism and hope for antidepressants To obtain Food and Drug Administration approval, a medication requires two positive studies (showing that the drug beats placebo), and on average, an SSRI requires five to seven studies to get the two positive studies. A meta-analysis of negative SSRI studies that were “filed away” found only a 1.8-point difference on Hamilton Depression Rating Scale score between SSRI vs placebo. The difference between SSRI and placebo in treatment disappeared among patients who were less depressed. Geddes et al., presented a more balanced view in a published meta-analysis of 522 trials that included more than 100,000 patients. Antidepressants had a modest benefit, compared with placebo. In head-to-head studies, some antidepressants were better than others, such as amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine.  Predictors of response Poor response to antidepressants: Presence of comorbid anxiety disorder, failure of first or subsequent antidepressant trials. Within STAR-D, among those who failed three treatment steps, only 13% responded to the next treatment. Good response to antidepressants: An acute response to an antidepressant predicts long-term response. A 20% or greater improvement within 2 weeks of treatment resulted in a higher chance of remission, compared with those who don’t initially respond, who then had a less than 5% chance of remission. Are antidepressants good for everyone? The difference between active antidepressants and placebo is small. A latent growth curve analysis of placebo vs. antidepressants for depression showed that there are two separate trajectories with antidepressants: 70% will respond and are vastly improved, while 30% actually do worse. A National Institute of Mental Health study from 1980s randomized patients to two types of psychotherapy vs. tricyclic antidepressants (TCAs) vs. waitlist control group. Treatment took place for 16 weeks, and patients were followed for 18 months. People who went into remission on TCAs were more likely to relapse than those who went into remission on psychotherapy. Epidemiological Catchment Area (ECA) trial: Prospective data of 92 people from the total 3,500 in the study. Of the 92 with a first major depressive episode, 50% had a second major depressive episode. Of those who were treated into complete remission, even after 5 years, more than 50% had a relapse of their depression. Conclusion: Relapse of depression is common when patients come off antidepressants To stay well, a patient with depression should continue to receive an antidepressant. Clinicians must ask: Do the antidepressants increase the risk of relapse of depression? Depression is a disabling disease, so treatment is necessary. But clinicians should question for whom and when antidepressants should be used. References Turner EH et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358:352-60. Cipriani A et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet. 2018 Apr 7:391(10128):1357-66. Penninx BW et al. Two-year course of depressive and anxiety disorders: Results from the Netherlands study of depression and anxiety (NESDA). J Affect Disord. 2011 Sep;133(1-2):76-85. Perlman K et al. A systematic meta-review of predictors of antidepressant treatment outcome in major depressive disorder. J Affect Disord. 2019 Jan 15;243:503-15. For more MDedge Podcasts go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych        

For more MDedge Podcasts go to mdedge.com/podcasts In part II of this Psychcast Masterclass, Patricia Westmoreland, MD, returns to discuss severe, enduring eating disorders, including management and ethical questions.  In Dr. RK this week, Renee Kohanksi explores the impact of censorship and self-censorship.  Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Guest Patricia Westmoreland, MD, a forensic psychiatrist at the University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; adjunct assistant professor of psychiatry at the University of Colorado Denver. Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.   Harm reduction, palliative care, and futility Harm reduction model: A focus on returning to reasonable level of functioning without focus on full weight restoration, especially if full weight restoration has not proven sustainable with previous treatment. Harm reduction is managed an as outpatient with regular check-ups. Team collaborates for attainable, mutual treatment goals. Patients are allowed to stay at a lower body mass index (BMI) and are able to partially function and do things they enjoy, such as living with family and working part time. Patients maintain an agreed-upon weight and regularly check labs. Inpatient hospitalization is pursued only to restore weight back to previously agreed-upon goal: BMI is a marker of risk; BMI greater than 15 kg/m2 is lower risk, and BMI less than 13 kg/m2 is higher risk (lower BMI is tied to higher immunocompromised risk, more fractures, and other illnesses, as well as a greater risk of suicide, etc.) Palliative care is offered when patients have failed harm reduction and cannot sustain an acceptable body weight (not weight restored): Palliative care is NOT hospice, and therefore, there are no specific expectations.  Treatment goal is comfort care, i.e., analgesics for fractures and decubitus ulcers, anxiolytics for refractory anxiety.   Ethics and futility: When to say “enough is enough”? In anorexia nervosa (AN), frequently, many treatments have been implemented, and there may be no cure. Some think that anorexia should never be an end-stage diagnosis.   Cynthia Geppert, MD, MPH, a health care ethicist and a professor of psychiatry and internal medicine at the University of New Mexico, Albuquerque, who wrote in the American Journal of Bioethics: “Futility and chronic anorexia nervosa: A concept whose time has not yet come,” argues against futility: AN does not meet definition of a terminal illness: The patient’s depleted weight renders a patient as having a life-threatening illness. Can a patient be terminal and is care futile if there is hope for long-term recovery? Legally: Cognitive distortions make up the core of AN as an illness. Do patients with AN have the capacity to decide that further treatment is futile? Cognitive impairments often normalize with treatment. Are physicians obligated to treat first in order to restore a patient’s decision-making capacity before allowing them to choose palliative care? People with AN may lack capacity because they cannot appreciate the consequences of their decision, which is one of the four components of capacity.  In support of futility, Cushla McKinney, PhD, of the biochemistry department at University of Otago (New Zealand), argues against the complete rejection of the concept of futility, saying it risks forcing a small and chronic group of patients into an intolerable situation.  Arguments for futility: Not EVERY individual with AN lacks capacity. Some argue for futility, and allowing patients to make choices in line with what they value in life. Prognosis, even with treatment, is poor, especially for older individuals with years of failed treatments and medical comorbidities. Are we doing harm by forcing an invasive treatment that patients don't want – especially after much treatment? Illustrative case of AG, a 29-year-old female with chronic AN, who had a guardian for medical decision making: The guardian had decided in favor of tube feedings many times; AG had suffered complications such as heart failure. AG wanted to enter palliative care, arguing that she did not want to die, but if death were the result of AN, then “so be it.” The judge ruled she could refuse treatment. He did not comment on capacity, but ruled she could make this decision to die on her terms.   Emerging concerns: Is anorexia nervosa an end-stage illness or not? How will physician aid-in-dying overlap with AN? Do eating disorder patients have the capacity to request aid-in-dying, and what is the physician obligation?   References Eddy J. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. Clin Psychiatry. 2017 Feb;78(2):184-9. Sjostrand M et al. Ethical deliberations about involuntary treatment: Interviews with Swedish psychiatrists. BMC Med Ethics. 2015;16:37. Geppert C. Futility in chronic anorexia nervosa: A concept whose time has not yet come. Am J Bioethics. 2015. 15(17):34-43. Cushla M. Is resistance (n)ever futile? A response to “Futility in chronic anorexia nervosa: A concept whose time has not yet come,” by Cynthia Geppert. Am J Bioethics. 2015 Jul 6. 15(7):53-4.

In Episode 59 Patricia Westmoreland, MD, gives a masterclass lecture on managing severe and enduring eating disorder (SEERS).  Renee Kohanksi, MD, poses the question, "What do we want?" Contact us: podcasts@mdedge.com Twitter: @mdedgepsych  Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Guest Patricia Westmoreland, MD: forensic psychiatrist at University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; and adjunct assistant professor at University of Colorado Denver in department of psychiatry. Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.   Introduction, definition, role of involuntary treatment, and novel treatment options Introduction: Prognosis: Anorexia nervosa (AN) has the highest mortality of any psychiatric disorder. Risk factors for death: Older age at first presentation, lower weight at presentation, greater duration of illness, comorbid alcohol or diuretic abuse, comorbid mood disorder, history of psychiatric hospitalization and suicide attempts, and self-harm. Less than 50% recover completely, about 30% improve somewhat but require frequent hospitalizations or treatments, and 20% develop a SEED. Eddy et al. longitudinal study of eating disorders (EDs):  AN patients can recover over the long term. Overall, 31% were better at 9 years; 63% better at 22 years of follow-up.  Treatment: Treat ASAP, especially if patient is seen at a young/pediatric age before symptoms are fully developed and weight loss is profound. Weight gain as the central treatment: Many patients are reluctant to get treatment that focuses only on food intake and weight gain. Predictors of improvement: Weight gain that is parallel to improvement in physical and psychological well-being, diagnosis at a younger age, and shorter duration of illness. Medications: Fluoxetine is the only Food and Drug Administration-approved treatment for EDs, including bulimia, at doses of 60 mg and above. Patients with EDs have poor response to selective serotonin reuptake inhibitors because of starvation and limited production of serotonin and serotonin receptor abnormalities.  Severe and enduring eating disorders (SEED) definition:   6-12 years of an ED can qualify as chronic. Lower likelihood of recovery with symptoms substantially interfering with quality of life.  Role for involuntary treatment in EDs: Few treatment centers do involuntary treatment of ED. Involuntary treatment can involve guardianship for medical decisions. Guardianship is useful for medical treatment and admission to a medical ward, for example, when a patient requires forcible tube feeding for life-threatening starvation. Commitment or certification is required for involuntary treatment in a psychiatric hospital. Commitment is sought by a psychiatrist and is a tool in cases when the patient is dangerous to self or others and is gravely disabled. It is useful to commit a patient who is refusing care and has not been sick for long. Often, commitment/certification is used as a last resort, and the patient is too sick to truly recover. Pros and cons of involuntary treatment: Pro: No difference in weight restoration in voluntary vs. involuntary treatment, and patients are often grateful after involuntary treatment. Cons: Involuntary tube feeding has unclear long-term outcomes. Some studies show poor outcomes for people who are treated involuntarily, though this is likely because of their comorbidities.  Novel treatment options: Ketamine has been used in EDs. Concerns remain about the drug’s addictive potential and inability to clearly change eating disorder pathology. Oxytocin: There are reduced cerebrospinal fluid levels of oxytocin in AN, and oxytocin restores during recovery. Experimentally in rats, oxytocin may reduce the fear and social phobias related to eating. Electroconvulsive therapy does not reduce ED symptoms such as restricted eating and fear of fatness, but it can improve depression. People with ED are often medically ill, so the patient must be physically able to undergo treatment. Because of medical comorbidities, AN patients are more likely to have complications like delirium. Transcranial magnetic stimulation: Dorsolateral prefrontal cortex involved in self-regulatory control, inhibitory control, and cognitive flexibility. Some studies show promising results of using this intervention with ED and mild side effects like syncope and headache. Deep brain stimulation (DBS): Treatment targets the nucleus accumbens and the subcallosal cingulate gyrus, which theoretically alter balance between reward and cognitive inhibitory and control systems that are related to pathological eating behaviors. DBS has strongest theoretical rationale in terms of neurocircuitry targets.  References  Eddy J. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. Clin Psychiatry. 2017 Feb;78(2):184-9.  Sjostrand M et al. Ethical deliberations about involuntary treatment: Interviews with Swedish psychiatrists. BMC Med Ethics. 2015;16:37.  Geppert C. Futility in chronic anorexia nervosa: A concept whose time has not yet come. Am J Bioethics. 2015. 15(17):34-43. Cushla M. Is resistance (n)ever futile? A response to “Futility in chronic anorexia nervosa: A concept whose time has not yet come,” by Cynthia Geppert. Am J Bioethics. 2015 Jul 6. 15(7):53-4.   In part 2, Dr. Westmoreland will discuss harm reduction, palliative care, and futility.  

Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.   Masterclass guest Richard Balon, MD: professor of psychiatry and training director at Wayne State University, Detroit. In March, Dr. Balon spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.   Physician burnout and effective interventions The scales (for example, the Maslach Burnout Inventory) do not necessarily represent the full extent of burnout: If physicians work 12 hours but find fulfillment in work, they will be tired but not necessarily burned out. However, if physicians work 12 hours a day feeling frustrated by the systemic problems, then burnout can ensue. Common contributors to provider burnout: Excessive workload: Pressures of working with an electronic medical record, extensive time spent on documentation; lack of work satisfaction and job control; lack of respect for the work; student loan burden. “Moral injury”: The emotional burden, which occurs when physicians cannot deliver ideal care/treatment to patients, especially when limited by resources (such as insurance or poverty), or other systemic health care issues. Work environment and organizational culture: These factors also contribute to physician burnout. Burnout is a problem for health care organizations as a whole Two main ways to address burnout: Physician-directed interventions (focused on individuals) and organization-directed interventions. Organization-directed burnout prevention strategies include: Reducing workload; reducing time spent on documentation, such as decreasing time spent in front of EMRs; cultivating effective teamwork; fostering a sense of job control. Organizations prefer individual-focused interventions over systemic changes. Examples include mindfulness teaching, yoga, cognitive-behavioral therapy techniques, education about burnout, and education. Individual-focused interventions are great, but they are not realistic for changing the culture that contributes to burnout. Interventions for burnout In a systematic review and meta-analysis in JAMA Internal Medicine, Maria Panagioti, PhD, and colleagues found that: Burnout interventions focused on individual physicians have small, significant effect on physician burnout. Organizational-directed approaches result in greater treatment effects, especially when interventions focus on promoting healthy individual-organization relationships. The impact of individual interventions can be improved when supported by organizational interventions. Interventions targeted at more experienced physicians within primary care settings show greater treatment effect than interventions targeted at less experienced physicians within secondary treatment settings. Approaches identified by staff, as outlined in a New England Journal of Medicine article, can lead to meaningful change. A Hawaiian health care system queried individuals (physicians, mid-levels, and nursing staff) to identify parts of EMR documentation that are poorly designed and unnecessary, and lead to unintended burdens contributing to burnout. This type of survey improves efficiency of a system and shows that the health care organization cares about preventing clinician burnout. References Panagioti M et al. “Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis.” JAMA Intern Med. 2017 Feb 1;777(2):195-205. Ashton M.  “Getting rid of stupid stuff.” N Engl J Med. 2018 Nov. 8;379(10):1789-91.      

In this episode of the MDedge Psychcast, Sidney Zisook, MD, gives a Masterclass lecture on physician suicide and Dr. RK talks about what can be spoken into existence.  If you have ideas, suggestions, questions for Dr. Norris or Dr. RK, or feedback for the show, please email us at podcasts@mdedge.com. You can also follow us on Twitter @MDedgePsych.   Show NotesBy Jacqueline Posada, MD Introduction Suicide in general population increased by 30% since 1999. The suicide rate was 14 people in every 100,000 up from 10.5 people per 100,000 in 1999. 400 physicians die per year. However, there is not great data collection about profession-specific suicide Suicide is the leading cause of death in male residents and the 2nd leading cause of death in female residents This represents a serious loss of the medical profession as well as the thousands of patients who lose their physician as well    Risks factors for physician suicide   Psychological: Physicians tend be contentious, perfectionistic, and compulsive. They are able to cope with delayed gratification, and this may lead to a false sense of ability to cope with all obstacles, without failures. Medicine presents physicians with many obstacles such as the deaths of our patients and human frailty. Human imperfection and physician failures are juxtaposed against these traits listed above Historical and genetic risk factors: Past suicide attempt and presence of mood disorder Untreated depression is an especially high risk for physicians as they may leave their mental illness untreated due to stigma As of 2017, 32 of 48 state licensing boards continue to question doctors about their mental health history. There is increased risk of suicide with the presence of the long arm version of the serotonin transporter gene and history of childhood trauma Workplace risk factors: Physicians identify electronic medical records (EMR) and increased documentation demands as contributing to burnout and less job satisfaction EMR means that doctors feel like they spend more time with records than face to face with patients. With EMR there is less eye contact and direct connection with patients so it’s hard to foster relationships Physicians feel the stress of increased use of technology and connectivity via cell phones and the need to “keep up”    Change in culture As a profession we are starting to talk about physician suicide; acknowledgment of the issue can lead to change. ACGME and other workplaces are starting to integrate physician wellness into curriculums and culture. References:  NCHS Data Brief No. 330. 2018 Nov.“Suicide mortality in the United States, 1999-2017” Yaghmour, NA et al. Acad Med. 2017 Jul. 92(7):976-83.“Causes of death of residents in ACGME-accredited programs 2000 through 2014” Implications for the learning environment” Babbott S et al. J Am Med Inform Assoc. 2014 Feb;21(e1):e100-61. Electronic medical records and physician stress in primary care: Results from the MEMO Study” Gold KJ et al.Gen Hosp Psychiatry. 2013 Jan-Feb;35(1):45-9. “Details on suicide among U.S. physicians: Data from the National Violent Death Reporting System” ACGME Symposium on Physician Well-Being

Episode 52: Tardive dyskinesia masterclass II Leslie Citrome, MD, MPH, returns to the MDedge Psychcast to lecture on Tardive Dyskinesia. In episode 52, where we caught up with Dr. Citrome at the Psychopharmacology Update meeting in Cincinnati, he discusses how to evaluate treatments for TD within the context of P values and effect sizes. Dr. Citrome joined Psychcast host Lorenzo Norris, MD, in the 13th edition of the Psychcast to talk about management of TD. In episode 13, Dr. Citrome said that you can start screening your patients in the waiting room as well as when they walk to the exam room. He and Dr. Norris also discussed movement conditions and the role antipsychotics might play in patients with TD. You can listen to the conversation between Dr. Norris and Dr. Citrome from July of 2018 by clicking here. TD has been a recent topic of interest at the Psychcast. In the 45th episode Johnathan Meyer, MD, noted that TD has been the bane of the psychiatrist's existence for the better part of a half-century. You can listen to our tardive dyskinesia Masterclass I by clicking here.  We would love to hear from you. Contact the show if you have feedback, questions, or ideas for segments, guests or topics. Email us at podcasts@mdege.com or Tweet at us @MDedgePsych.  

If you would like to respond to any of Dr. Nasrallah’s comments in this masterclass, email us at podcasts@mdedge.com. In this edition, the inaugural guest on the MDedge Psychcast, Henry Nasrallah, MD (http://bit.ly/2LZX7wC), returns to lecture on first-episode psychosis. Dr. Nasrallah is Editor-in-Chief of Current Psychiatry and is the Sydney W Souers Endowed Chair and professor and charming of the department of Neurology an Psychiatry at the University of Cincinnati College of Medicine. You can read more work from Dr. Nasrallah here: http://bit.ly/2Qx8SLP  

Introducing the Postcall Podcast from MDedge. In the first edition, MDedge producer and host, Nick Andrews sits down with Lorenzo Norris, MD. Dr. Norris is the host of the MDedge Psychcast (http://bit.ly/2uWxaG6) as well as the editor-in-chief of MDedge Psychiatry and Dean at the George Washington University School of Medicine and Health Sciences.

In this episode of the MDedge Psychcast, Jack Rozel, MD, comes back to the show to discuss how things are in Pittsburgh following the shooting at the Tree of Life Synagogue. 

In this episode of the MDedge Psychcast, Lorenzo Norris, MD and Petros Levounis, MD, discuss pharmacological and psychosocial options for treating patients with substance abuse disorders including alcohol, opiates, and even the holy grail -- cocaine. And Dr. DK wants you to know that it’s time for sanity.

The MDedge Psychcast is new with Dr. John Rozel and a conversation on gun violence. ( TENS cuts fibromyalgia pain in large, randomized controlled trial.  Brisk walking may decrease total knee replacement risk in osteoarthritis.  Smoking neglected in patients with peripheral arterial disease. The American College of Physicians beefs up firearms policy.

Introducing the Postcall Podcast.  Apple Podcasts: https://apple.co/2IeKD2y Google Podcasts: http://bit.ly/2OYLSZg At MDedge, we know that medicine can be a bit of an awakening at every step of your career. So, we launched the Postcall Podcast as a way to share your stories; what you love about medicine and what you love outside of your career. This is meant to be a place for you to find your truth. In the first episode, Nick Andrews welcomes the Editor-In-Chief of MDedge Psychiatry and the host of the MDedge Psychcast, Dr. Lorenzo Norris. 

Introducing the Postcall Podcast from MDedge. In the first edition, MDedge producer and host, Nick Andrews sits down with Lorenzo Norris, MD. Dr. Norris is the host of the MDedge Psychcast (http://bit.ly/2uWxaG6) as well as the editor-in-chief of MDedge Psychiatry and Dean at the George Washington University School of Medicine and Health Sciences.

Lorenzo Norris, MD, is a dean at the George Washington University School of Medicine & Health Sciences. Dr. Norris is also the Editor-in-Cheif of MDedge Psychiatry (http://bit.ly/2zmIA9A) and the host of the MDedge Psychcast (http://bit.ly/2uWxaG6).  The Postcall Podcast comes out every Friday. 

Is ketamine the anti-PTSD? In this edition of the MDedge Psychcast, Charles L. Raison, MD, discusses the possible impacts that ketamine and other psychedelic drugs have on specific mental illnesses. Dr. Raison is the Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families at the University of Wisconsin School of Human Ecology.

In part 1 of a 3 part series, James Griffith, MD joins MDedge Psychiatry Editor-in-Chief Lorenzo Norris, MD to define resiliency. Dr. Griffith is the chair of the Department of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine. In this episode, Dr. Griffith notes that currently, there are as many as six or seven different definitions of resilient and that whenever a clinical term becomes widely used in popular culture, the term can get muddled. Dr. Griffith says that he draws heavily on previous work by Froma Walsh, Ph.D., to help him define resilience as a practice -- “something that you do, not something that you are.” The MDedge Psychcast is published every Wednesday morning and is available wherever podcasts are found.

Welcome to the MDedge Psychcast, the new podcast from Clinical Psychiatry News and Current Psychiatry. In this first episode, Lorenzo Norris, MD, talks with Henry A. Nasrallah, MD, about some of the etiology, presentation, and recent advances in conceptualizing the psychiatric illness considered the most disabling: schizophrenia.