Podcasts about psychiatr serv

In this Complex Care Journal Club podcast episode, Dr. Kathleen C. Thomas discusses a cross-sectional study of associations between neighborhood context with psychotropic polypharmacy and psychotherapy among children with high-needs for medical or psychiatric care. She describes the inclusion of parent advisors on the study team, the inclusion of children with medical complexity in the study population, key insights including the importance of non-medical supports, and the next steps from this work. SPEAKER Kathleen C. Thomas, PhD, MPH Professor and Vice Chair of Research and Graduate Education Division of Pharmaceutical Outcomes and Policy Eshelman School of Pharmacy University of North Carolina at Chapel Hill HOST Kristina Malik, MD Assistant Professor of Pediatrics, University of Colorado School of Medicine Medical Director, KidStreet Pediatrician, Special Care Clinic, Children's Hospital Colorado DATE Initial publication date: January 13, 2025. ARTICLE REFERENCED Thomas KC, Annis IE, deJong NA, Christian RB, Davis SA, Hughes PM, Prichard BA, Prichard JR, Allen PS, Gettinger JS, Morris DN, Eaker KB. Association Between Neighborhood Context and Psychotropic Polypharmacy Use Among High-Need Children. Psychiatr Serv. 2024 Sep 11:appips20230639. doi: 10.1176/appi.ps.20230639. Epub ahead of print. PMID: 39257315. TRANSCRIPT https://cdn.bfldr.com/D6LGWP8S/as/3rffshwp3q2km53w7xckq38/011025_CCJCP__Where_You_Live_Matters Clinicians across healthcare professions, advocates, researchers, and patients/families are all encouraged to engage and provide feedback! You can recommend an article for discussion using this form: forms.gle/Bdxb86Sw5qq1uFhW6 Please visit: http://www.openpediatrics.org OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children's Hospital and in collaboration with the World Federation of Pediatric Intensive and Critical Care Societies. It is designed to promote the exchange of knowledge between healthcare providers around the world caring for critically ill children in all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open access-and thus at no expense to the user. For further information on how to enroll, please email: openpediatrics@childrens.harvard.edu CITATION Thomas KC, Malik KE. Where You Live Matters: Psychotropic Polypharmacy and Psychotherapy in Children with High-Needs‌. 01/2025. OPENPediatrics. Online Podcast. https://soundcloud.com/openpediatrics/where-you-live-matters-psychotropic-polypharmacy-and-psychotherapy-in-children-with-high-needs.

Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. In this episode, we discuss the practice of involuntary hospitalization (also referred to as involuntary commitment or certification) with two special guests and fellow podcast creators — Jesse Mangan and Dr. Jim McQuaid. Their podcast, Committable, focuses on the topic of involuntary commitment and features stories from people with lived experience as a window into complex conversations with attorneys, physicians, psychologists, and more. Jesse Mangan is the producer of Committable and someone who has experienced involuntary hospitalization. Dr. Jim McQuaid is an Assistant Professor of Sociology at Framingham University. The learning objectives for this episode are as follows: By the end of this episode, the listener will be able to… Appreciate the individual and societal functions of involuntary hospitalization Understand the potential benefits and risks associated with involuntary hospitalization from the perspective of health care professionals as well as service users and the community at large Describe actions you can take as a practitioner (who has the power to certify) that may better serve your community and those you care for Identify meaningful ways to continue the conversation about these issues in medical education or training and beyond *This episode was recorded in 2021. Through a saga involving lost and recovered audio files, we're thrilled to finally be able to release it, and believe that the topic is just as timely and relevant as ever! Guests: Jesse Mangan and Dr. Jim McQuaid Hosts: Anita Corsini, Nikhita Singhal, Gray Meckling, and Alex Raben Audio editing by: Nikhita Singhal Show notes by: Nikhita Singhal Interview content: Introduction - 00:34 Committable podcast trailer - 01:52 Guest introductions - 04:26 Learning objectives - 07:22 Defining terms and setting the context - 08:11 Jesse's experience - 12:03 Exploring the functions of involuntary hospitalization - 23:06 Power differentials and the importance of humility - 41:05 Training considerations - 45:18 False divide between patients and providers - 51:39 Primary prevention and public health - 55:57 Professional identity formation - 57:57 Societal functions and processes - 01:05:00 Building trust - 01:11:57 Legal safeguards - 01:20:20 Alternative approaches/systems - 01:30:11 Rosenhan experiment - 01:37:12 Final thoughts - 01:39:21 End credits - 1:43:50 Resources: Committable podcast website: https://sensiblenonsense.squarespace.com PsychEd Episode 18: Assessing Suicide Risk with Dr. Juveria Zaheer On Being Sane in Insane Places References: Jaeger S, Hüther F, Steinert T. Refusing medication therapy in involuntary inpatient treatment—a multiperspective qualitative study. Front Psychiatry. 2019 May 9;10:295. https://doi.org/10.3389%2Ffpsyt.2019.00295 Johansson IM, Lundman B. Patients' experience of involuntary psychiatric care: good opportunities and great losses. J Psychiatr Ment Health Nurs. 2002 Dec;9(6):639-47. https://doi.org/10.1046/j.1365-2850.2002.00547.x McGuinness D, Murphy K, Bainbridge E, Brosnan L, Keys M, Felzmann H, Hallahan B, McDonald C, Higgins A. Individuals' experiences of involuntary admissions and preserving control: qualitative study. BJPsych Open. 2018 Nov 16;4(6):501-509. https://doi.org/10.1192%2Fbjo.2018.59 Ontario Hospital Association. A Practical Guide to Mental Health and the Law, Fourth Edition. Toronto: Ontario Hospital Association; 2023. Available from: https://www.oha.com/Legislative%20and%20Legal%20Issues%20Documents1/A%20Practical%20Guide%20to%20Mental%20Health%20and%20the%20Law%2c%20Fourth%20Edition%2c%202023.pdf Paksarian D, Mojtabai R, Kotov R, Cullen B, Nugent KL, Bromet EJ. Perceived trauma during hospitalization and treatment participation among individuals with psychotic disorders. Psychiatr Serv. 2014 Feb 1;65(2):266-9. https://doi.org/10.1176%2Fappi.ps.201200556 Rosenhan DL. On being sane in insane places. Science. 1973 Jan 19;179(4070):250-8. https://doi.org/10.1126/science.179.4070.250 Sposini FM. Confinement and certificates: consensus, stigma and disability rights. CMAJ. 2020 Nov 30;192(48):E1642-E1643. https://doi.org/10.1503/cmaj.201750 For more PsychEd, follow us on Instagram (@psyched.podcast), X (@psychedpodcast), and Facebook (PsychEd Podcast). You can provide feedback by email at psychedpodcast@gmail.com. For more information, visit our website at psychedpodcast.org.

Welcome to PsychEd — the psychiatry podcast for medical learners, by medical learners. This episode covers the “big picture” relationship between violence and severe mental illnesses such as schizophrenia and bipolar spectrum disorders. Our guest experts in this episode are Dr. Robert McMaster, Assistant Professor of Forensic Psychiatry at the University of Toronto and Dr. Ragy R. Girgis, Associate Professor of Clinical Psychiatry at Columbia University in New York. This episode is a good companion to Episode 15: Managing Aggression and Agitation with Dr. Jodi Lofchy, which covers how to identify and manage acute risk of violence in a clinical setting. The learning objectives for this episode are as follows: By the end of this episode, you should be able to… Describe the epidemiology of violence in severe mental illness (rates of perpetration vs. victimization, risk factors, quality of evidence)  Understand and critique how society currently addresses violence in those with severe mental illness  Discuss this topic with patients, caregivers and the public, and address common myths  Guests:  Dr. Robert McMaster - Assistant Professor of Forensic Psychiatry at the University of Toronto Dr. Ragy R. Girgis - Associate Professor of Clinical Psychiatry at Columbia University in New York Hosts: Dr. Alex Raben (Staff Psychiatrist), Dr. Gaurav Sharma (PGY4), Sena Gok(IMG), Josh Benchaya (CC4) Audio editing by: Gaurav Sharma Show notes by: Josh Benchaya, Gaurav Sharma, Sena Gok   Interview Content:   Learning Objectives: 02:29 Perceptions of Violence and Mental Illness: 03:53 Mental illness & Violence Link Evidence: 06:48 Violence Perpetration & Victimisation: 10:10 Risk of Violence Assessment (HCR 20 Model): 17:00 Mass Shootings & Mental Illness & Predictions: 20:30 Violence Risk Prediction: 25:25 Severe Mental Illness & Violence Risk Treatments: 29:40 Society's approach to Severe Mental Illness & Violence Misperceptions: 38:30 Mental Illness and Violence Stigma: 45:03 Case Vignette & Approach: 46:44 Summary of the episode: 58:00   References:   de Mooij, L.D., Kikkert, M., Lommerse, N.M., Peen, J., Meijwaard, S.C., Theunissen, J., Duurkoop, P.W., Goudriaan, A.E., Van, H.L., Beekman, A.T. and Dekker, J.J., 2015. Victimization in adults with severe mental illness: prevalence and risk factors. The British Journal of Psychiatry, 207(6), pp.515-522. Desmarais, S. L., Van Dorn, R. A., Johnson, K. L., Grimm, K. J., Douglas, K. S., & Swartz, M. S. (2014). Community violence perpetration and victimization among adults with mental illnesses. American journal of public health, 104(12), 2342-2349. Metzl, J.M., Piemonte, J. and McKay, T., 2021. Mental illness, mass shootings, and the future of psychiatric research into American gun violence. Harvard review of psychiatry, 29(1), p.81.   Buchanan, A., Sint, K., Swanson, J. and Rosenheck, R., 2019. Correlates of future violence in people being treated for schizophrenia. American Journal of Psychiatry, 176(9), pp.694-701.   Rund, B.R., 2018. A review of factors associated with severe violence in schizophrenia. Nordic journal of psychiatry, 72(8), pp.561-571.   Markowitz FE. Mental illness, crime, and violence: Risk, context, and social control. Aggress Violent Behav. 2011 Jan 1;16(1):36–44.   Pescosolido BA, Manago B, Monahan J. Evolving Public Views On The Likelihood Of Violence From People With Mental Illness: Stigma And Its Consequences. Health Aff Proj Hope. 2019 Oct;38(10):1735–43.   Ross AM, Morgan AJ, Jorm AF, Reavley NJ. A systematic review of the impact of media reports of severe mental illness on stigma and discrimination, and interventions that aim to mitigate any adverse impact. Soc Psychiatry Psychiatr Epidemiol. 2019 Jan 1;54(1):11–31.   Srivastava K, Chaudhury S, Bhat PS, Mujawar S. Media and mental health. Ind Psychiatry J. 2018;27(1):1–5.   Stuart H. Media portrayal of mental illness and its treatments: what effect does it have on people with mental illness? CNS Drugs. 2006;20(2):99–106.   Rowaert S, Vandevelde S, Lemmens G, Audenaert K. How family members of mentally ill offenders experience the internment measure and (forensic) psychiatric treatment in Belgium: A qualitative study. Int J Law Psychiatry. 2017;54:76–82.   Bjørn Rishovd Rund (2018) A review of factors associated with severe violence in schizophrenia, Nordic Journal of Psychiatry, 72:8, 561-571, DOI: 10.1080/08039488.2018.1497199  References cited by our experts:   Steadman, H.J., Monahan, J., Pinals, D.A., Vesselinov, R. and Robbins, P.C., 2015. Gun violence and victimization of strangers by persons with a mental illness: data from the MacArthur Violence Risk Assessment Study. Psychiatric services, 66(11), pp.1238-1241. [00:05:26]   Appelbaum PS, Robbins PC, Monahan J. Violence and delusions: data from the MacArthur Violence Risk Assessment Study. Am J Psychiatry. 2000 Apr;157(4):566-72. doi: 10.1176/appi.ajp.157.4.566. PMID: 10739415. [00:05:26]   Torrey EF, Stanley J, Monahan J, Steadman HJ; MacArthur Study Group. The MacArthur Violence Risk Assessment Study revisited: two views ten years after its initial publication. Psychiatr Serv. 2008 Feb;59(2):147-52. doi: 10.1176/ps.2008.59.2.147. PMID: 18245156. [00:05:26]   Witt, K., Hawton, K. and Fazel, S., 2014. The relationship between suicide and violence in schizophrenia: analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) dataset. Schizophrenia research, 154(1-3), pp.61-67. [00:08:46] Sariaslan, A., Arseneault, L., Larsson, H., Lichtenstein, P., & Fazel, S. (2020). Risk of subjection to violence and perpetration of violence in persons with psychiatric disorders in Sweden. JAMA psychiatry, 77(4), 359-367. [00:11:20] Douglas, K. S., Shaffer, C., Blanchard, A. J. E., Guy, L. S., Reeves, K., & Weir, J. (2014). HCR-20 violence risk assessment scheme: Overview and annotated bibliography. HCR-20 Violence Risk Assessment White Paper Series, #1. Burnaby, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University. [00:18:53] Girgis, R.R., Rogers, R.T., Hesson, H., Lieberman, J.A., Appelbaum, P.S. and Brucato, G., 2022. Mass murders involving firearms and other methods in school, college, and university settings: findings from the Columbia Mass Murder Database. Journal of forensic sciences. [00:25:11]       CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association. For more PsychEd, follow us on Twitter (@psychedpodcast), Facebook (PsychEd Podcast), and Instagram (@psyched.podcast). You can provide feedback by email at psychedpodcast@gmail.com. For more information, visit our website at psychedpodcast.org.  

Host: Charles Turck, PharmD, BCPS, BCCCP Guest: David Mohr, PhD In addition to potentially improving access to mental health care, digital tools have also been shown to improve symptoms in many types of mental illness1 and can serve as an adjunct to psychotherapy or pharmacotherapy. Despite this, these tools have not yet been widely adopted in the United States. So what are some strategies we can use to implement these tools and develop an improved framework? Joining Dr. Charles Turck to discuss mental health treatments and their application in clinical practice is Dr. David Mohr, a Professor in the Department of Preventive Medicine at Northwestern University Feinberg School of Medicine in Chicago. Reference: Mohr DC, Azocar F, Bertagnolli A, et al. Banbury Forum Consensus Statement on the Path Forward for Digital Mental Health Treatment. Psychiatr Serv. 2021;72(6):677-683. December 2022 US.UNB.X.22.00074

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

  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  

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 Lorenzo Norris, MD, interview with Robert McCarron, DO, at the American Psychiatric Association meeting (#APAAM19) Dr. McCarron is vice chair of education and integrated care at University of California, Irvine, department of psychiatry. He is also trained as an internist. Shortage of psychiatrists, other mental health providers About 70% of all psychiatrists are over the age of 50 years and looking toward retirement. This also pertains to other mental health providers, such as psychologists. Implications of shortage People with severe mental illnesses (SMIs) are not getting the care they need. On average, they die 10-15 years younger than people who do not have SMIs. Patients with SMIs have a higher risk of death from illnesses such as heart disease, hypertension, and osteoarthritis because they are not getting preventive/primary care. Patients with chronic pain issues are not getting care. In California, physician assistants provide care to many patients, but they get only 2 weeks of instruction in psychiatry. About 80% of all antidepressants are prescribed by nonpsychiatrists. About 60% of all mental health care is delivered in the United States by clinicians who do not specialize in mental health. This care is delivered in primary care settings. About 40%-45% of patients seen in primary care offices are treated for behavioral health issues, such as depression, anxiety, or substance use disorders. Suicides are up more than 20% over the last decade. On average, 25 veterans die by suicide each day. Training primary care colleagues in psychiatry Primary care physicians have a core baseline in biomedical sciences. Giving them a booster in behavioral health is a way to address the shortage. The Train New Trainers Primary Care Psychiatry Fellowship was launched at University of California, Davis, and the University of California, Irvine. It has 125 fellows throughout the country, and the hope is to double that number. The program lasts 1 year, including two intensive weekends. It teaches fellows how to conduct motivational interviewing; short, targeted, and brief psychotherapies that are effective and evidence based. The Fellowship includes Web-based presentations two to three times per month. It also includes small group mentorship meetings in which fellows discuss patients and learn how to navigate complex cases. A combined residency program might be another way to address the need for more training in psychiatry. References Price S. Front line: Using primary care to prevent suicide. Tex Med. 2018 Nov 1;114(11):16-21. Santiani A et al. Projected workforce of psychiatrists in the United States: A population analysis. Psychiatr Serv. 2018 Jun;69(6):710-3. Huff C. Shrinking the psychiatrist shortage. Manag Care. 2018 Jan;27(1):20-2. Wilkins KM et al. Integration of primary care and psychiatry: a new paradigm for medical student clerkships. J Gen Intern Med. 2018 Jan;33(1):120-4. McGough PM et al. Integrating behavioral health into primary care. Popul Health Manag. 2016;19(2):81-7.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych    

Episode 3 - Aren't Psych Patients Dangerous? An exploration of risk of violence in mental health patients and review of relevant large studies. Funding graciously provided by the Alberta Medical Association. References Elbogen EB, Johnson SC. The Intricate Link Between Violence and Mental DisorderResults From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. JD009;66(JD):15JD–161. doi:10.1001/archgenpsychiatry.JD008.537 U.S Department of Health and Human Services / National Institutes of Health / National Institute on Alcohol Abuse and Alcoholism. (JD006).National Epidemiologic Survey on Alcohol and Related Conditions. Retrieved from https://pubs.niaaa.nih.gov/publications/arhJD9-JD/74-78.htm Steadman HJ, Mulvey EP, Monahan J, et al. Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods. Arch Gen Psychiatry. 1998;55(5):393–401. doi:10.1001/archpsyc.55.5.393 Van Dorn R, Volavka J, Johnson N. Mental disorder and violence: is there arelationship beyond substance use? Soc Psychiatry Psychiatr Epidemiol. 2012 Mar;47(3):487-503. doi: 10.1007/s001JD7-011-0356-x. Epub 2011 Feb 26. PubMed PMID: 21359532. Walsh E, Moran P, Scott C, McKenzie K, Burns T, Creed F, Tyrer P, Murray RM, Fahy T; UK700 Group. Prevalence of violent victimisation in severe mental illness. Br J Psychiatry. JD003 Sep;183:JD33-8. PubMed PMID: 1JD948997. Hiroeh U, Appleby L, Mortensen PB, Dunn G. Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study. Lancet. JD001 Dec JDJD-JD9;358(9JD99):JD110-JD. PubMed PMID: 117846JD4. Hiday VA, Swartz MS, Swanson JW, Borum R, Wagner HR. Criminal victimization of persons with severe mental illness. Psychiatr Serv. 1999 Jan;50(1):6JD-8. PubMed PMID: 9890581.

In this in service Dr. Stephen Price and I discuss the relationship between mental illness and violence and delve into our experiences with this population. According to the Department of Justice violent crime has been decreasing since the early 1990s. Although there is a statistical relationship between mental illness and violence, only 4% of all violent crimes are committed by persons with mental illness. Conversely, persons with mental illness are at high risk for violent victimization. Despite this violent crimes involving persons with mental illness are over-reported. Research indicates that mental illness only needs to be mentioned in news stories for people to infer that there is a causal relationship between the two. References for this in service are listed below.   If you enjoy our podcast please consider liking us in Apple podcast. You can also find our podcast in Google, Spotify, and at https://forensicinservice.com   The music for our podcast was composed and performed by Adam Price. The artwork "Blocked Thoughts" was hand painted by Jenn Koonz, Ph.D. Both are used with permission. Forensic InService podcast by Stephen Koonz & Stephen Price is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.   References: Alia-Klein, N, O’Rourke, TM, et al. (2007). Insight into illness and adherence to psychotropic medications are separately associated with violence severity in a forensic sample. Aggressive Behavior, 33(1), 86-96. Chan, G, & Yanos, PT. (2018). Media depictions and the priming of mental illness stigma. Stigma and Health, 3(3), 253-264. Choe, JY, Teplin, LA, & Abram, KM. (2008). Perpetration of violence, violent victimization, and severe mental illness: Balancing public health outcomes. Psychiatr Serv, 59, 153-164. da Cunha-Bang, S, Hjordt LV, et al. (2017). Serotonin 1B receptor binding is associated with trait anger and level of psychopathy in violent offenders. Biological Psychiatry, 82(4), 267-274. George, DT, Umhau, JC, et al. (2001). Serotonin, testosterone and alcohol in the etiology of domestic violence. Psychiatry Research, 104(1), 27-37. Hein, S, Barbot, B, et al. (2017). Violent offending among juveniles: A 7-year longitudinal study of recidivism, desistance, and associations with mental health. Law and Human Behavior, 41(3), 273-283. Hodgins, S. (2008). Violent behavior amongst people with schizophrenia: A framework for investigation of causes and effective treatment, and prevention. Philos Trans R Soc Lond B Biol Sci, 363, 2505-2518. inSocialWork Podcast #135 - Chris Veeh: Traumatic Brain Injury and Incarcerated Youths: A Role for Social Work. (2014). Retrieved 23 September 2018, from http://www.insocialwork.org/episode.asp?ep=135. Kuehn, BM. (2012). Evidence suggests complex links between violence and schizophrenia. Journal of the American Medical Association, 308(7), 658-659. Latalova, K, Kamaradova, D, & Prasko J. (2014). Violent victimization of adult patients with severe mental illness: A systematic review. Neuropsychiatr Dis Treat, 10, 1925-1939. Lee, AMR, & Galynker, II, (2010). Violence in bipolar disorder. Psychiatric Times. Retrieved 23 Septemer 2018 from: http://go.galegroup.com/ps/anonymous?id=GALE%7CA392573273&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=08932905&p=AONE&sw=w Maio HA. (2004). Stigma and public education about mental illness: Comment. Psychiatric Services, 55(7), pp. 834. Newman, JM, Turnbull, A, Berman, BA, et al. (2010). Impact of traumatic and viiolent victimization experiences in individuals with schizoprenia and schizoaffective disorder. J. Nerv Ment Dis, 198, 708-714. Robbins, PC, Monahan, J, & Silver, E. (2003). Mental disorder, violence, and gender. Law and Human Behavior, 27(6), 561-571. Sirotich, F. (2008). Correlates of crime and violence among persons with mental disorder: An evidence-based review. Brief Treatment and Crisis Intervention, 8(2), 171-194. Swanson, JW, Holzer, CE III., Ganju, VK, et al. (1990). Violence and psychiatric disorder in the community: Evidence from epidemiologic catchment area surveys. Hops Community Psychiatry, 41, 761-770. The Lobotomist | American Experience | PBS. (2018). Pbs.org. Retrieved 28 September 2018, from https://www.pbs.org/wgbh/americanexperience/films/lobotomist/ Varney, KH. (2014). By the numbers: Mental illness behind bars. PBS News Hour. Retrieved 21 September 2018, from https://www.pbs.org/newshour/health/mental-illness-behind-bars. Varshney, M, Mahapatra, A, Krishnan, V, Gupta, R, & Debs, KS. (2015). Violence and mental illness: What is the true story? Journal of Epidemiology and Community Health, 70(3), 223-225. Weierstall, R, Moran, J, Giebel, G, & Elbert, T. (2014). Testosterone reactivity and identification with perpetrator or a victim in a story are associated with attraction to violence-related cues. International Journal of Law and Psychiatry, 37(3), 304-312.