Psychcast

Official podcast feed of MDedge Psychiatry, part of the Medscape Professional Network. Episodes include interviews with leaders in psychiatry and psychology, masterclass lectures, and clinical perspective. Interviews are hosted by Dr. Lorenzo Norris, MD, Clinical Correlaction featuers Dr. Renee Kohanski, MD, and lecturers are chosen by MDedge Psychiatry. The information in this podcast is provided for informational and educational purposes only.

The Psychcast goes on hiatus | Clinical Correlation 05/10/2021

Creative approaches to treatment during the COVID-19 pandemic with Dr. Craig Chepke 05/05/2021

Creative approaches to treatment during the COVID-19 pandemic with Dr. Craig Chepke Craig Chepke, MD, speaks with Lorenzo Norris, MD, about changes he made to his practice during the COVID-19 pandemic, and plans to make some of those changes permanent. is a psychiatrist in Huntersville, N.C., and adjunct associate professor at Atrium Health and adjunct assistant professor at the University of North Carolina at Chapel Hill. He disclosed serving as a consultant and speaker for Otsuka and Janssen, and as a speaker for Alkermes. is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Chepke discussed his strategies for adapting his practice to the restrictions of the pandemic. He engaged in shared decision-making with patients when modifying his practice, including starting a drive-through pharmacotherapy clinic. To ensure that patients continued to have access to treatments such as long-acting injectable antipsychotics and esketamine, Dr. Chepke created a system in which patients could drive up to his clinic to have the medication administered. Because esketamine requires a 2-hour monitoring period after administration, he adapted the safety protocol. After patients received their intranasal spray dosage, they would complete the monitoring period in their car in the parking lot outside of his office, which was close enough to the clinic for Dr. Chepke to physically observe the patient, and to monitor vital signs wirelessly via a Bluetooth-enabled blood pressure cuff. Throughout the pandemic, Dr. Chepke found ways to care for his patients’ physical and mental health. He also adopted technologies that help him monitor his patients' vital signs and glucose levels. Especially while focusing on treatment-resistant psychiatric illness, Dr. Chepke invites family members to participate in evaluation and treatment. He uses this approach because he realizes that effective treatment must involve the system in which the individual exists. Dr. Chepke and Dr. Norris discussed ways in which clinicians can extend hope to their patients through flexibility and innovation, especially throughout the pandemic. Providing hope to patients demonstrates belief in a better future. Reference Chepke C. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18971642

Examining a model for intervening in gun-related violence in the US with Dr. Jack Rozel 04/28/2021

Examining a model for intervening in gun-related violence in the US with Dr. Jack Rozel John “Jack” Rozel, MD, MSL, returns to the Psychcast to talk with Lorenzo Norris, MD, about American gun violence and steps clinicians can take to disrupt it. is medical director of the resolve Crisis Network. He also serves as associate professor of psychiatry and adjunct professor of law at the University of Pittsburgh. Dr. Rozel is also past president of the American Association for Emergency Psychiatry. He has no disclosures. is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Mass violence with guns is occurring with greater frequency and severity in the United States, compared with other countries. Mass shootings have been on the rise. In 2020 there were nearly 200 more mass shootings, compared with 2019. The United States has a broad swath of firearm violence: Deaths by suicide account 60% of gun deaths, and the remaining 40% are deaths by homicide. Only 1%-2% of firearm homicides are completed in mass shootings – which are defined as an event in which four or more people are shot in an indiscriminate manner. It is also a distinctly American problem that we have so many guns in our country. The United States has more civilian-held firearms (393 million) than the next 39 countries combined. Being an adult in the United States means being 25 times more likely to be the victim of a firearm homicide, compared with adults in any other country. Dr. Norris and Dr. Rozel conclude that violence assessments must always cover suicide and homicide risk because they are related types of violence, especially when it comes to guns. Summary Suicide risk is increased by 100-fold when a new gun enters the home, and the risk peaks in the first days to weeks of ownership and then trails off. However, there is a measurable difference in risk of suicide in the 5 years after the purchase. Dr. Rozel emphasizes that it is essential to ask patients about acquisition of new guns, because as circumstances change as with the pandemic, people may feel the need to buy a gun. Dr. Rozel presented a model for possibly reducing gun violence: Grievance: All violence starts with feeling like a victim; some people feel aggrieved after a disagreement or even a threat. The Pivot: This is a transition from simply having a grievance to violent ideation and wanting vengeance through violence. Perpetrators of violence shift from fantasy into research about planning and preparing to attack. Preparation: This stage includes acquiring weapons and, in some cases, tactical clothing. It also could include probing into their targets’ vulnerabilities, a “test attack,” and eventually the final attack. Breach: This entails a change in the safety of the potential victim. Attack: This stage encompasses perpetrating the attack. Identifying a person at the grievance stage is the most effective place to intervene and potentially diffuse a violent situation by using motivational interviewing to enhance protective factors. Psychiatry’s greatest strength is meeting the aggressor where they are and hearing out the grievance. References Victor D and Taylor DB. A partial list of mass shootings in the United States in 2021. Kim NY. Gun violence spiked during pandemic, even as the deadliest mass shootings waned. . Rozel JS and Mulvey EP. . Metzl JM et al. . Firearm access is a risk factor for suicide. . National Council for Behavioral Health. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18884519

Crawling in my skin | Clinical Correlation 04/26/2021

Changing the culture in medical schools to meet the mental health needs of physicians, students, and residents with Dr. Omar Sultan Haque 04/21/2021

Changing the culture in medical schools to meet the mental health needs of physicians, students, and residents with Dr. Omar Sultan Haque Omar Sultan Haque, MD, PhD, talks with Lorenzo Norris, MD, about the need for medical schools to become responsive to physicians, medical students, and residents with mental disabilities. is a physician, social scientist, and philosopher who is affiliated with the department of global health and social medicine at Harvard Medical School, Boston. He disclosed founding Dignity Brain Health, a clinic that seeks to provide clinical care for patients struggling with major depressive disorder. Dr. Haque also serves as medical director of Dignity Brain Health. is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Haque and colleagues recently published a perspective piece in the New England Journal of Medicine about the “double stigma” against mental disabilities, which the authors define as “psychiatric, psychological, learning, and developmental disorders that impair functioning,” including common diagnoses, such as attention deficit disorder and major depressive disorder. Physicians and physicians-in-training, such as students and residents, face major challenges in disclosing mental disabilities, from fear of discrimination during the admissions process to stigma throughout training and licensure. Medical leave is often the only suggested solution to an exacerbation of a disability, and this response is likely to instill fear in trainees, because taking leave will require future disclosure and worsen the double stigma. Reasonable accommodations could improve functioning and allow trainees to remain enrolled and on their desired academic path. Dr. Haque recommends that medical schools and training programs have trained disability service providers (DSP) with specialized understanding of medical education and curricula who do not have conflicts of interest – as sometimes happens when they participate in other roles, such as serving as deans or professors within a medical school. A continued challenge to disability disclosures are questions on medical licensing applications and renewals about past or current diagnoses or treatment for mental disabilities. Dr. Haque reminds listeners that, according to the American Disabilities Act, these questions about past and current diagnoses are illegal if the answers to those questions do not affect physicians’ current functioning. Summary Dr. Haque’s article offers several recommendations for medical schools, training programs, and licensing boards aimed at addressing the burden of the double stigma against mental disabilities within the culture of medical training and practice. Medical schools should clearly communicate that applicants with disabilities are welcome as part of a larger commitment to diversity, and individuals with mental disabilities should be admitted and allowed to complete training. Universities should hire medical school–specific disability service providers who understand medical education and are committed to parity for individuals with physical and mental disabilities. Policies related to mental disabilities should be clearly publicized so that students and trainees know what to expect if they disclose a disability, and should create reasonable accommodations for those with mental disabilities instead of promoting medical leave as the only option. Faculty members and administrators could publicly describe their own protected time for therapy and highlight the professional successes of people who were able to disclose their condition and get reasonable accommodations. The Federation of State Medical Boards should enforce the ADA-based legal standard that questions about mental disabilities should be asked and answered only if they address current functional impairments that affect a physician’s ability to practice medicine safely. References Haque OS et al. . Wimsatt LA et al. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18795557

Understanding Zoom fatigue and how to make videoconferencing less anxiety provoking with Dr. Géraldine Fauville 04/14/2021

Understanding Zoom fatigue and how to make videoconferencing less anxiety provoking with Dr. Géraldine Fauville Géraldine Fauville, PhD, joins Lorenzo Norris, MD, to discuss some of the causes of Zoom fatigue and strategies that can make videoconferences productive. is the lead researcher on the Zoom Exhaustion & Fatigue Scale project. She also is assistant professor in the department of education, communication, and learning at the University of Gothenburg (Sweden). Dr. Fauville has no disclosures. is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Fauville started her research on Zoom fatigue in the at Stanford (Calif.) University, founded by . The lab has pioneered research on the common but poorly understood phenomenon of Zoom fatigue. Videoconferencing, often through Zoom, has allowed people to connect throughout the pandemic, but there are features of this modality that can contribute to stress, and for many, social anxiety. Dr. Fauville and Dr. Norris discuss Zoom fatigue and which dynamics of videoconferencing contribute to a sense of anxiety, fatigue, and affect our general wellness in a society that has come to rely on videoconferencing as a primary form of communication and central to parts of our economy during the pandemic. Dr. Fauville discusses how the size of faces on the screen and feeling observed activate anxiety and stress. Constant mirroring from seeing yourself reflected from the camera onto a screen can lead to self-judgment and negative emotions. Loss of traditional nonverbal communication and being forced to pay attention to verbal cues or exaggerate gestures can increase the cognitive load associated with conversations that occur via videoconference. Videoconferencing also restricts mobility, because people feel tethered to a small area within their camera’s view where they can be seen. Summary During an in-person meeting, people will stare at you while you’re speaking, but on videoconferencing it can feel as if all eyes are on you the whole time, which contributes to stress and social anxiety. Dr. Fauville discusses the “large face” dynamic; if these conferences were real-life interactions, it would be like having a very large face just a few inches from ours, which can feel like an invasion of privacy. For the brain, having a face in close proximity to yours signals either a desire for intimacy or conflict. Recommendation: Minimize the videoconferencing application as much as possible and keep the size of the faces smaller. Zoom and other platforms lead to “constant mirroring.” Seeing our own image can result in persistent self-evaluation and judgment, which can contribute to anxiety and negative emotions. Recommendation: Keep your camera on but hide self-view; doing so can combat this constant mirroring. Videoconferencing has severely limited mobility during meetings, which make people feel trapped in the view of the camera. Recommendation: Using a standing desk allows for more freedom from the view of the camera. You can stretch your legs, walk around in the view of the camera, and create distance, especially if you have an external keyboard. Nonverbal communication and behaviors are essential cues between humans. Videoconferencing that focuses on head and shoulders diminishes a large portion of body language. Videoconferences are more taxing for the brain than audio-only communication because people have to be even more in tune to the cues in speakers' verbal tones, and some nonverbal cues, such as nodding, become exaggerated. Recommendation: Organizations should create guidelines aimed at mitigating Zoom fatigue. Suggestions include allowing people to turn off their cameras for portions of meetings or didactics, having a mix of audio/telephone and video meetings, and assessing whether the information from some meetings can included in email messages or shared documents. Dr. Fauville and colleagues created the Zoom Exhaustion & Fatigue Scale ) to quantify the phenomenon. Fifteen items on the scale focus on five dimensions of Zoom fatigue, such as general, visual, emotional, social, and motivational fatigue. Part of the evaluation of Zoom fatigue should include examining how many videoconferences you have per day, the amount of time between each, and how long the conferences last. References Ramachandran V. Stanford researchers identify four causes for ‘Zoom fatigue’ and their simple fixes. . Fauville G et al. Zoom Exhaustion & Fatigue Scale. Bailenson JN. Nonverbal overload: A theoretical argument for the causes of Zoom fatigue. Technology, Mind & Behavior. 2021 Feb 23;2(1). . Zoom Exhaustion & Fatigue Scale survey: * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18706553

Patients can read our notes now? | Clinical Correlation 04/12/2021

Precision medicine and mental health: Implementing pharmacogenomics into your private or institutional practice with Dr. Vicki L. Ellingrod 04/07/2021

Precision medicine and mental health: Implementing pharmacogenomics into your private or institutional practice with Dr. Vicki L. Ellingrod Guest host Vicki L. Ellingrod, PharmD, talks with Kristen M. Ward, PharmD, and Amy Pasternak, PharmD, about integrating pharmacogenomic testing into psychiatric practice. is senior associate dean at the University of Michigan College of Pharmacy, Ann Arbor, and professor of psychiatry in the medical school. She is also section editor of the savvy psychopharmacology department in Current Psychiatry. Dr. Ellingrod has no relevant financial relationships to disclose. and are clinical assistant professors of pharmacy at the University of Michigan. Dr. Ward and Dr. Pasternak report no relevant disclosures. Dr. Ward and Dr. Pasternak are team leads in the Take-home points Pharmacogenomics is defined as the study of the relationship between genetic variations and how our body responds to medications. Two common reasons for ordering pharmacogenomic testing are that a patient or clinician wants testing completed before starting the trial of a psychotropic medication and that there are concerns about nonresponse or loss of response to medications. Common insurance criteria used to justify such testing include at least one failed medical trial; future use of a medication likely to be affected by genetic variants, such as metabolism through or ; or identification of human leukocyte antigen () variants before starting carbamazepine or oxcarbazepine. Quality improvement and usability campaigns around pharmacogenomic testing include ensuring that testing results are readily available in the medical record. Results should be searchable. Alerts can be created for prescribers when they order a medication for which a patient has a relevant genetic variant. After ordering testing, clinicians should document the patient’s medication response genotype and phenotype in the medical record so the information can be used for medications other than psychotropics. Summary Pharmacogenomic testing may be ordered for several reasons, including cases in which a patient or clinician wants information before switching to another medication or there are questions about failed medication trials. For approximately 50% of individuals who undergo pharmacogenomic testing, there may not be a change in treatment plans, or the results might not be conclusive enough to affect treatment. However, pharmacogenomic testing is useful in reassuring and improving adherence in patients who experience somatic adverse effects to psychotropic medications and want to know whether those effects are related to their metabolism. Getting insurance companies to cover pharmacogenetic testing can be tricky, and clinicians should be familiar with the criteria requested by insurers before ordering the tests. Many of the genetic-testing companies include a patient-assistance program to cover payment when insurance companies do not. In the medical record, it’s important to document the patient's genotype and phenotype. The patient’s genotype affects their metabolism of medications beyond psychotropics. Pharmacogenomic testing results can prevent serious adverse drug reactions. If testing comments on a patient’s carrier status for specific HLA subtypes implicated in drug metabolism, carbamazepine or other related medications should be added to the patient’s drug allergy list. States requirements about informed consent for genetic testing vary, so any clinicians who order such tests should be informed about their local laws. References Ellingrod VL. . Deardorff OG et al. . Ellingrod VL and Ward KM. . Bishop JR. . Maruf AA et al. National Institutes of Health. National Human Genome Research Institute. . Clinical Pharmacogenetics Implementation Consortium. .. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18609899

Providing mental health services and fostering resilience in the wake of mass traumas such as the Jan. 6 Capitol siege 03/31/2021

Providing mental health services and fostering resilience in the wake of mass traumas such as the Jan. 6 Capitol siege Lorenzo Norris, MD, speaks with Tonya Cross Hansel, PhD, about processing incidents such as the Jan. 6, 2021, siege on the Capitol, and determining how to foster recovery. is an associate professor with the Tulane University School of Social Work in New Orleans. She has no conflicts of interest. is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Dr. Hansel’s research focuses on measuring traumatic experiences and implementing systematic recovery initiatives that address negative symptoms by emphasizing individual and community strengths. The tendency to come together in times of vulnerability is a human instinct. The Jan. 6 Capitol siege was a traumatic and polarizing event; in a Pew survey 1 week later, 37% of respondents expressed a strong negative emotion in response to the riot. The unpreparedness of the U.S. Capitol Police and other law enforcement agencies led to fear and shock as much of the nation watched the breach unfold in real time on television. A variety of groups attended the protest. Some groups were involved in domestic terrorism, and others were part of political groups who came protest their grievances against the government. Those who attended the event with the intent of engaging in violence and instilling fear are considered . Dr. Hansel said an event such as the insurrection wears on society by causing chronic stress, and one-time events such as the insurrection can lead to a prolonged state of anxiety. Terrorism and violence are sometimes triggered by disenfranchisement when violence seems like the only way to make one’s voice heard. Disasters with an economic fallout, such as natural disasters or the ongoing COVID-19 pandemic, can result in greater disenfranchisement. Prevention of future attacks and domestic terrorism must balance people’s ability to speak out and protest with an effort to avoid disenfranchisement. The way forward must also include addressing chronic fear. Dr. Hansel suggests that building community over shared values is a powerful way to foster resilience after disaster. In the pandemic, we have all experienced sacrifice and hardship. When society moves beyond survival mode, efforts must be made to connect over our shared sense of loss. References Hartig H. In their own words: How Americans reacted to the rioting at the U.S. Capitol. . Pape RA and Ruby K. The Capitol rioters aren’t like other extremists. . Ellis BH et al. Studies in Conflict & Terrorism. 2019 May 31. . Hansel T et al. . Saltzman LY et al. Curr Psychiatry Rep. 2017 Jun 19. Hall BJ et al. PLoS One. 2015 Apr 24. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18537101

Spectrum vs. narcissism: An unlikely differential | Clinical Correlation 03/29/2021

Psychedelics, violence, and psychiatric treatment: Assessing the early and emerging research with Dr. Brian Holoyda 03/24/2021

Psychedelics, violence, and psychiatric treatment: Assessing the early and emerging research with Dr. Brian Holoyda Brian Holoyda, MD, MPH, MBA, conducts a Masterclass on the history of psychedelic research and how the renaissance of this drug class could affect psychiatric patients. , a forensic psychiatrist, practices in the San Francisco Bay Area. He also provides psychiatric consultations across the country. Dr. Holoyda has no disclosures. Take-home points The effects of psychedelics are dose dependent and difficult to predict. The impact of psychedelic treatment on violent behaviors was studied since the 1960s with varying results. More recent studies suggest that psychedelic use (excluding phencyclidine, or PCP) is associated with less violent crime. Dr. Holoyda recommends that, before psychiatrists treat patients with psychedelic-assisted psychotherapy, patients should be screened for history of violence or aggression while using psychedelics (and in general) and a history of serious mental illness. Patients require informed consent about the risk of violence and interventions used to control aggressive behaviors. Summary In 1960, the Harvard Psilocybin Project included a study in the Concord (Mass.) Prison in which researchers hypothesized that using psychedelic-assisted psychotherapy in prisoners would reduce risk of violent recidivism. The original authors, including , published varying results of the study – including that psychedelic use reduced recidivism. However, some argue the overly positive results from the first analysis were attributable to a halo effect. A recent reanalysis showed that the base rate for recidivism in the intervention group was 34%, and not significantly different from that of the control group. Psychiatrists have continued to use psychedelic-assisted therapy for patients with psychopathology and treatment-resistant sexual offenders to investigate whether the transcendent experiences can change their personalities, including the development of insight and empathy. Dr. Holoyda published a review of all published cases in medical literature discussing psychedelic use and violent behavior. Most of the cases were published in the 1960s-1970s, when psychedelics were viewed negatively as a product of the counterculture era. More recent observational studies identified that psychedelics use is associated with a greater likelihood of carrying a firearm as well as intimate partner violence, but these newer studies are fraught, because PCP is sometimes classified as a psychedelic. Other epidemiological studies have identified reductions in violent behaviors associated with psychedelics use, compared with other illicit substances. Those reductions in violent behaviors include a lower probability of supervision failure, and a lower risk of intimate partner violence and drug distribution. , and associates analyzed data from 225 million individuals who took the National Survey on Drug Use and Health from 2002 to 2014 with a focus on psychedelics use, excluding PCP. They that a lifetime history of psychedelic use decreased the odds of theft, assault, and arrest for property and violent crime. Studies such as this suggest that individuals who favor psychedelics may be less prone to violent crime rather than a direct effect of psychedelics on decreasing violent crime. As psychedelics enter the clinical sphere, clinicians must keep in mind that experiences on these agents are unpredictable. In a study of unmonitored psychedelic use, individuals report putting themselves or others at risk. Others reported behaving aggressively or violently, and others sought help at a hospital. Before using psychedelics in a therapeutic environment, clinicians should assess patients’ past use and experience on psychedelics. They also should screen for history of “bad trips,” leading to aggression, agitation, paranoia, and risky behaviors. In clinical trials with psychedelics, individuals with history of bipolar and psychotic disorders have been excluded to reduce the risk of triggering an episode. For medicolegal protection, psychiatrists should engage in a thorough informed consent process before using psychedelic-assisted therapy. References Holoyda B. . Holoyda B. . Hendricks PS et al. J Psychopharmacol. 2017 Oct 17. . Carbonaro TM et al. . Metzner R. Reflections on the Concord prison project and the follow-up study. . Arendsen-Hein GW. LSD in the treatment of criminal psychopaths, in ". Leary T. . Leary T and Metzner R. Brit J Soc Psychiatry. 1968;2:27-51. Leary T et al. . Doblin R. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18437081

The ripple effects of the COVID-19 pandemic on mental health with Dr. Dost Öngür 03/17/2021

The ripple effects of the COVID-19 pandemic on mental health with Dr. Dost Öngür Dost Öngür, MD, PhD, joins host Lorenzo Norris, MD, to discuss the emerging mental health effects of the pandemic. is chief of the Center of Excellence in Psychotic Disorders at McLean Hospital in Belmont, Mass. He also serves as the William P. and Henry B. Test Professor of Psychiatry at Harvard Medical School, Boston. Dr. Öngür has no disclosures. is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures. Take-home points Without a doubt, the COVID-19 pandemic will have a lasting mental health impact on society. Öngür discusses the role of trauma, grief, mourning, and social isolation during the pandemic. Summary One emerging mental health effect of the pandemic is lasting psychiatric symptoms after infection and inflammatory response, including anxiety, depression, insomnia, and fatigue. Many individuals have lost loved ones or witnessed someone close to them experience severe illness and prolonged hospitalizations. Early in the pandemic, in a 2020 Centers for Disease Control and Prevention representative survey, 30% of Americans reported symptoms of depression and anxiety, 13% reported increased substance use, and 11% thought about suicide. Individuals report greater distress, substance use, and suicidal ideation in the United States, but deaths from suicide did not increase dramatically, compared with 2019. A recent noted, however, that emergency department visits for social and mental health emergencies such as suicide attempts, overdoses, and intimate partner violence were higher in mid-March through October 2020 during the COVID-19 pandemic, compared with the same period a year earlier. One possible resilience factor for individuals with mental illness may be the protective nature of family ties. Though the shutdown led to social isolation and detachment from some networks, certain individuals came to rely more on nuclear relationships, such as family. With the pandemic, mental illness and mental health treatment have entered the public consciousness and conversation more than ever before. After the pandemic, more people will need mental health services as the social effects continue to ripple for years to come. References Czeisler ME et al. Mental health, substance use, suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020. . Faust JS et al. Suicide deaths during the COVID-19 stay-at-home advisory in Massachusetts, March to May 2020. . John A et al. Trends in suicide during the COVID-19 pandemic. . Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. . Holland KM et al. Trends in U.S. emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. 2020 Feb 3. . *** Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge podcasts, go to Email the show: /episode/index/show/psychcast1/id/18354512

'The journey of a thousand miles begins with two roads diverged in a yellow wood' | Clinical Correlation 03/15/2021

Intervening in the lives of people who embrace White supremacy with Dr. Pete Simi 03/10/2021

Intervening in the lives of people who embrace White supremacy with Dr. Pete Simi Pete Simi, PhD, joins host Lorenzo Norris, MD, to discuss some of the factors that lead people to join hate groups, and strategies that have enabled some to leave the life of extremism behind. , associate professor of sociology at Chapman University in Orange, Calif., has studied extremist groups and violence for more than 20 years. His research has received from the National Institute of Justice, the Department of Homeland Security, the Department of Defense, the National Science Foundation, and the Harry F. Guggenheim Foundation. is associate dean of student affairs and administration at George Washington University, Washington. Dr. Norris has no disclosures. Take-home points Dr. Simi discusses how many of the White supremacists he studied live mundane, ordinary lives organized around extremist, violent beliefs. These individuals may be socialized in early life through exposure to beliefs consistent with White supremacy, such as racist ideas, slurs, and jokes, but they are not usually raised within a White supremacist family. The biggest challenge of leaving White supremacy is finding a new overarching identity, which ultimately requires redefining one’s emotional habits when it comes to engaging with society. White supremacist programming not only includes hateful beliefs but an emotional orientation that influences how an individual interprets the world around them. White supremacist violence and terrorism have long been a U.S. problem, and Dr. Simi said his awareness of the problem grew after the Oklahoma City bombing in 1995. Dr. Simi hopes that, through research and initiatives, the United States will address the root causes of White supremacist beliefs rather than focus on specific groups. Summary Dr. Simi first started studying White supremacists by evaluating their engagement on early Internet forums. Eventually, he made contact with a group that allowed him to observe their daily lives, including staying in their homes and attending collective events, such as music festivals. More recently, he has been evaluating and researching individuals who leave the White supremacist movement. As with many individuals who find solace in extremist groups, the childhood and adolescence of those who become White supremacists usually contain adverse childhood experiences and instability, such as physical and emotional abuse, and substance use in the home. These events cultivate vulnerability to White supremacy, because these adolescents and young adults are searching for a stabilizing force. In the Internet age, it’s much easier for vulnerable individuals to have chance encounters with extremist groups and beliefs, and even brief exposures are an opportunity for some to be recruited into White supremacist groups. A selling point of White supremacy is the sense of “fellowship” and “family,” which is attractive for individuals who feel disillusioned and isolated from society at large. In Dr. Simi’s research, half of his sample participants of White supremacists reported mental health diagnoses and similarly high rates of suicidal ideation. Mental illness is not an excuse for the behaviors and beliefs, but an example of another vulnerability that makes these individuals susceptible to strong support groups that often hold extremist beliefs. References Simi P et al. Am Sociol Rev. 2017 Aug 29. . Bubolz BF and Simi P. Am Behav Sci. 2019. . Simi P et al. J Res Crime Delinquency. 2016. . Windisch S et al. Terrorism Polit Violence. 2020. . Ask a researcher: Pete Simi. What domestic groups pose the largest threats? . National Counterterrorism Innovation, Technology, and Education Center. A U.S. Department of Homeland Security Center of Excellence. McDonald-Gibson C. ‘Right now, people are pretty fragile.’ How coronavirus creates the perfect breeding ground for online extremism. . Garcia-Navarro L. Masculinity and U.S. extremism: What makes young men vulnerable to toxic ideologies. . Life After Hate. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18255128

How schizophrenia patients are faring during COVID-19 with Dr. Frank Chen 03/03/2021

How schizophrenia patients are faring during COVID-19 with Dr. Frank Chen Frank Chen, MD, joins host Lorenzo Norris, MD, to discuss the impact of the COVID-19 pandemic on patients with schizophrenia. is the chief medical director for Houston Behavioral Healthcare Hospital and Houston Adult Psychiatry. He is a speaker for Alkermes and Otsuka. Dr. Chen has served on advisory boards for Alkermes, Intracellular Therapies, Otsuka, and Teva Pharmaceuticals. is associate dean of student affairs and administration at George Washington University. He has no disclosures. Take-home points Schizophrenia is associated with an increased risk of death from COVID-19, even when controlling for other medical comorbidities. Individuals with schizophrenia have many biological and situational risk factors for COVID-19, including an elevated risk of metabolic syndrome from antipsychotic medications, higher rates of nicotine addiction, a greater likelihood of living in a group setting, limited access to medical care, and the underlying inflammatory state of schizophrenia. Summary An article published in JAMA Psychiatry in January 2021 evaluated a large cohort of patients in a New York health system and identified schizophrenia as the second most highly associated risk factor for 45-day mortality from COVID-19, after the risk factor of advanced age. The study controlled for other medical comorbidities to avoid confounding the results. However, it is essential to remember that individuals with schizophrenia have environmental and biological factors that increase their risk of infection and complications from COVID-19, such as metabolic syndrome, cigarette smoking, limited access to health care, and living in a group or institutional setting. Dr. Chen points out that many patients with schizophrenia already have skills to adapt to the stresses of the pandemic. For example, individuals with schizophrenia might already be accustomed to living with a certain level of fear and uncertainty inherent to their thought disorder. He also comments that negative symptoms make social distancing easier for individuals with schizophrenia than for other people. Dr. Chen notes that telepsychiatry has been a boon to treating individuals with schizophrenia, because using this tool is almost like making a “home visit.” Telemedicine removes the barriers to care, such as transport and resistance to coming to the office. Adaptation to telepsychiatry has varied among different patient populations. Dr. Chen says some of his “higher functioning” patients with more controlled and stable lives did not want to see their clinician via video. They preferred the “secure” and more private setting of an office. Ultimately, psychological flexibility and ability to adapt influence the amount of stress people experience during crisis. References Nemani K et al. JAMA Psychiatry. 2021 Jan 27. . Mazereel V et al. Lancet. 2021 Feb 3. . Muruganandam P et al. Psychiatry Res. 2020 Jun 29. . Kozloff N et al. . Smith BM et al. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18161462

My C...cccccorona | Clinical Correlation 03/01/2021

Treating patients with delusional infestation with Dr. John Koo and Dr. Scott Norton 02/24/2021

Treating patients with delusional infestation with Dr. John Koo and Dr. Scott Norton John Koo, MD, and Scott A. Norton, MD, MPH, join host Lorenzo Norris, MD, for this special edition of the Psychcast. This is a crossover episode with our sister podcast, . is a psychiatrist and a dermatologist at the University of California, San Francisco. He has no disclosures. is a dermatologist with the Uniformed Services University of the Health Sciences in Bethesda, Md., and with George Washington University, Washington. He has no disclosures. They are featured in an on this topic online at MDedge.com/Psychiatry. is associate dean of student affairs and administration at George Washington University. He has no disclosures. Take-home points Delusional infestation or delusions of infestation, also known as delusional parasitosis, is a fixed false belief that one has an infestation of animate or inanimate pathogens, despite strong evidence against infestation. Common precipitants of delusional infestation include previous exposure to external or internal parasites, stress, and travel. The condition is more common among highly functional older women. A recent estimated the prevalence of delusional infestation as 1.9/100,000, though the condition is an area of limited study. Delusional infestation is poorly recognized by physicians, therapists, and families, which leads patients to search for an external cause of the symptoms and contributes to distress for patients and their loved ones. Patients with delusional parasitosis often lack insight into their disease, and it can be difficult to persuade them to take the recommended treatment of antipsychotics. Low-dose pimozide, a first-generation antipsychotic, is the most common treatment for delusional infestation, particularly because it does not have Food and Drug Administration approval as a treatment for psychosis. Therefore, patients are less biased against taking this medication. Summary Delusions of infestation are a monosymptomatic hypochondriacal psychosis in which the only delusion present is one of infestation, and patients do not have other symptoms of psychotic spectrum illness. Secondary delusions of infestation may occur in individuals who use drugs, such as methamphetamine or cocaine, or who have a primary psychotic disorder, such as schizophrenia. Delusions of infestation is related to Morgellons disease, which is defined as a skin condition characterized by the presence of “threads” or filaments that patients believe are embedded in their skin and might be accompanied by stinging and itching sensations. Patients with delusions of infestation usually present to a primary care physician or ED with symptoms of abnormal sensations of their skin, including crawling sensations. In addition, patients usually bring personal proof of their condition, such as a small bag of “specimens,” including pieces of lint, threads, or scabs. Some patients also bring in journals detailing the timing and associated factors of their symptoms. Dr. Norton advises that physicians treating the patients with delusions of infestation should mentally prepare themselves against initial bias and set aside time for longer visits or several follow-up visits. Dr. Norton starts with the premise that the patient has an actual infestation or other underlying cause of their pruritus and performs a thorough, full-body exam for dermatologic conditions, and examines the materials patients bring with them using a double-headed microscope – so that he and the patient can look at the specimens together. Dr. Koo often tells patients that they have Morgellons disease because it does not include the stigmatizing term of “delusional.” He reframes Morgellons as an infestation that cannot be cured by internal or external antiparasitic medications. He then pivots away from etiology to validation of their emotions and eventually to treatment. Dr. Koo usually often starts treatment with pimozide because it is an antipsychotic with FDA approval for Tourette syndrome – not schizophrenia. This perceived absence of a connection of the medication to psychiatric illness allows patients to be more open to taking the medication. For primary delusional infestation, Dr. Koo starts with pimozide. The dose, which is daily and taken orally, starts low at 0.5 mg and goes up by 0.5 mg every 2-4 weeks. The aim is to get up to 3 mg per day. Low doses of pimozide and other antipsychotics lead to decreased sensation of itching and formication. Dr. Koo refers to his treatment plan as a “trapezoid-like dosage strategy.” Once he gets the patient to 3 mg, he continues the medication until all the symptoms disappear and then continues the medication for an additional 3 months. Dr. Koo then slowly tapers the dosage over an additional few months. The keys to successful treatment include communicating with patients and working collaboratively with them. This approach builds trust and rapport. References Brown GE et al. . Kohorst JJ et al. . Lepping P et al. . Middelveen MJ et al. . Lepping P et al. Acta Derm Venereol. 2020 Sep 16. . Freudenmann RW et al. . Wolf RC et al. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/18060554

Exploring the connections between the microbiome and Alzheimer’s disease with Dr. George Grossberg 02/17/2021

Exploring the connections between the microbiome and Alzheimer’s disease with Dr. George Grossberg George T. Grossberg, MD, conducts a Masterclass examining emerging treatment options for Alzheimer’s disease that are tied to the new research on the microbiome. is the Samuel W. Fordyce professor and director of geriatric psychiatry in the department of psychiatry and behavioral neuroscience at Saint Louis University. He disclosed that he is a consultant for Acadia, Alkahest, Avanir, Axovant, Axsome Therapeutics, Biogen, BioXcel, Genentech, Karuna, Lundbeck, Novartis, Otsuka, Roche, and Takeda; receives research support from the National Institute on Aging, Janssen, and Genentech/Roche; performs safety monitoring for ANAVEX, EryDel, Intra-Cellular Therapies, Merck, and Newron; and serves on the data monitoring committee of ITI Therapeutics. Dr. Grossberg also serves on the speakers’ bureau of Acadia. Take-home points Dr. Grossberg discusses burgeoning research about treatment of Alzheimer’s disease (AD) by altering the microbiota using diet and medications. The microbiome refers to the entirety of microorganisms that live throughout the body. Microbiota are those organisms that live within the gut. Dysbiosis refers to a microbial imbalance, which has been linked to numerous disorders, including inflammatory diseases, psychiatric illness, obesity, diabetes, and more recently, AD. The gut-brain axis describes the impact of microbiota and GI tract health on the brain. Periodontal disease, as a marker of inflammation and as part of the microbiome, is linked to AD. Increasing research into the role of the microbiome, inflammation, and AD has revealed promising treatments. , a drug approved for mild to moderate AD in China, has been shown to slow the progression of AD by remodeling the microbiota and suppressing the production of specific amino acids that promote neuroinflammation. Summary The microbiota has many purposes, including digestion, communication with the immune system, generation of signaling peptides, refining vitamins, and producing antioxidants. Many factors influence the microbiome, including diet, use of antibiotics, exposure to breast milk as an infant, stress, and old age. The gut microbiota can be altered by consuming “prebiotics,” which are food sources that influence the composition of the microbiota. These foods include fermented foods such as yogurt, kombucha, sauerkraut, and kimchi. The Mediterranean diet also has good sources of prebiotics. Birthing method (C-section versus vaginal birth) also influences the microbiota; a recent study shows that an infant’s microbiota after C-section can be altered by giving them an early fecal transplantation from the mother. As further proof of the link between periodontal disease and AD, a recent study identified the presence of , a bacteria that causes gum disease, in the brain in close proximity to the tau tangles of AD. Gingipain, the toxin secreted by this bacteria, is found in high concentrations in brains of individuals with AD. Dr. Grossberg reviewed his “recipe” for AD prevention and treatment: Recommend adequate activity in four spheres: Physical, mental, social, and spiritual. Treat and control all cardiovascular risk factors, including smoking, obesity, diabetes, hypertension, and hyperlipidemia. Recommend good oral hygiene based on the increasing research about the link of periodontal disease and AD. Recommend dietary changes, including a prebiotic or probiotic, and the Mediterranean diet. Dietary changes may also include supplements such as curcumin, B-complex multivitamin, and vitamin E. Control exposure to air pollution as possible. Use a combination pharmacotherapy of an N-methyl-D-aspartate antagonist and a cholinesterase inhibitor for individuals with AD. References Jones ML et al. . Askarova S et al. . Beydoun MA et al. . Wang X et al. . Korpela K et al. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/17972507

I hear the secrets that you keep when you're talking in your sleep | Clinical Correlation 02/15/2021

Thinking through the medical ethics of COVID-19 with Dr. Rebecca Brendel and Dr. Allen Dyer 02/10/2021

Thinking through the medical ethics of COVID-19 with Dr. Rebecca Brendel and Dr. Allen Dyer Rebecca W. Brendel, MD, JD, and Allen R. Dyer, MD, PhD, join guest host Carol A. Bernstein, MD, to discuss the ethical challenges that have been occurring during the COVID-19 pandemic. is director of law and ethics at the Center for Law, Brain, and Behavior at Massachusetts General Hospital, Boston. She also serves as director of the master of bioethics degree program at Harvard Medical School, Boston. Dr. Brendel has no disclosures. is professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as vice chair for education at the school of medicine and health sciences. Dr. Dyer has no disclosures. , a past president of the American Psychiatric Association, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures. Take-home points Medical ethics often deal with decisions between doctors and patients, but during the COVID-19 pandemic, the medical community has been forced to reckon with ethics on a population scale. Examples of ethical challenges include issues of scarcity, justice, transparency, and navigating distrust of the medical system. In the beginning of the pandemic, individuals such as Dr. Brendel and Dr. Dyer participated in ethical planning so that hospital systems would be prepared to deal with scarcity of resources that could result in some individuals going without lifesaving interventions. During times of scarcity, transparency and accountability are necessary, because the community will ask questions about the fairness and justice of specific outcomes. The philosophy of is a reason-based decision-making model that strives to maximize the greatest good for the greatest number, and it has been commonly used as a template for ethical discussions during the pandemic. Yet, utilitarianism calculus is complicated by questions of how to define “good” and the challenge of accurately predicting the outcomes. Summary In situations of urgency, demand, and scarcity, ethics usually turns to utilitarianism with the intention of maximizing the greatest good for the greatest number. Inevitably, people or populations are harmed. Especially in the beginning of the COVID-19 pandemic, American society grappled with the issue of scarcity and allocation of medical resources, ranging from personal protective equipment, ventilators, medical staff, ICU space, and the vaccine. Now we must think about the ethical decisions influencing COVID-19 vaccination, including weighing the risks and benefits of who gets the vaccine and when – and how certain vaccine schedules forestall the spread in the population. For example, institutionalized individuals are at great risk of contracting COVID-19, yet society debates the “good” of vaccinating elderly in nursing homes versus incarcerated individuals. Question of defining good and grappling with the consequences are present throughout the entire vaccination algorithm. Communities contend with the question of who in their ranks are essential workers: Health care workers? Teachers? Restaurant staff? Factory workers? Justice and transparency are commonly discussed ethical principles, especially when we think about the algorithms created to allocate resources. Transparency is required to foster trust in the public health system, and actors within the system must demonstrate their accountability through being honest about the evidence behind policy decisions, following set parameters, and acknowledging historical reasons for distrust. The pandemic has pushed society to think about the ethics of community solidarity and reflect on governmental and individual responsibility of protecting the health and well-being of the community. As the pandemic ravaged the U.S. economy and further disadvantaged already vulnerable communities, we must use this opportunity to reexamine the ethics of how health care is distributed in the United States, and work toward a just and equitable system. References Ethics and COVID10: Resource allocation and priority-setting. . AMA Journal of Ethics. . Emanuel EJ et al. . Dyer AR and Khin EK. . . American Psychiatric Association. American Psychiatric Association. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/17885057

Understanding and dismantling structural racism within organizations with Dr. Ruth S. Shim 02/03/2021

Understanding and dismantling structural racism within organizations with Dr. Ruth S. Shim Ruth S. Shim, MD, MPH, joins Carol A. Bernstein, MD, to discuss how to understand systemic racism within psychiatric institutions and the implications for patient care. is the Luke & Grace Kim Professor in Cultural Psychiatry in the department of psychiatry and behavioral sciences at the University of California, Davis. She has no disclosures. , a past president of the American Psychiatric Association, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures. Take-home points Dr. Shim discusses her about why she left the APA, and describes her frustration about what she sees as the APA’s failure to prioritize mental health inequity and structural racism within the organization. Dr. Shim describes systemic racism and oppression as generational traumas that must be recognized and processed if our professional organizations and country are to move forward with equity. Psychiatry plays a role in healing societal trauma, so psychiatrists need to understand and address the damage of structural racism in our own system. Summary After psychiatry training, Dr. Shim became faculty at Morehouse School of Medicine, one of the few historically Black medical schools. During her clinical work in Atlanta, Dr. Shim noted the difference in health outcomes of inpatients at Emory University Hospital, which treated majority White patients, compared with those of Grady Memorial Hospital, which treated majority Black patients. This observation propelled her research into health disparities, which continues to inform her academic work. Dr. Shim’s decision to leave the APA occurred during the presidential term of , who, even as the first African American president of the organization, was thwarted in her attempt to push the APA to focus attention and resources on addressing mental health disparities, inequity, and systemic racism within the organization and psychiatry, according to Dr. Shim. Dr. Shim observes that systemic racism occurs when the structures of an organization, not individuals, perpetuate the inequity. An example within the APA is the disconnect and power disparity between the group’s executive leadership structure and its elected officials. This disconnect and power disparity stymie progressive voices and interventions, Dr. Shim said. Addressing systemic racism within an organization is challenging because it may not be considered a problem by all members, and usually the leadership of an organization caters to its majority. As an example, Dr. Shim discussed the APA’s systematic attempt to reduce resources and cancel the Mental Health Services Conference (formerly Institute for Psychiatric Services, or IPS meeting), which focuses on health care delivery to the most vulnerable populations. As observed by Dr. Bernstein, the IPS meeting might have incurred financial losses, but investment in such a meeting demonstrated the APA’s concern for mental health equity. (The Mental Health Services Conference was not held in 2020 but is scheduled to be held virtually Oct. 7-8, 2021). References Shim RS and Vinson SY, eds. . Washington, D.C.: American Psychiatric Association Publishing, 2021. Shim RS. Structural racism is why I’m leaving organized psychiatry. . Marmot M et al. . Okun T. White supremacy culture. . APA apologizes for its support of racism in psychiatry. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/17791166

We're so tired, we haven't slept a wink | Clinical Correlation 02/01/2021

Why some people cannot accept reality, even when presented with facts with Dr. David H. Rosmarin 01/27/2021

Why some people cannot accept reality, even when presented with facts with Dr. David H. Rosmarin David H. Rosmarin, PhD, joins Lorenzo Norris, MD, to discuss how to think about the concept of denial and its role in the sociopolitical challenges of our society. is a clinical psychologist and director of the spirituality and mental health program at McLean Hospital in Belmont, Mass. He also is an assistant professor of psychiatry at Harvard Medical School, Boston. Dr. Rosmarin has no disclosures. has no disclosures. Take-home points Denial is defined as a cognitive and emotional process by which a person avoids facing aspects of reality, especially when it is difficult to assimilate the details of reality into one’s current thinking. Arguably, denial is a coping or defense mechanism meant to address the tension that arises from trying to change an individual’s current way of thinking and understanding of reality. Another form of denial is choosing to focus only on one’s perception of reality and struggling to see the other side of an argument. We can see this form of denial play out in COVID-19 pandemic denial and in certain political narratives. Denial in its most potent form causes individuals to disconnect from any conversation around the salient topic, which can make denial even worse. Summary Denial can be adaptive in its role of protecting a person's psyche. When the midbrain and limbic system are activated, the frontal lobe needs time to process and integrate the information. For example, people will deny the presence of an event they regret or fear until they have enough emotional capacity to integrate new facts into their current model of reality. Yet, denial can be harmful when there are “side effects.” The classic example of pathologic denial is an individual who has experienced trauma, and through continued denial of its impact and poor integration of the event, starts to experience somatic symptoms. Dr. Rosmarin says the problem with denial is that people who are experiencing denial are often the last to recognize their need for treatment or an intervention. Dr. Rosmarin discusses how, with certain topics, we must value and preserve relationships over persuading certain social contacts, such as family and friends, to overcome their denial. Validating emotions and finding the validity in a person's beliefs and grievances can go a long way toward preserving relationships that are challenged by denial of certain facts. References Rosmarin DH et al. . Hall C and Pick D. . Miller BL. . Rosmarin DH. . New York: Guilford Press, 2018. * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/17696324

Dr. Dorothy Lewis of 'Interview with a Serial Killer' and 'Crazy, Not Insane' on a lifetime in psychiatry 01/20/2021

Dr. Dorothy Lewis of 'Interview with a Serial Killer' and 'Crazy, Not Insane' on a lifetime in psychiatry Guest host Eva Ritvo, MD, interviews Dorothy Otnow Lewis, MD, about her more than 40-year career in studying death row inmates as examined in the HBO documentary “Crazy, Not Insane.” is clinical professor of psychiatry at Yale University, New Haven, Conn. She has no disclosures. is a psychiatrist in private practice in Miami Beach, Fla. She has no disclosures. Take-home points Dr. Lewis has an extensive archive of taped interviews with death row inmates that she has used to inform her work as an expert witness. While doing her child psychiatry training at the Yale Child Study Center and sitting in at the juvenile court, she began to see that some of the children had psychiatric and neurologic problems that had not been addressed. The parents of these children sometimes had psychotic or bipolar disorders. After seeing these themes, Dr. Lewis started a clinic at the court. Dr. Lewis and her team were able to study approximately 15 inmates in four states, including Texas and Florida, both of which had the greatest number of condemned juveniles. One key theme that emerged is that all of the inmates had been sentenced to death as juveniles. Eventually, the for convicted killers who committed their crimes before age 18. Digging deeper and asking more questions of child and adolescent patients who commit violent acts can help clinicians identify environmental stressors that might underlie behavior that is aggressive and antisocial. In some cases, the psychiatric and neurologic impairments identified are treatable. Dr. Lewis would like to study whether identifying child abuse early might prevent future violence. References Yaeger CA, Lewis DO. Mental illness, neuropsychologic deficits, child abuse and violence. . Lewis DO. Ethical Implications of what we know about violence. . Lewis DO et al. Ethics questions raised by the neuropsychiatric, neuropsychological, educational, developmental, and family characteristics of 18 juveniles awaiting execution in Texas. . Griffith EEH et al. Re: Ethics questions raised by characteristics of 18 juveniles awaiting execution in Texas. . Lewis DO et al. Some evidence of race bias in the diagnosis and treatment of the juvenile offender. . Lewis DO. . New York: Fawcett Columbine, 1998. . . For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/17613422

Doctor, doctor, give me the news | Clinical Correlation 01/18/2021

Addressing how individual and social determinants affect mental health equity and inclusion with Dr. Regina James 01/13/2021

Addressing how individual and social determinants affect mental health equity and inclusion with Dr. Regina James Regina James, MD, tells her personal story and discusses how to understand health equity with guest host Carol A. Bernstein, MD. is deputy medical director and chief of the division of diversity and health equity at the American Psychiatric Association. She also serves on the advisory board of The PACT group (Pan African Clinical Trials) and receives no income from the group. , a past president of the APA, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures. Take-home points The Robert Wood Johnson Foundation defines health equity as: “Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Equity embraces the idea of inclusiveness and evaluates a whole health care system instead of focusing only on individual marginalized communities. For example, it is essential to understand the social determinants that lead to groups being medically underserved and then to understand the impact of the medically underserved on the entire system. Dr. James led a 20-year career in research and leadership within the National Institutes of Health, including the National Institute of Mental Health, the National Institute on Minority Health and Health Disparities, and the Eunice Shriver National Institute of Child Health and Human Development. She later transitioned to 2M, a research consulting agency, and then to the APA. Within the APA, Dr. James has developed a 5-point strategic plan with the vision that all APA members will be culturally competent and sensitive, and able to provide mental health care for any individual regardless of age, race, gender, or sexual orientation. The strategic plan focuses on raising awareness about mental health equity and destigmatization and leveraging the expertise of the APA membership in their communities. A cornerstone of the plan is an educational agenda, including materials on health equity in psychiatry and outreach to APA members and their community partners. In addition, Dr. James and her office partner with APA leadership to lobby the government for mental health equity and inclusion. Dr. James describes structural racism as current policies within an organization that lead to racial inequalities. Separate from the Office of Diversity and Health Equity, the APA established a to identify the scope and targets of structural racism within organized psychiatry, including the APA. It also seeks to identify how structural racism affects practicing psychiatrists and their patients. References Braveman P et al. What is health equity? . American Psychiatric Association. . American Psychiatric Association. APA Presidential Task Force to Address Structural Racism Throughout Psychiatry. Rosenkranz KM et al. J Surg Education. 2020. . Simonsen KA and Shim RS. . Alves-Bradford J-M et al. . Aggarwal NK et al. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/17520422

The year of living dangerously | Clinical Correlation 01/11/2021

Providing psychiatric consultation services for individuals living in nursing homes with Dr. Bradford L. Frank 01/06/2021

Providing psychiatric consultation services for individuals living in nursing homes with Dr. Bradford L. Frank Bradford L. Frank, MD, MPH, MBA, conducts a Masterclass on how to provide nursing home consultations for psychiatrists. The documents Dr. Frank refers to during this Masterclass are available at () is a board-certified geriatric psychiatrist who provides consultations for more than 30 nursing homes in North Dakota. He has no disclosures. Take-home points Dr. Frank reviews practical information about documentation, prescribing, and diagnoses for psychiatric clinicians who treat individuals living in nursing homes. The Centers for Medicare & Medicaid Services has many rules and regulations governing the psychiatric treatment of individuals in nursing homes, including special mental status testing, a policy of gradual dose reduction, and restrictions on how long certain medications can be used. Documentation Even for geriatric patients who live in nursing homes, a full past psychiatric history, including substance abuse and social history, is essential to diagnosis and treatment. To obtain these histories, Dr. Frank sends documents to the nursing home to be completed ahead of time, and then, while he starts to make his differential diagnoses, he talks with the nursing staff about why they want the consultation. The Brief Interview for Mental Status (BIMS) is a 15-item mental status exam mandated by the CMS during nursing home evaluations. A score of 13-15 indicates that a patient is cognitively intact, 8-12 indicates moderately impaired, and <8 is severe impairment. However, even patients with a BIMS score of 15 may still be diagnosed with moderate dementia when a more sensitive neuropsychiatric assessment is used. Patients should also complete a and have labs done as they would in a clinic. The assessment must also address gradual dose reduction using language from the CMS (see below). Prescribing and medications Gradual dose reduction is a CMS policy defined as “the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.” In collaboration with nursing home staff, prescribers must attempt to taper the doses of psychotropic medications during at least two quarters during the first year of the prescription and at least annually thereafter. The Food and Drug Administration has provided a black-box warning for the use of atypical antipsychotics in geriatric patients with dementia, and their use in such patients is audited by the CMS. To avoid censure and low ratings, nursing home clinicians must prescribe antipsychotics only for psychotic symptoms, such as hallucinations and delusions, and not for “dementia” or “agitation.” As-needed (PRN) antipsychotic medications can only be used for 14 days, and to extend the period another 14 days, the patient must be evaluated in person by the primary prescriber. PRN medications from other drug classes, such as benzodiazepines, can be used for longer without an exam, but their timeline must be specifically documented. Psychiatrists are most commonly consulted in nursing homes for agitation, and antipsychotics are not supposed to be used solely for agitation. Dr. Frank recommends citalopram (maximum dose of 20 mg), then escitalopram, Nuedexta (dextromethorphan HBr and quinidine sulfate), and pimavanserin for agitation associated with Alzheimer's disease (AD). Diagnosis Research based on autopsy findings has concluded that mixed etiology dementia is the most common type of dementia. On autopsy, AD is concurrently found with either vascular dementia, as evidenced by cerebral infarcts, or . To use cognitive enhancers that are FDA approved only for AD, Dr. Frank will update the diagnosis to multiple etiologies with a severity specifier. Frank discusses that nursing homes are reimbursed at a higher rate for the diagnoses of restlessness and agitation (), noncompliance (), and wandering (), and these are helpful diagnoses because they describe behaviors. Nursing homes use ICD-10 codes to diagnoses dementia with or without behavioral disturbance. For psychosis not attributed to delirium or severe dementia, Dr. Frank uses psychotic disorder with delusions or hallucinations because of a known physiological condition ( and ). Regulatory agencies recommend against use of the unspecified diagnoses. References Center for Clinical Standards and Quality/Survey & Certification Group. . Minimum Data Set – Version 3.0. Resident Assessment and Care Screening. . Bennett DA et al. . Yunusa I et al. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. /episode/index/show/psychcast1/id/17435027

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Recognizing medical symptoms that can mimic psychiatric diagnoses with Dr. Richa Bhatia 12/16/2020

Recognizing medical symptoms that can mimic psychiatric diagnoses with Dr. Richa Bhatia Richa Bhatia, MD, conducts a Masterclass on how to identify medical and neurologic illnesses that present with psychiatric symptoms and mimic psychiatric diagnoses. is a board-certified general and child and adolescent psychiatrist in private practice. She has no disclosures. Take-home points Psychiatric diagnoses are diagnoses of exclusion. Psychiatric clinicians must maintain a high level of clinical suspicion for medical and neurologic illnesses that present with psychiatric symptoms and mimic psychiatric diagnoses. When patients have a “strange” presentation of their psychiatric illness, including being out of the usual age range, a fast progression, or an unusual constellation of symptoms, clinicians should pursue a medical work-up and think broadly about other diagnoses that might mimic the psychiatric diagnosis. Dr. Bhatia provides an overview of common medical and neurologic illnesses that mimic psychiatric diagnoses, including hypothyroidism, delirium, HIV/AIDS, Addison disease, autoimmune encephalitis, temporal lobe epilepsy, frontotemporal dementia, Wilson’s disease, and Parkinson’s disease. Summary Hypothyroidism is an endocrine disease that can mimic depression. The physical symptoms include constipation, edema, dry skin, hair loss, weight gain, and cold intolerance. Individuals with comorbid hypothyroidism and depression report inadequate response to antidepressants, so psychiatrists should check the patient’s or refer them to their primary care physician if they suspect hypothyroidism with elevated TSH. Delirium is a common yet underdiagnosed syndrome that occurs secondary to medical illness and can produce an array of neuropsychiatric symptoms, including psychosis, irritability, and disorganized behaviors, which can lead to misdiagnosis as schizophrenia or mania. Delirium presents as an abrupt change in cognition with disorientation and significantly impaired attention. Hypoactive delirium presents with lethargy, apathy, and decreased alertness, and is often mistaken for depression in the hospital setting. Simple beside tests such as the can be used to quickly aid in diagnosing delirium. HIV/AIDS can mimic psychiatric disease through direct effect on the nervous system, opportunistic disease, intracranial tumors, cerebral vascular disease, and medication adverse effects. HIV can mimic depression by causing neurovegetative symptoms; apathy, psychomotor slowing, and working memory deficits are more characteristic of the neuropsychiatric impairment from HIV rather than a primary depressive disorder. In late-stage HIV/AIDS, dementia can cause bizarre behaviors, delusions, and mood disturbance such as euphoria and irritability. Addison disease is characterized by low blood pressure, hyperpigmentation, nausea, vomiting, weakness, fatigue, hypokalemia, and hyponatremia. Addisonian crisis can present with neuropsychiatric symptoms of delirium, anxiety, agitation, cognitive impairment, and auditory and visual hallucinations. Autoimmune encephalitis, with anti–N-methyl-D-aspartate receptor encephalitis as the most common type, often masquerades as a primary psychotic symptom. Notable symptoms include subacute onset with fast progression and no clear prodrome, working memory impairment, agitation, or lethargy. Other presenting symptoms include focal neurologic deficits, new-onset or rapidly developing catatonia, fever, headaches, flu-like illness, and autonomic disturbance. Temporal lobe epilepsy also can mimic a primary psychiatric disorder. The symptoms of seizure-like staring, blinking, lip-smacking, and behavioral arrest are precipitated by a sensation of fear or epigastric sensation and depersonalization, which can lead to misdiagnosis as a panic attack. Frontotemporal dementia (FTD) can be mistaken for a primary psychiatric diagnosis in the initial stages. Hallmark symptoms include progressive behavioral change with disinhibition and a decline in executive functioning and language skills such as verbal learning and reasoning. FTD is the second most common dementia in people aged younger than 65 years. Patients with FTD struggle to give a history, and often lack a psychiatric history or exposure to psychotropic drugs. Clinicians should maintain a high degree of clinical suspicion for FTD in new-onset psychiatric syndromes in older individuals. Stroke can lead to poststroke depression and anxiety, apathy, emotional lability, and personality changes. Depression after stroke, occurring hours to days after the insult, is associated with greater cognitive impairment and increased mortality. The diagnosis of poststroke depression is challenging because of impairments in language and cognition after stroke. Apathy can occur separately from depression and diminish recovery. Wilson’s disease results in copper deposits in the brain and liver. The psychiatric symptoms, including psychosis, occur before neurologic changes. Parkinson’s disease also can result in depression-like symptoms, given the motor and neurovegetative symptoms from the neurodegeneration. Fatigue, psychomotor slowing with diminished facial expression, postural changes, and sleep disturbance are common conditions that can mimic depression. References Carroll VK. . Welch KA and Carson AJ. . Scarioni M et al. . Evans DL et al. Neuropsychiatric manifestations of HIV-1 infection and AIDS, in “.” Philadelphia: Lippincott Williams & Wilkins, 2002, pp. 1281-99. Deng P and Yeshokumar A. . Kumar A and Sharma S. Complex partial seizure, in “.” Treasure Island, Fla.: StatPearls Publishing, 2020 Jan. (Updated 2020 Nov 20). Rao V. Neuropsychiatry of stroke. . * * * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show: /episode/index/show/psychcast1/id/17207078

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