Psychcast

Ruta Nonacs, MD, PhD, conducts a Masterclass lecture on treating women with postpartum depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Nonacs is a staff psychiatrist with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital in Boston.

* * *

Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019

* * *

Features of postpartum depression

• Postpartum depression (PPD) affects 10%-15% of women after delivery. For many women, their depression starts in the third trimester and worsens after delivery.
• Unique symptoms of PPD include difficulties bonding with the baby, feeling like an inadequate mother, and experiencing severe sleep disturbance with anxiety and edginess. In a common scenario, the mother will not be able to sleep at night, though her baby is sleeping well. Anxiety is a common comorbidity, especially obsessive thoughts about the baby's safety.

Treatment of PPD

• Treatment in this population is complicated by many demands placed on a mother as the primary caregiver of an infant. The medication chosen must target depression and anxiety, improve sleep, yet not be too sedating.
• The concentration of antidepressants in breast milk is low, but many women will defer treatment for their depression until they've stopped breastfeeding.
• Treatment of mild PPD includes recruiting more support to help the mother with care of the infant and psychotherapy to identify stressors and coping skills. In moderate to severe PPD, antidepressants are needed. Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are the preferred treatments, and studies support the use of sertraline, fluoxetine, paroxetine, and venlafaxine at their standard dosages. SSRIs and SNRIs are compatible with breastfeeding, because the medications are detected in the breast milk at very low levels.
• Brexanolone (Zulresso) is the only Food and Drug Administration–approved medication for postpartum depression. It is a neurosteroid and derivative of allopregnanolone, which is a positive allosteric modulator of the gamma-aminobutyric acid receptor. Brexanolone has low oral bioavailability and is administered only as a 60-hour infusion in a certified medical setting with continuous monitoring. The trials for brexanolone included women with moderate to severe PPD, and Hamilton Depression Rating Scale scores (HAM-D) scores ranging from 20 to 25. After the 60-hour infusion, 45% of the subjects with severe PPD in the brexanolone group achieved remission by the end of treatment, compared with 23% in the placebo group. Women retained the antidepressant effect at the 30-day follow-up. The results in the moderate PPD group were not as impressive; these women had a decrease in their depression HAM-D scores, but the antidepressant effect did not continue to the 30-day follow-up.
• The FDA approval came with a Risk Evaluation Mitigation Strategy in place.

Currently, approximately 100 sites are ready to administer brexanolone; however, some obstacles remain:

Obstacles to using brexanolone

• The medication costs more than $30,000 per infusion, and it is uncertain how much insurance will cover.
• Since brexanolone is administered in hospital settings, women must be separated from their children for several days.
• Breastfeeding must be stopped while women are on the medication because of the lack of data about excretion in breast milk.
• Brexanolone is labeled as a Schedule IV medication because it has a similar mechanism of action to midazolam and diazepam. Likelihood of diversion is low, but some women with substance abuse histories might be concerned about this treatment.

References

Leader LD et al. Brexanolone for postpartum depression: Clinical evidence and practical considerations. Pharmacotherapy. 2019 Nov;39(11):1105-12.

Meltzer-Brody S et al. Brexanolone injection in postpartum depression: Two multicenter, double-blind, randomized, placebo-controlled, phase 3 trials. Lancet. 2018 Sep 22;392(10152):1058-70.

Nonacs R. A Deeper Shade of Blue: A Woman's Guide to Recognizing and Treating Depression in Her Childbearing Years. New York, NY: Simon & Schuster; 2006.

Massachusetts General Hospital Center for Women's Mental Health. womensmentalhealth.org

National Institutes of Health. Drugs and Lactation Database (LactMed).

* * *

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Roberto Lewis-Fernández, MD, returns to the MDedge Psychcast, this time to discuss ways to approach pharmacotherapy for Latino patients with depression. Previously, on episode 36 of the Psychcast, Dr. Lewis-Fernández discussed the role of cultural assessments in providing person-centered mental health care.

Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University and director of the New York state Center of Excellence for Cultural Competence and the Hispanic Treatment Program at the New York Psychiatric Institute, spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP.

And later, in the "Dr. RK" segment, Renee Kohanski, MD, asks whether some euphemisms that are becoming more common in society keep us from finding real solutions to problems.

* * *

Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019

* * *

How Latino patients typically think of illness and medications

• Commonly, patients of Latino descent seek mental health treatment after trying other interventions, such as talking with family, clergy, and primary care clinicians. Latino patients, similar to other patient populations, sometimes present with ambivalence about medications and concerns that the medications might be "fairly strong" or addictive. The need to take medications is seen as an admission of sorts that the presenting problem of depression or anxiety is serious.
• Specifically, Latino patients are concerned about medications and risk of physical and psychological addiction and being reliant on a crutch. For example, a Latino patient might worry that by taking an antidepressant medication, they will lose their innate ability to improve on their own. This belief plays out when Latino patients stop medication prematurely, just as it begins to be effective, in order to "poner de mi parte," which translates to "do my share." The Latino culture puts weight on self-reliance.
• Latino patients often look for flexibility in medications and express concern about their effect on the body. For example, some patients might want to take medication only on days in which they feel sick. Others might ask for days off from the medication to ensure that the body does not weaken from being dependent on medications.
• Natural remedies often are favored by Latino patients. In some Latino communities, there might be natural pharmacies and "botanicas," which provide herbal and vitamin remedies. Natural medicines are viewed as "gentle" and more in line with what the body needs.
• Psychotherapy for the treatment of mild depression often is favored by patients who want to use therapy before medications. Latino patients usually prefer more "advice"-driven psychotherapy that focuses on problem solving.

Possible structural barriers to treating Latino patients

• Common structural barriers to accessing care include limited time to make appointments because of work and family obligations as well as a fragmented health care system with ever changing clinicians.
• Stigma and concerns about "harm to the body" can prove to be barriers.

How clinicians might work with Latino patients

• Be open to being flexible to patients' requests, such as the desire to perhaps skip a day each week or even stop medications. Exerting clinical authority based on biological understanding of the medication and diagnosis can backfire and can result in patients stopping the medication altogether.
• Understand different conceptions in the Latino community about how and when emotions should be expressed. The "ataque de nervios" ("attack of nerves") presented in the DSM-5 as a culture-bound syndrome is indicative of the Latino attitude that emotions are meant to be expressed but also controlled. So "un ataque de nervios" represents a situation that is so overwhelming that emotions take over, such as an attack and cannot be controlled.
• Know that warmth is more important than expertise in the eyes of some Latino patients.

References

Vargas SM et al. Toward a cultural adaptation of pharmacotherapy: Latino views of depression and antidepressant therapy. Transcult Psychiatry. 2015 Apr;52(2):244-73.

Lewis-Fernández R et al. Impact of motivational pharmacotherapy on treatment retention among depressed Latinos. Psychiatry. 2013 Fall; 76(3):210-2.

Moitra E et al. Examination of ataque de nervios and ataque de nervios like events in a diverse sample of adults with anxiety disorders. Depress Anxiety. 2018 Dec;35(12):1190-7.

* * *

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Martha Sajatovic, MD, conducts a Masterclass lecture on older-age bipolar disorder from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Sajatovic is professor of psychiatry and of neurology at Case Western Reserve University in Cleveland. She also directs the Neurological and Behavioral Outcomes Research Center at University Hospitals Cleveland Medical Center.

* * *

Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019

* * *

Conceptualizing OABD

• Older–age bipolar disorder (OABD), defined as a person aged 60 years or older with bipolar disorder, makes up one-quarter of bipolar patients. It is a heterogeneous population that includes early- and late-onset disease. Late onset is diagnosed when a person has a manic or hypomanic episode at or after the age of 50 years.
• Bipolar depression in later life has long been seen as a "special population," and the treatment has been extrapolated from larger clinical trials of younger patients.
• Late–onset bipolar disorder usually has attenuated manic episodes and depressive episodes are prolonged and severe. In OABD, the patients are more likely to have multiple morbidities, which makes medication management more complex.
• People with bipolar disorder lose 1-2 decades of life, compared with the general population.
• No medications are specifically approved by the Food and Drug Administration for bipolar disorder or bipolar depression in older adults. However, the treatment follows general geriatric psychiatry principles: Start low and go slow.

International guidelines on treating bipolar disorder

• Starting low means using half or even less of the recommended dose that a clinician would use in mixed-aged populations. Titrate slowly to allow the person time to acclimate to side effects that usually resolve. Bipolar disorder is a chronic disease, so medication adherence is paramount. Adherence can be jeopardized when a person experiences excessive side effects from the beginning of treatment.
• First-line treatment for bipolar depression in OABD include lurasidone (Latuda) or quetiapine (Seroquel) with low dosing and slow titration. This recommendation is supported by data from a post hoc analysis of the clinical trial data of lurasidone for bipolar depression.
• Lithium is also recommended and underused. The level should be lower for OABD; an appropriate target for older adults with bipolar disorder is 0.4-0.8 mEq/L, especially in people who are older and frailer.
• Lamotrigine (Lamictal) also is helpful and fairly well tolerated.
• Clinicians need to be attentive to a patient's medical comorbidities and psychosocial support to enhance adherence and improve outcomes. This approach would entail working closely with primary care clinicians and using an integrative approach as the medical comorbidities will influence the success of bipolar treatment.

References

Sajatovic M and Chen P. Geriatric bipolar disorder. Psychiatr Clin North Am. 2011 Jun 3;34(2):319-33.

Eyler LT et al. Understanding aging in bipolar disorder by integrating archival clinical research datasets. Am J Geriatric Psychiatry. 2019 Oct;27(10):1122-34.

Shulman Kl et al. Delphi survey about using lithium in OABD. Bipolar Disord. 2019 Mar;21(2):117-23.

Forester BP. Safety and effectiveness of long-term treatment with lurasidone in older adults with bipolar depression: Post hoc analysis of a 6-month, open-label study. Am J Geriatr Psychiatry. 2018 Feb;26(2):150-9.

* * *

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

This week, we are replaying five interviews that MDedge Psychiatry editor in chief Lorenzo Norris, MD, conducted at the 2019 American Psychiatric Association annual meeting.

Dr. Norris spoke with Igor Galynker, MD, (Mount Sinai Beth Israel, N.Y.) about identifying suicide crisis syndrome; Jonathan M. Meyer, MD, (University of California, San Diego) about prescribing clozapine for treatment refractory schizophrenia; Robert M. McCarron, DO, (University of California, Irvine) about psychiatry and primary care; Cam Ritchie, MD, MPH, about preparing patients for disruptions in psychiatric medications; and Richard Balon, MD, (Wayne State University, Detroit) about overcoming resistance to prescribing benzodiazepines for patients with serious mental illnesses.

* * *

Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019

* * *

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Jack Drescher, MD, returns to the MDedge Psychcast, this time to discuss ethical issues raised by the treatment of gender-variant prepubescent children with MDedge Psychiatry editor in chief Lorenzo Norris, MD. The two spoke at the 2019 Group for Advancement in Psychiatry (GAP) meeting in White Plains, N.Y.

Dr. Drescher is a Distinguished Life Fellow of the American Psychiatric Association, past president of GAP, and a past president of the APA's New York County Psychiatric Society. He has a private practice in New York.

And later, in the "Dr. RK" segment, Renee Kohanski, MD, says artificial intelligence is much more powerful than we imagined.

* * *

Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019

* * *

Three approaches used to address gender-variant children

Despite the acceptance of gender dysphoria as a diagnosis with standardized treatments, the treatment of gender-variant prepubescent children remains a controversial area. There are several treatment approaches regarding how and when a child should have a social transition to their desired gender.

• The oldest treatment approach is based on research that shows that most children will grow out of their gender dysphoria when the therapies applied help the children get used to living in the body of their assigned gender. Essentially, this approach discourages public or private social transition.

• The Dutch Protocol is based on research that shows the difficulty in predicting which children will continue to have gender dysphoria and which will not. Some children will have persistent gender dysphoria and become transgender; some may become homosexual; and others may identify with their own biological sex. The Dutch approach encourages children to have cross-gender interests and to privately identify with their desired gender, but there is not a public social transition.
  • Families and clinicians use watchful waiting to see whether the gender dysphoria persists. It's based on the idea that one cannot predict the future and so parents accept the child wherever they are.

• The final approach focuses on social transition without a medical or surgical treatment. Therefore, if the child's gender dysphoria desists, they can "detransition," since there was no medical intervention.
  • The gender-affirmative approach, mostly found in the United States, presupposes that it is possible to identify which children will persist in their transgender presentations and encourages a public, social transition to living as their identified gender. In case the child "makes a mistake," they can transition back to their biological sex.
  • A social transition occurs when a child, with the help of clinicians, explains to the family that they believe the gender dysphoria is going to last and that the child should be allowed to present publicly as their desired gender. This includes communicating with the school, family, and friends to help the child to be treated respectfully in the gender they desire.

Treatments for gender-variant children

• Puberty suppression is a medical treatment used by physicians in all three approaches. These medications block sex hormone action and are used to delay puberty and prevent the development of undesired secondary sex characteristics of the biologic sex. Adolescents frequently experience anxiety, depression, even suicidal ideation during this period because they feel pressured to choose their gender and avoid developing the secondary sexual characteristics of their biological sex.

• Social changes are outpacing the science. More frequently, children show up at gender clinics already socially transitioned by their parents; these children outnumber the subjects in the persist and desist literature. Regardless of the approach used, parents and clinicians should try to act on the exigent circumstances to relieve the distress of the child.

• Patients who are transitioning should be referred to a specialist, because this is a sensitive topic and treatment requires expertise.

References

Shumer DE et al. Advances in the care of transgender children and adolescents. Adv Pediatr. 2016 Aug;63(1):79-102.

Reed GM et al. Disorders related to sexuality and gender identity in the ICD-11: Revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21.

Zraick K. Texas father says 7-year-old isn't transgender, igniting a political outcry. New York Times. 2019 Oct 28.

* * *

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Michelle Magid, MD, conducts a Masterclass lecture on botulinum toxin for depression from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Magid is associate professor University of Texas in Austin, and associate professor of Texas A&M University in College Station. She disclosed serving as a speaker for Ipsen, maker of Dysport (abobotulinumtoxinA, or ABO), and as a consultant for Allergan, maker of Botox (onabotulinumtoxinA).

* * *

Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019

* * *

This week in psychiatry:

Conduct disorder in girls gets overdue research attention by Bruce Jancin

The physiological and emotion-procession abnormalities that underpin conduct disorder in teen girls are essentially the same as in teen boys. however, the clinical presentation of conduct disorder in the two groups is often different.

What we know about botulinum toxin

• Botulinum toxin is the product of Clostridium botulinum. The neurotoxin inhibits the release of acetylcholine, resulting in flaccid muscle relaxation. Its clinical use started in 1989 to treat strabismus (crossed eyes) and blepharospasm, a dystonic reaction in the eyes. Currently, botulinum is a Food and Drug Administration–approved treatment of chronic migraine in adults.
• For use in depression, 30-40 units of botulinum toxin is injected into the glabellar region of the face (the forehead). A purported mechanism of action of botulism for depression includes the "facial feedback hypothesis," in which the activation of muscles of facial expression, consciously or unconsciously, influences emotions.
• Botulinum toxin for depression is an off-label treatment with four case series, five randomized, controlled studies, and a phase 2 trial by supported by Allergan.

New findings on use of botulinum toxin for depression

• Magid and colleagues completed a pooled analysis of three randomized, controlled trials totaling 134 patients. Fifty-nine people were included in the botulinum toxin intervention group with a Beck Depression Inventory (BDI) score of 29, and 75 individuals in the placebo group with BDI of 26. In each group, 64% of patients were continued on other medications for depression, and the groups had similar histories of long-standing depression.
• In the botulinum toxin group, 52% had a response to the intervention, with an at least 50% reduction in their baseline depression scores, compared with a limited response in the placebo group.
• In the pooled analysis, Dr. Magid's group analyzed whether the cosmetic effect of botulinum toxin could be a confounding factor. The investigators ruled out that effect by using a subanalysis to evaluate whether the decrease in wrinkles correlated with decrease in depression, and it did not.
• Allergan moved forward with a phase 2 proof-of-concept trial; the results were mixed. The endpoint was response rate in Montgomery-Åsberg Depression Rating Scale (MADRS) at week 6. With a 30-unit Botox dose, there was a statistically significant decrease in MADRS at week 9, but not at week 6. There was no statistically significant divergence in data between the placebo and intervention group with the 50-unit dose. Given the response rate at week 9, Allergan is proceeding with a phase 3 trial.
• The cost is about $400 per treatment, and the treatment is given three to four times a year, which makes the cost comparable to that of other psychopharmacologic treatments. Adverse events are mild and include headache and local site irritation. In the current studies, botulinum treatment has been used as both monotherapy and augmentation; however, there are not enough data to know whether one is more effective than the other.
• In conclusion, burgeoning psychopharmacology research on treatments such as botulinum toxin for depression and novel medications, such as esketamine and brexanolone, broaden our understanding of the etiology of depression. This research is generating novel modes of treatment that will help more patients with refractory illness.

References

Magid M et al. Treating depression with botulinum toxin: A pooled analysis of randomized controlled trials. Psychopharmacology. 2015 Sep;48(6):205-10.

Magid M et al. Treatment of major depressive disorder using botulinum toxin: A 24-week randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2014 Aug;75(8):837-44.

* * *

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Andrew Penn, MS, NP, conducts a Masterclass lecture on psychedelic-assisted psychotherapy from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Mr. Penn, a psychiatric nurse practitioner, is associate clinical professor of community health systems in the School of Nursing at the University of California, San Francisco.

Later, Dr. Renee Kohanski is back – this time to discuss the need to call out the truth when we see it.

* * *

Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019

* * *

Reemergence of MDMA for PTSD and psilocybin for MDD

• Psychedelic-assisted psychotherapy is currently being investigated with 3,4-methylenedioxy-methamphetamine (MDMA) for treatment-resistant post-traumatic stress disorder (PTSD) and psilocybin for the treatment of major depressive disorder (MDD). The use of these compounds would be highly regulated. These are not medications that would be dispensed for a patient to take home.
• Both would be given in the clinical setting of one or more psychotherapy sessions with two therapists who would continue to work with the patient over time.
• MDMA was first patented by Merck in 1912, synthesized again in the 1970s, and used by psychotherapists to assist treatment. However, its recreational use spread, leading to its classification as a Schedule I controlled substance, thus prohibiting research or use in a medical setting.
• Lobbying through the Multidisciplinary Association for Psychedelic Studies, also known as MAPS, managed to bring MDMA into phase 3 clinical trials, and in 2017 the Food and Drug Administration granted breakthrough therapy designation for its use with psychotherapy for PTSD.
• MDMA is a potent releaser of serotonin, oxytocin, and prolactin, which in combination, allow the patient to feel less fear, trust the psychotherapist more, and overcome the defenses blocking them from talking about traumatic experiences. MDMA permits patients to stay in the optimal arousal zone to discuss the traumatic event. After the psychedelic-assisted session, patients continue to process memories and sequelae of the event and integrate changes into their lives to overcome trauma.
• If MDMA is approved by the FDA, it would be available only under a REMS, or Risk Evaluation and Mitigation Strategy, or drug safety program.
• Psilocybin is a partial agonist on 5-HT2A serotonin receptors. The brain of a severely depressed person is extremely rigid with limitations on the usual predictive capacity of the human brain. Psilocybin facilitates plasticity to "reset" and see a situation as it truly is, rather than through the rigid cognitive distortions of depression.
• Although MDMA and psilocybin are controlled substances, we can think of these medications like anesthetics, which are drugs that can be prescribed in clinical settings under supervision only.
• These are old compounds used in a novel manner that can reduce suffering for patients who have not responded to the current modes of therapy for PTSD and MDD.

References

Mithoefer MC et al. MDMA-assisted psychotherapy for treatment of PTSD: Study design and rationale for phase 3 trials based on pooled analysis of six phase 3 randomized trials. Psychopharm (Berl). 2019 Sep;236(9):2735-45.

Carhart-Harris RL et al. Psilocybin with psychological support for treatment-resistant depression: An open-label feasibility study. Lancet. 2016 Jul 1:3(7):619-21.

Pollan M. The Trip Treatment. New Yorker. 2015 Feb 9.

Cooper A. Psilocybin sessions: Psychedelics could help people with addiction and anxiety. 60 Minutes. 2019 Oct 13.

Sessa B. "The Psychedelic Renaissance: Reassessing the Role of Psychedelic Drugs in 21st Century Psychiatry and Society." London: Muswell Hill Press, 2012.

Usona Institute: News on Psychedelics

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Mark S. Gold, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to discuss the intersection between the rise in suicide and the opioid crisis in the United States.

Dr. Gold is adjunct professor of psychiatry at Washington University in St. Louis. He also serves on the editorial advisory board of MDedge Psychiatry. Previously, Dr. Gold served as distinguished professor and chairman of the psychiatry department at the University of Florida, Gainesville.

* * *

Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019

* * *

Timestamps:

• This week in Psychiatry (01:11)
• Interview with Dr. Gold (03:40)

This week in Psychiatry

Demeaning patient behavior takes an emotional toll on physicians by Steve Cimino

Suicide and the opioid crisis

• In 2017, more than 70,000 people died from overdose, and 47,600 of those deaths involved prescription or illicit opioids. Most coroners list the deaths as "accidental" unless there is a suicide note or the deceased spoke about an intent to die.
  • Chronic opioid self-administration changes the brain. The person becomes less high and more depressed over time.
• The prevalence of depression is at least 50% in those with opioid use disorder. Some experts estimate that up to 30% of opioid overdoses are intentional and count as suicide. A person with opioid use disorder has 13 times the risk of attempting and completing suicide, compared with the general population.
• Until recently, psychiatric evaluations and suicide assessments were not routine in the chain of events from opioid use to overdose to transition to medication-assisted treatment (MAT).
• People whose overdoses are reversed by naloxone are prime candidates to ask whether an overdose was accidental. In an emergency department in Flint, Mich., 30% of overdose patients rescued with naloxone described their overdose as a suicide attempt.
• Although some people revived with naloxone are angry, it is important to consider irritability and anhedonia that come from giving an opioid antagonist during a high.

Future of treatments in the opioid crisis

• Much is still unknown. For example, there are no MAT options for either stimulant or cannabis use disorders, which are implicated in the morbidity and mortality of the overdose crisis. More research is needed to determine how long patients should be on MAT and when their brains "reset" after addiction.
• Also, in the pipeline is advanced imaging showing how drug use changes a person's neurocircuitry and genetics. The OPRM1 gene, for example, is a polymorphism whose presence predicts whether a person is more likely to become addicted after their first use of opiates and determines treatment resistance to recovery.
• In the next year, efforts aimed at preventing overdoses and investigating the risk and rates of suicide are likely to continue.
• If every patient with a high-dose opioid prescription were offered naloxone, nearly 9 million more naloxone prescriptions could have been dispensed in 2018. So, we might see state-level policies that seek to increase naloxone prescriptions to patients based on morphine equivalents.
• Looking beyond overdoses and relapse prevention, the National Institute on Drug Abuse (NIDA) has identified novel targets focused on regenerating the reward system in order to return the brains of people with addictions to premorbid function after years of abuse.

References

Volkow N and Gordon J. Suicide deaths are a major component of the opioid crisis. NIDA. 2019 Sep 19.

Oquendo MA and Volkow ND. Suicide: A silent contributor to opioid-overdose deaths. New Engl J Med. 2018;378:1567-9.

5-point strategy to combat the opioid crisis. U.S. Department of Health & Human Services.

Still not enough naloxone where it's most needed. Centers for Disease Control and Prevention. 2019 Aug 6.

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Dinah Miller, MD, returns to the MDedge Psychcast, this time to do a Masterclass lecture on involuntary commitment.

Dr. Miller is coauthor of "Committed: The Battle Over Involuntary Psychiatric Care." She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. In addition, Dr. Miller is a columnist for Clinical Psychiatry News and serves on the editorial advisory boards of CPN and MDedge Psychiatry.

Timestamps:

• This week in Psychiatry (00:37)
• Masterclass lecture (02:00)
• Dr. RK (40:50)

This week in Psychiatry:

Duloxetine 'sprinkle' launches for patients with difficulty swallowing by Christopher Palmer

Drizalma Sprinkle (duloxetine delayed-release capsule) has launched for the treatment of various neuropsychiatric and pain disorders in patients with difficulty swallowing.

Overview of the involuntary commitment debate

Four main controversies surround involuntary treatment

• First, standards for involuntary commitment vary by state; most states require that a person be diagnosed with a mental illness and is imminently dangerous to self or others. Some states extend their parameters to include those who are "gravely disabled" or need of psychiatric treatment.
• Second, as involuntary beds decrease, there is no place for involuntary treatment.
• Third, involuntary treatment includes outpatient civil commitment (OCC), and policy groups differ in their opinions of involuntary inpatient and outpatient treatments. Laws defining the need and amount of mandated outpatient services vary, based on geographical area. Also, outpatient commitment is difficult to enforce.
• The final controversy addresses a patient's right to refuse treatment with medication.

Groups hold wide-ranging positions along policy spectrum

• The Treatment Advocacy Center is a strong proponent of involuntary hospitalization. The group advocates for more state hospital beds in the United States, monitors the number of state hospital beds, proposes an involuntary standard of based on need for treatment, and argues that anosognosia justifies involuntary hospitalization.
• The National Alliance on Mental Illness (NAMI) is a grassroots organization founded by parents of individuals with serious mental illness (SMI) and initially represented a view in favor of involuntary hospitalization based on protecting those with SMI. However, as NAMI has grown to represent a broad swath of people with mental illness, the organization has struggled with whether it represents the interests of people with SMI only or a broader group of people with any mental illness.
• The American Psychiatric Association holds the middle ground, identifying dangerousness as the standard of involuntary care. In 2015, the APA released a carefully worded stance in support of outpatient commitment on a limited basis.
• Organizations strongly against involuntary treatment include the Bazelon Center for Mental Health Law, whose mission is to protect and advance the rights of adults and children with mental illness. The Bazelon Center opposes anything that restricts the rights of people with mental illness.
• The recovery movement, which developed as a backlash against the perceived paternalism of psychiatry, prioritizes the mental health consumer's autonomy with an emphasis on peer support and being proactive in health care choices.
• On the antipsychiatry spectrum are the groups MindFreedom International and the Citizens Commission on Human Rights. Both of those groups oppose involuntary treatment.

Violence and mental illness

• In the community, psychiatric illness is thought to be responsible for 4% of total violence and 7%-10% of murders.
• The MacArthur Foundation investigated rates of violence in people with mental illness 10 weeks after an inpatient hospitalization. It found that, compared with community samples, people with mental illness following hospitalization have higher rates of violence. The rate of violence was 8% for people with schizophrenia, 15% for bipolar disorder, 18% for depression, and 23% for personality disorder. Twenty weeks after discharge, patients with more treatment contacts were less likely to be violent.
• Mental illness does not belong in conversations about violence prevention because violence is more strongly correlated with substance use, anger, and early exposure to violence. Thus, mass murder cannot be prevented with forced care or institutionalization.
• The case is less clear for involuntary treatment for suicide prevention. For example, we know that two-thirds of gun deaths are suicides; however, we do not have statistics to elucidate whether involuntary hospitalization would prevent suicides.

Final thoughts

• Involuntary hospitalization should be the treatment choice of last resort. A psychiatrist should pursue careful assessment with as many sources as possible and strongly suggest alternatives, such as voluntary hospitalization.
• Involuntary hospitalization could be less traumatizing by implementing steps such as reducing forced treatments, minimizing seclusion and restraints, asking patients for feedback at the end of their stays, and acknowledging that involuntary treatment is difficult.
• Involuntary care would be less necessary if voluntary care were easier to access earlier in an illness to avoid crisis and hospitalization.

References

Miller D and Hanson A. "Committed: The Battle Over Involuntary Psychiatric Care" (Baltimore: Johns Hopkins University Press, 2016).

Torrey EF et al. The MacArthur Violence Risk Study revisited: Two views ten years after its initial publication. Psychiatr Serv. 2008 Feb 1;59(2):147-52.

Testa M and West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010 Oct;7(10):30-40.

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Kent A. Kiehl, PhD, joins host Lorenzo Norris, MD on the MDedge Psychcast to discuss the use of MRI scans to provide information about the brains of people who exhibit antisocial behaviors. The goals are to use the information to treat patients and prevent violent crimes.

Timestamps:

• This week in Psychiatry (00:33)
• Meet the guest (03:35)
• Interview (04:25)
• Credits (54:10)

Dr. Kiehl is professor of psychology, neuroscience, and law at the University of New Mexico, Albuquerque. He also codirects a nonprofit mental health research institute called the Mind Research Network, also in Albuquerque. He also helps run a for-profit consulting firm that helps attorneys do better science, called MINDSET.

This week in Psychiatry:

Suicide attempts up in black U.S. teens by Randy Dotinga

Overall rates of suicide dipped from 1991 to 2017, according to research published in Pediatrics. However, the rate of suicide attempts grew slightly in black adolescents during that time.

SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI: 10.1542/peds.2019-1187.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Brain imaging can support diagnoses

• Dr. Kiehl works with cutting-edge technology using noninvasive structural and functional brain imaging; machine learning, such as artificial intelligence; and algorithms to evaluate forensic patients and understand psychopathology, predict outcomes, and measure the impact of interventions. Dr. Kiehl and his team travel to prisons across the country with two mobile MRI units imaging incarcerated individuals and forensic patients.
• More and more, brain imaging is considered in capital cases, because MRI provides valuable information for defense attorneys and prosecutors. For example, a man was charged with murder and his MRI supported a diagnosis of frontotemporal dementia with a behavioral variant, so he was able to plead not criminally responsible based on his illness – and was sent to a state mental hospital rather than to death row. The case of John W. Hinckley Jr., who shot former President Ronald Reagan and his press secretary, James Brady in 1981, was an initial case in which neuroscience and imaging influenced the verdict. The shooter's brain imaging showed enlarged ventricles and cortical atrophy, which supported a diagnosis of schizophrenia – particularly when compared with the imaging of age-matched controls.
• Structural and functional MRI is an adjunct to neuropsychological tests. Neuroscientists are elucidating patterns through artificial intelligence and algorithms that can be useful to civil and criminal cases.
• For example, age is considered a strong predictor of antisocial behaviors. To enhance accuracy, Dr. Kiehl's team has developed a neuroprediction model in which MRI quantifies brain age, which correlates closely with cognitive testing scores. So, brain age might be more useful for predicting behavior than chronological age. This study used more than 1,000 imaging studies of inmates. The data were analyzed using an algorithm called independent component analysis, which evaluates distinct neural circuits to identify components that predict age. In the next step of analysis, the algorithm identifies patterns associated with reoffending. Younger brain age in the anterior temporal lobe and orbitofrontal cortex – brain areas associated with decision making – accurately estimates the risk of reoffending better than just chronological age.
• Based on an understanding of brain plasticity, dogma suggesting that people who commit violent crimes cannot be changed should be challenged. A group at the University of Wisconsin, Madison, was asked to create an evidence-based, multimodal treatment program for the hardest-to-treat violent juvenile offenders. The program, which includes interventions such as multisystemic family therapy and positive reinforcement contingency treatment, resulted in a decrease in reoffending and violent crimes in participants who received 10 months of treatment. Dr. Kiehl's group followed up with those juvenile boys using MRI to evaluate what had changed in their brains, how much treatment is required, and how or whether those brain changes can be reinforced. Reduction in incarceration costs is a return on investment for the states that fund those types of programs.

Take-home points

• If scientists can identify useful interventions and identify brain changes though imaging, perhaps science can affect outcomes such as societal violence and incarceration rates.
• Implementation is the primary short-term obstacle. This type of research needs more funding and institutional change to identify programs that work.
• The brain has an incredible amount of plasticity, which translates into opportunities for change.

References

The Mind Research Network

Kiehl KA. The Psychopath Whisperer: The Science of Those Without Conscience. Random House, 2014.

Kiehl KA et al. Age of gray matters: Neuroprediction of recidivism. Neuroimage Clin. 2018;19:813-23.

Steele VR et al. Machine learning of structural magnetic resonance imaging predicts psychopathic traits in adolescent offenders. Neuroimage. 2017 Jan 15;145(Pt B);265-73.

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych