Psychcast

Susan Hatters Friedman, MD, returns to the MDedge Psychcast to join host Lorenzo Norris, MD, to discuss postpartum psychosis.

Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman and colleagues recently wrote an article published in Current Psychiatry examining this topic, Postpartum psychosis: Protecting mother and infant.

Timestamps:

• This week in psychiatry (01:09)
• Interview (05:07)
• Dr. RK (22:07)

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

Overview of postpartum psychosis

• Postpartum psychosis is a medical emergency with a fulminant development occurring within 1-4 weeks after delivery.
• Onset is usually 3-10 days postpartum, and women experience a spectrum of symptoms from psychosis to dysphoric mania and confusion. Many women who experience postpartum psychosis do not have a past psychiatric history, although they might go on to develop bipolar disorder.
• Symptoms change quickly, with risks of devastating consequences. A woman with postpartum psychosis might minimize or even conceal her symptoms to avoid being separated from her child or out of fear that her child will be taken away. Collateral information is extremely important.
• A woman is at the greatest risk of developing a mental illness in the period around childbirth. The rate of postpartum depression is 1 in 9, and the baseline rate of postpartum psychosis is 1/500. Women with bipolar disorder (which may be undiagnosed until the postpartum psychosis) or a previous episode of postpartum psychosis are at highest risk of postpartum psychosis.

Prevention and intervention

• Clinicians must be proactive with their psychoeducation about pregnancy, contraception, and the natural course of mental disorders during pregnancy and postpartum. If a patient with bipolar disorder is of childbearing age, the clinician should consider having her on medications that are relatively safe during pregnancy. In 2011, 45% of pregnancies in the United States were unintended; thus, preconception counseling is necessary.
• Medications for bipolar disorder can help prevent postpartum psychosis. Other preventive measures include using sleep strategies after childbirth, such as arranging support to assist at night and weighing the risks of breastfeeding. Breastfeeding can lead to sleep deprivation, which in turn, increases the risk of decompensation.
• If a woman wants to breastfeed, the psychiatrist should be in touch with the pediatrician and plan for breastfeeding by having the mother on medications that are safe for breastfeeding.
• Involuntary hospitalization might be required if the postpartum psychosis puts the mother or child at imminent risk of harm. Family and nonpsychiatrists on the health care team might be resistant to psychiatric hospitalization because it would mean separating the mother from the child.
• Psychiatrists can broach resistance by explaining the details of a thorough risk assessment and emphasizing that, while bonding is important, the hospitalization is meant to prevent the worst outcomes of suicide or infanticide.

Review of key points

• Postpartum psychosis can present with mood symptoms or delirium, so those signs should make a clinician vigilant for postpartum psychosis.
• The symptoms of postpartum psychosis change rapidly with escalating danger, such as infanticide and suicide, so collateral from family and speedy treatment are essential.
• Focused early collaboration and education with team member such as ob.gyns. and pediatricians help make future interventions go more smoothly.

References

Friedman SH et al. Postpartum psychosis: Protecting mother and infant. Curr Psychiatr. 2019 Apr 1;18(4):13-21.

Sit D et al. A review of postpartum psychosis. J Womens Health (Larchmt). 2006 May;15(4):352-68.

Harlow BL et al. Incidence of hospitalization for postpartum psychosis and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry. 2007;64(1):42-8.

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Susan Hatters Friedman, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about family murder.

Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western.

In addition, Dr. Hatters Friedman is editor of Family Murder: Pathologies of Love and Hate, which was written by the Group for the Advancement of Psychiatry's Committee on Psychiatry & Law.

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

Overview of family murder

• Family murder is defined as situations in which any member of a family kills another family member. It encompasses a wide scope of violence that includes intimate partner homicide; infanticide, including purposeful feticide; neonaticide (murder in first day of life); siblicide; and parricide (a child killing a parent).

• The book, Family Murder: Pathologies of Love and Hate, discusses the epidemiology and public health implications of family murder, various motivations, and pertinent psychiatric assessments, including risk assessments and sanity evaluations. It was written to prompt better screening and risk assessments, with the goal of prevention.

Motivating factors leading to murder

Phillip J. Resnick, MD, who also works in forensic psychiatry at Case Western, identified five main motives of parent-child violence.

1. Fatal maltreatment is the result of fatal neglect or abuse by a parent. This type of family murder is common and is most likely to be prevented, especially with intervention by Child Protective Services.
2. Altruistic murder occurs in three categories in which a parent wants to spare a child from perceived suffering:

• Psychotic parents with delusions about their children being harmed.
• Murder-suicide, such as when a severely depressed and suicidal parent kills their child to avoid leaving them without a parent after their suicide.
• Parents who kill a child with serious, chronic physical illness as a means of "saving" the child from a "worse" fate.

1. Acutely psychotic murder occurs in the context of serious mental illness such as schizophrenia, bipolar disorder, or postpartum psychosis. Preventing this type of murder means monitoring the content of delusions and hallucinations related to family members. The Andrea Yates murders are a prime example of this type of murder.
2. Unwanted child motive is most common in neonaticide cases. The child is considered a hindrance to something the parent wants, such as a relationship. To screen for this risk, physicians can ask whether the pregnancy was planned and observe the interaction between child and parent, especially during the first hours to days of life.
3. Partner revenge is rare but is most likely to occur in context of a custody battle, with one partner seeing murder as a means of revenge. Psychiatrists can observe interactions between partners and inquire about threats from partners.

Screening and preventing violence

• Psychiatrists can screen for violence by asking: "How are disagreements handled in your family?" This broad, neutral question elucidates family dynamics about partner violence, anger, and negative parental practices. It can generate information aimed at preventing fatal outcomes.
• Strong human emotions, such as anger, jealousy, and pride, combined with risk factors such as a history of violence and access to weapons, drive family murder.
• Psychoeducation about childhood development can decrease the risk of violence, especially in the fatal maltreatment category.

Addressing countertransference issues

• Family murder stimulates strong countertransference in response to the perpetrator. Working as a team can diffuse these emotions and allows a venue for processing.
• Building rapport with patients and recognizing their humanity by using phrases such as "When he died," rather than "When you killed him."

References

Family Murder: Pathologies of Love and Hate. Group for the Advancement of Psychiatry, 2018.

Hatters Friedman S. Filicide-suicide: Common factors in parents who kill their children and themselves. J Am Acad Psychiatry Law. 2005 Jan. 33(4):496-504.

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Henry Nasrallah, MD, was the first-ever guest on the MDedge Psychcast. In a three-part series, he joined Lorenzo Norris, MD, host of the Psychcast and editor in chief of MDedge Psychiatry, to talk about schizophrenia. In this throwback episode, the three-part conversation has been edited together into one episode.

1. Part I: Etiology, presentation, and recent advances
2. Part II: Manifestations; treating early
3. Part III: Treatment of first-episode schizophrenia

In part I, Dr. Nasrallah and Dr. Norris talk about the etiology, presentation, and the recent advances in how schizophrenia is conceptualized.

In part II, the two discuss the need for clinicians to treat the schizophrenia as early in the disease process as possible.

In part III, the conversation continues, as they talk about treatment of a patient's first episode of schizophrenia.

Henry Narallah, MD, is Sydney W. Souers Endowed Chair and professor and chairman of psychiatry and behavioral sciences at Saint Louis University. He also is editor in chief of Current Psychiatry.

You can read some of Dr. Nasrallah's work in Current Psychiatry here.

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Karl Doghramji, MD, is professor of psychiatry with secondary appointments in neurology and medicine at Thomas Jefferson University in Philadelphia. He also directs the Sleep Disorders Center at Thomas Jefferson.

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

Classification and consequences

• Insomnia is defined by the DSM-5 as dissatisfaction with sleep quantity or quality, difficulty falling asleep or staying asleep, or both. The symptoms need to occur at least three times per week for more than 3 months and cause dysfunction or distress in the patient.
• 20%-30% of the population reports insomnia; within inpatient psychiatry populations, the rates rise to up to 80%.
• Insomnia is thought to be caused by central nervous system hyperarousal or hyperactivity of unclear etiology, and there is evidence of genetic vulnerability.
• Insomnia is associated with significant impairments, such as diminished ability to enjoy life and sleep during inappropriate times (i.e., while driving or in occupational settings). In addition, insomnia confers increased risk for chronic illnesses such as major depressive disorder, substance use disorder, as well as diabetes, hypertension, and dementia.

Treating insomnia

• It is best to first treat the comorbidities of insomnia, such as mood disorders and anxiety, and then target insomnia with both behavioral modifications and medications. When prescribing medications, choose a pharmacologic agent that targets the period of sleep difficulty.
• Evaluation of insomnia must examine the dimensions of sleep, including falling asleep (sleep initiation), compared with staying asleep (sleep maintenance).

Behavioral techniques

• Stimulus control therapy: If a person is unable to fall asleep within 20-30 minutes, either at initiation or in the middle of sleep cycle, he/she should get out of bed and do something outside of the room and return to bed only when feeling sleepy.
• Relaxation therapies, such as progressive muscle relaxation, can improve sleep if performed once a week for 12 weeks.
• Sleep hygiene improvements, such as addressing late caffeine consumption, room brightness, and daytime napping can mitigate insomnia.

Pharmacologic interventions

• Over-the-counter options include valerian root and histamine1 antagonists, such as diphenhydramine and melatonin. Melatonin is modestly effective at low doses, though the effects have not panned out in meta-analyses. At low doses, melatonin may increase total sleep time or improve sleep initiation by a few minutes. Watch out for adverse effects with long-term use of melatonin, such as disruption of other receptors, decreased fertility, and altered efficacy of chemotherapeutic agents.

Prescription drugs approved by the Food and Drug Administration

• Benzodiazepines approved for insomnia include flurazepam (Dalmane), temazepam (Restoril), estazolam (Prosom), and triazolam (Halcion). However, those medications have long half-lives and tend to contribute to excessive daytime sedation.
• "Z-drugs" are the selective benzodiazepine receptor agonists. Zaleplon (Sonata) and zolpidem are useful for sleep initiation but might not help with sleep maintenance through the entire night. Eszopiclone (Lunesta) and zolpidem extended release (Ambien CR) can help with sleep initiation and sleep maintenance through the entire sleep period.
• Z-drugs, especially if mixed with alcohol, can contribute to parasomnias such as sleep walking and sleep driving. The FDA counsels that if patients develop parasomnias, they should not be rechallenged with those drugs.
• Nonscheduled medications include ramelteon (Rozerem), a melatonin receptor agonist that is effective for sleep initiation, and low-dose doxepin (Sinequan), which is effective for middle to late portions of the night.

References

Pavlova MK and Latreille V. Sleep disorders. Am J Med. 2019 Mar 132(3):292-9.

Clark J. Slumber Camp. Conquer insomnia. For clinicians. Slumber Camp is an award-winning, 28-day, online course that teaches the principles of cognitive-behavioral therapy for insomnia.

Cui R and Fiske A. Predictors of treatment attendance and adherence to treatment recommended among individuals receiving cognitive behavioral therapy for insomnia. Cogn Behav Ther. 2019 Mar 14:1-7.

Christensen MA et al. Direct measurements of smartphone screen-time: Relationships with demographics and sleep. PLoS One. 2016 Nov 9;11(11):e0165331.

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Judith R. Milner, MD, MEd, SpecEd, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about steps psychiatrists can take to address the mental health needs of people traumatized by a natural disaster, such as Hurricane Dorian survivors.

In This Week in Psychiatry, Katherine Epstein, MD, and Helen M. Farrell, MD, write about miracle cures in psychiatry. You can read the article online by clicking here or you can access the downloadable PDF by clicking here.

Time Stamps:

• This Week in Psychiatry (02:37)
• Interview with Dr. Milner (06:33)
• Dr. RK with Dr. Renee Kohanski (39:31)

Dr. Milner is a general and child and adolescent psychiatrist in private practice in Everett, Wash. She has traveled across the globe with various groups in an effort to alleviate some of the suffering caused by war and natural disaster.

Don't miss the "Dr. RK" segment by Renee Kohanski, MD, who discusses the extent to which people choose what is important and meaningful. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

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

STAGES OF NATURAL DISASTERS

Devastation stage

• During the devastation stage, the primary objectives are giving basic first aid and attending to the sick, searching for those who are missing, and getting people safely into shelters.
• Psychological first aid (PFA) is the primary form of mental health treatment. PFA addresses basic needs by helping people find shelter, food, water; assisting with communication; reuniting families; and conducting case management to address acute needs.

Normalization stage

• The normalization stage continues for several months after the disaster and includes the honeymoon phase, in which people are grateful to have survived and the community unites to rebuild; and then the disillusionment phase, during which frustrations and hopelessness arise as communities and individuals realize the limits of disaster assistance.
• Psychiatric disorders are likely to develop during the normalization stage. Acute stress disorder (ASD) typically occurs 3-30 days after the event with cardinal symptoms such as hyperarousal, hypervigilance, and negative cognitions that affect relationships. Medical professionals should monitor for development of chronic disorders such as PTSD, major depressive disorder, and anxiety disorders. Prolonged stressors, such as living in a damaged home, increase the risk of depression and anxiety.
• Those with preexisting vulnerabilities – such as past traumatic experiences from physical, sexual, or emotional abuse; previous natural disasters; or other chronic stressors of poverty and medical illness – are at greatest risk of developing a trauma-related disorder after a natural disaster.
• The normalization stage is a critical period to use the "training the trainer" model. Because many locations do not have a surplus of mental health clinicians, psychiatrist volunteers can train local individuals to provide services. For example, mental health professionals can train the trainers to recognize symptoms of common psychiatric conditions and to provide basic treatment.
• Manualized therapies are useful but require in-depth training. Other simple modalities, such as deep breathing, visualization, and relaxation techniques, can be useful.

Acceptance stage

• During the acceptance stage, rates of persistent PTSD range from 25% to 40%.
• Ongoing therapy is helpful, especially group therapy, which is an effective use of resources. Facilitation of group therapy can be taught while training the trainers.
• If a mental health professional volunteers and participates in the training the trainers' model, there must be follow-up, which should include providing intellectual support and refresher courses, evaluating how training is being used, and checking up on patients/clients who have received services.

Predisaster advice: Do not go it alone. Affiliate with a group that has a plan, so that your presence on the scene does not add to the chaos.

Postdisaster advice:

• Be aware of compassion fatigue and take time away from volunteerism. Recognize signs of secondary traumatic stress.
• Counsel volunteers upon their return from the disaster site.

References

Substance Abuse and Mental Health Services Administration. Phases of disaster. Last updated 2018 Oct 1.

Pfefferbaum B et al. Practice parameter on disaster preparedness. J Am Acad Child Adolesc Psychiatry. 2013 Nov;52(11):1224-38.

World Health Organization. Psychological first aid: Guide for field workers. 2011.

National Child and Traumatic Stress Network. Psychological first aid online.

International Institute for Psychosocial Trauma. Clinical assessment of survivors of trauma.

U.S. Department of Veterans Affairs. PTSD: National Center on PTSD.

Compassion Fatigue Awareness Project.

Disaster Psychiatry Outreach.

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Show Notes

J. John Mann, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about the need for medicine to shift its approaches to preventing suicide. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education.

Dr. Mann is professor of translational neuroscience at Columbia University in New York.

For a complete video of this interview, see this vodcast.

Don't miss the "Dr. RK" segment by Renee Kohanski, MD, who discusses how a religious wedding she attended made her think about the distinction between cults and cultures. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

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

Why are suicide rates on the rise?

• In the United States, between 2001-2017, the suicide rate increased by 33%, making suicide the second-leading cause of death for people aged 15-34 years.
• Why the suicide rate has increased is unclear. Factors influencing rising suicide rates include the 2008 recession and the opioid crisis; however, these events cannot fully explain the trend because they occurred in the middle of the rising rates.
• As suicide rates increase, the medical community missed opportunities for prevention at both primary care and psychiatry visits. A Centers for Disease Control and Prevention study that examined suicide rates and psychiatric illness found approximately half of suicide decedents did not have a known mental health condition.

Connections to untreated psychiatric illness

• Only 22% of people with psychiatric illness who die by suicide had their mental illness treated.
• The age of onset for major depressive disorder has been occurring earlier and indicates a greater pool of individuals is at risk of suicide. For example, during 2005-2014, major depressive episodes in adolescents increased by nearly one-third.
• Individuals who attempt and die by suicide have a predisposition to respond to their mental illness with suicidal behaviors. This trait poses a challenge in the face of rising rates of mental illness in the United States.

Role of treatment by primary care physicians

• 45% of individuals who die from suicide see their primary care clinician within a month of their death. If nonpsychiatrist doctors or primary care physicians are trained to recognize depression and suicide, the rates of death and disability from depression can be decreased.
• Most people who die by suicide are seeking help by going to a health care professional. How should the clinician respond? If a person presents with somatic complaints with no clear causes (for example, normal lab values), this is a time for the primary care physicians to ask about depression and suicide.

What steps can be taken to prevent suicide?

• Medicine needs an updated approach in education about depression and suicide that is similar to the changes that have taken place during the opioid crisis. Now all clinicians must complete continuing medical education about pain management and opioid prescribing, which has led to a decrease in deaths from prescription pain medications. All clinicians must be able to recognize and treat depression, because it is becoming a leading cause of death and disability.
• Clinicians need to do a better job of making connections between somatic complaints and mood disorders.

References

U.S. Department of Health and Human Services, National Institutes of Health. Mental health information: Suicide. Updated August 2019.

Stene-Larsen K and A Reneflot. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019 Feb;47(1):9-17.

Reed J. Primary care: A crucial setting for suicide prevention. SAMHSA-HRSA Center for Integrated Solutions.

U.S. Department of Health and Human Services. Adolescent mental health basics. Rising rates of MDD in adolescents.

Bruce ML et al. Reducing suicidal ideation and depressive symptoms in depressed older patients. JAMA. 2004 Mar 3;291(9):1081-91.

DA Brent and N Melhem. Familial transmission of suicidal behavior. Psychiatr Clin North Am. 2008 Jun;31(2):157-77.

Mohatt NV et al. A menu of options: Resources for preventing veteran suicide in rural communities. Psychol Serv. 2018 Aug;15(3):262-9.

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In this masterclass, Philip D. Harvey, PhD, professor of psychiatry and behavioral sciences at the University of Miami, discusses the relationships between aging, neurocognition, and functional outcomes.

And in a new segment from MDedge, called This Week in Psychiatry, we'd like to share a Current Psychiatry evidence-based review on using antidepressants for pediatric patients (PDF) by Jennifer B. Dwyer, MD, PhD, and Michael H. Bloch, MD, MS.

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

Introduction to normal aging

• Changes in cognitive abilities are part of normal aging.
• Crystalized intelligence, the storage of information learned throughout life, does not change over time in normal, healthy aging.
• Fluid intelligence, the ability to learn new information, solve problems, concentrate, and rapidly process information, starts changing at age 65 or so.
• Episodic memory performance, the ability to learn new verbal information, declines 30% between ages 65 to 80, followed by another equivalent decline from ages 80 to 90.
• Alzheimer's disease and amnestic mild cognitive impairment are characterized by signature memory loss called rapid forgetting, which occurs in cases in which a person is unable to remember information right after being told.
• Older people who are self-aware and sensitive to their age-related cognitive changes have a better prognosis.

Technology and aging

• Individuals in their 80s to 90s might have retired before the advent of technological advances such as ATMs, cell phones, the Internet, smartphones, and other touch screen devices.
• For these individuals, vital aspects of daily living, such as accessing finances online, requires using Internet navigation skills, and those skills were not acquired at a younger age.
• A direct connection exists between cognitive abilities and learning how to use technology for the first time.
• Healthy older people will be challenged by new technology the first time because of their lack of exposure. Yet, their ability to learn how to use technology is comparable to that of younger people.

Embracing technology to prevent normative cognitive decline

• The ACTIVE study, sponsored by the National Institute on Aging, enrolled 2,800 older healthy adults, with a mean age of 75, to evaluate the effectiveness of cognitive interventions in maintaining cognitive health and functional independence in older adults.
• Participants were randomized to either computerized speed training, memory training, problem solving training, or psychosocial intervention.
• The computerized speed training produced the most significant benefit in cognitive functioning. Participants randomized to computerized speed training sustained their functioning of instrumental daily activities of living and had a 50% lower rate of at-fault motor vehicle collisions, compared with controls, over a 6-year follow-up period.
• The ACTIVE study results suggest that age-related changes might be reversible with 14 1-hour sessions of brain training. Normative age-related cognitive decline can be attenuated through the use of affordable, accessible technology.

In summary, not all age-related cognitive complaints are pathological

• Clinicians must ask specifically about memory loss and rapid forgetting of information to differentiate normative age-related changes from Alzheimer's dementia.
• Patients should be empowered to use technology to intervene for their cognition.
• Both brain and physical fitness are paramount to preventing dementia.
• Physical fitness is essential to prevention, because chronic illnesses such as type 2 diabetes are primary risk factors for dementia, and being overweight in middle age is a major predictor for developing type 2 diabetes.
• Physical exercise, brain exercise, and embracing technology are essential to preventing social isolation and subsequent dementia.

References

Antidepressants for pediatric patients by Jennifer B. Dwyer, MD, PhD; Michael H Bloch, MD, MD

An evidence-based review from Current Psychiatry: 2019 September:18(9):26-30,32-36,41-42,42A-42F

• Click here for the webpage
• Click here for the downloadable PDF

Tennstedt SL and FW Unverzagt. The ACTIVE study: Study overview and major findings. J Aging Health. 2013 Dec;25(8 0):3S-20S. doi: 10.1177/0898264313118133.

Rebok GW et al. Ten-year effects of the ACTIVE cognitive training trial on cognition and everyday functioning of older adults. J Am Geriatr Soc. 2014 Jan;62(1):16-24.

Harvey PD and MT Strassnig. Cognition and disability in schizophrenia: Cognition-related skills deficits and decision-making challenges add to morbidity. World Psychiatry. 2019 Jun;18(2):165-7.

Brem AK and SL Sensi. Towards combinational approaches for preserving cognitive function in aging. Trends Neurosci. 2018 Dec;41(2):885-97.

Show Notes

Roger McIntyre, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about obesity, inflammation, and treatment implications for mental health conditions. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education.

Dr. McIntyre is a professor of psychiatry and pharmacology at the University of Toronto, and head of the mood disorders psychopharmacology unit at the University Health Network, also in Toronto.

For a complete video of this interview, please visit the vodcast.

Don't miss the "Dr. RK" segment by Renee Kohanski, MD, who discusses how to think through whether sharing personal information with patients helps move their therapy forward. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

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

Reconceptualizing mental illness by looking at inflammation

• Mental illness should be viewed as a disease involving many organs – including the brain – and psychiatry should expand its understanding of the etiology of mental illness.
• Increasingly, research suggests that a subgroup of people with mental disorders, including those with a variety of diagnoses, have symptoms related to alterations in their immune system and inflammation.
• Inflammation plays a role in disparate psychiatric diagnoses, including childhood disorders such as obsessive-compulsive disorder, ADHD, and autism, and adult disorders such as schizophrenia, depression, and Alzheimer's disease.
• Currently, psychiatry uses the monoamine paradigm to explain psychiatric diagnosis, and most medications were developed using that paradigm.
• A subgroup of people is not sufficiently helped by current medications, so looking at inflammation as a driver of mental illness provides another biological avenue to pursue drug development.

Role of obesity and chronic health conditions in worsening inflammation

• Obesity, particularly abdominal obesity, is overrepresented in people with mental illness and is not fully explained by either social determinants of health or medication side effects.
• Obesity and mental illness have a bidirectional relationship; each affects the body as multiorgan system diseases.
• Mental illness can be conceptualized as a kind of "metastasis to the brain." Adipose tissue releases a surfeit of neurochemicals hazardous to brain function and that disrupt neurocircuitry.
• For example, compared with an individual with major depressive disorder (MDD) only, an individual with MDD and obesity is more likely to have symptoms driven by inflammation, such as anhedonia, cognitive impairment, limited motivation, and a dysregulated reward system.
• Obesity should also be a target symptom worthy of a focused treatment plan.
• Heart disease is the leading cause of death in schizophrenia, and coronary artery disease is an inflammatory illness. Research is identifying connections between psychiatric illness such as schizophrenia and potentially inflammatory driven symptoms, often called "sickness behaviors," such as low motivation, anhedonia, and cognitive impairment.

Clinical implications of obesity and inflammation

• Alterations in inflammation and metabolism are not just a consequence of obesity. For example, patients will bipolar disorder who report sexual or physical trauma are more likely to be in a proinflammatory neurochemical state and benefit from anti-inflammatory interventions.
• Are patients with early trauma who do not respond fully to "traditional" monoamine medications part of the subpopulation who respond to anti-inflammatory interventions because trauma is driving inflammation?
• The genetics of mental illness already are complicated and will be influenced by the environment and a "proinflammatory milieu."

Which tests show inflammation?

• Current inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein, are not specific enough to direct treatment of inflammation in mental illness.
• Elements of a patient's history, including history of trauma, disrupted sleep and circadian disturbances, cigarette smoking, poverty, housing dislocation, and exposure to racism, can indicate inflammation.
• We can conceptualize as anti-inflammatory several current treatments, such as mindfulness-based therapy, electroconvulsive therapy, and selective serotonin reuptake inhibitors.
• Alternative treatments to treat inflammation exist; however, specific anti-inflammatory treatments, such as NSAIDs, cyclooxgenase-2 inhibitors, and minocycline, are not yet recommended for patients with mental illness.

Targeting inflammation as prevention of psychiatric illness

• Clinicians can target drivers of inflammation as a means of treatment and prevention of mental illness. They can also target the basics, such as sleep, diet, exercise, and socializing, as preventive measures that also target inflammation.
• The incidence of depression can be decreased by targeting lifestyle changes and metabolic illness with treatments such as exercise and statins.
• Interventions focused on inflammation are being investigated as a means of prevention for people at risk of mental illness. For example, a study in China in which Dr. McIntyre was involved explored whether exercise can decrease the development of bipolar disorder in children who have a genetic predisposition to the illness. Caloric restriction can reduce inflammation and improve cognition.

Inflammation and the absence of 'meaningful connections'

• In social baseline theory, human beings allocate energy in proportion to their social connectivity.
• People with fewer social connections are more likely to be in a proinflammatory state and more likely to consume high-carbohydrate food.
• Loneliness can be conceptualized as an epidemic associated with serious health outcomes, such as suicide, addiction, and other chronic mental and physical health problems. We are living in a society of anxious despair.
• Psychiatry needs to broaden its understanding of mental illness by investigating a variety of underlying causes, from inflammation to the monoamine theory.

References

Rosenblat JD et al. Inflamed moods: A review of the interactions between inflammation and mood disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2014 Aug 4;53:23-34.

Harvey SB et al. Exercise and prevention of depression: Results of the HUNT cohort study. Am J Psychiatry. 2018 Jan 1;175(1):28-36.

Redlich C et al. Statin use and risk of depression: A Swedish national cohort study. BMJ Psychiatry. 2014 Dec 4;14:348. doi: 10.1186/s12888-014.0348-y.

Leclerc E et al. The effect of caloric restriction on working memory in healthy non-obese adults. CNS Spectr. 2019 Apr 10:1-7. doi: 10.1017/S1092852918001566.

Schwabel D. "Vivek Murthy: How to solve the work loneliness epidemic." Forbes.com. Oct 7, 2017.

Ho RCM et al. Factors associated with risk of developing coronary artery disease in medical patients with major depressive disorder. Int J Environ Res Public Health. 2018 Oct;15 (10): 2073. doi: 10.33901/ijerph1510102073.

Dantzer R. Cytokine, sickness behavior, and depression. Immunol Allergy Clin North Am. 2009 May;29(2): 247-64.

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Show Notes

Jack Rozel, MD, returns to the MDedge Psychcast to discuss gun violence and a new report from the National Council for Behavioral Health. In episodes 29 and 33, Dr. Rozel talked with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about this topic in the wake of the shooting last year at the Tree of Life synagogue in Pittsburgh.

Dr. Rozel is medical director of resolve Crisis Services at the Western Psychiatric Institute and Clinic of the University of Pittsburgh. He also is president-elect of the American Association for Emergency Psychiatry and a member of the National Council. Dr. Rozel can be found on Twitter @ViolenceWonks.

Later, Renee Kohanski, MD, discusses betrayal in the context of Erik Erikson's conceptualization of trust vs. mistrust. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

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

Gun violence in the United States

• Mass violence with guns is a distinctly American problem occurring with greater frequency and severity in the United States, compared with other countries.
• The United States has a broad swath of firearm violence: Deaths by suicide account for 60% of gun deaths, and the remaining 40% are deaths by homicide.
• 1%-2% of homicides are completed in mass shootings, which are defined as an event in which a gunman indiscriminately shoots four or more people.
• Firearm homicides have been trending downward, while mass shootings have increased.
• Mass shootings might be influenced by media coverage; media exposure about mass shootings can incite possible perpetrators.
• Mass shootings are shown to cluster in ways similar to suicide contagion.

Responses to mass shootings/violence

• The National Council for Behavioral Health addresses mass violence by releasing a new report:
• The report, called "Mass Violence in America: Causes, Impacts and Solutions," was written by a group of 30 multidisciplinary experts, including Dr. Rozel.
• It was released in response to stigma and incorrect messages linking psychiatric diagnoses to mass violence.
• The report reviews models aimed at preventing violence and understanding threat assessment.

Predicting violence and diffusing threats

• Pathway to violence is a model for predicting mass violence generated by data and analysis of violent acts by the Los Angeles Police Department, U.S. Capitol Police, U.S. Marshals Service, and the U.S. Secret Service.
  • Grievances: Violence often starts with a grievance. Clinicians might be familiar with patients who are "grievance collectors" and do not get along with any person, whether at work, family, or society at large.
  • The pivot: A transition from simply having a grievance to violent ideation and wanting vengeance through violence. Psychiatrists certainly will see people who express violent fantasies. Perpetrators of violence shift from fantasy into research about planning and preparing to attack.
• Clinicians want to identify the point at which people feel aggrieved and should become most concerned when these people begin to get certain fixations.
  • Preparation: The person will start to acquire weapons and tactical clothing; probe into vulnerabilities of their targets, conduct "test attacks"; and eventually carry out the final attacks.
  • Identification: The grievance stage is the most effective place to intervene, once the identification has been made, and potentially diffuse a violent outcome.

The United States holds a unique position when it comes to gun ownership, violence

• The United States is one of the three countries in the world that allow citizen access to firearms in their constitutions.
• With 393 million civilian-held firearms, the United States has more civilian-owned firearms than the next 39 countries combined.
  • India, which has 70 million civilian-held firearms, ranks No. 2.
• Regardless of what happens with gun control following each mass shooting, the guns already are out there in civilian hands.
• Behavioral health clinicians must talk with patients about firearms safety.
• A person living in the United States is 10 times more likely to die of firearm-related suicide and 25 times more likely to die of firearm-related homicide, compared with people living in other economically developed countries.

Components of proposed legislation that could reduce gun violence:

• Increasing mental health access: Violent acts can be attenuated through access to mental health with anger-management classes and interventions at emotional regulation.
• Implementing universal background checks for gun purchases. Currently, this policy varies from state to state.
• Requiring a background check to obtain a concealed carry permit.
• Testing competency/shooting ability with guns before giving a permit.
• Increasing access to gun violence restraining orders, also called gun violence prevention orders. The restraining orders are aimed at temporarily stopping people who pose a threat to themselves or others by buying or possessing a firearm. The number needed to treat to prevent suicide with this type of restraining order is 11-20.

Education and research that could address the problem

• Research about the pathway to violence model and threat assessment can be used to create training for the array of professions that touch on violence – such as police, gun stores, teachers, and health care professionals. Training can focus on de-escalation and recognition of individuals at risk of perpetuating violence against themselves and others.
• Training for health care professionals should not be limited to just a psychiatry rotation, but also in emergency medicine and primary care, since gun violence affects patients within every field.
• Research into firearm violence prevention is incredibly underfunded, primarily because of the restrictions embedded in the Dickey Amendment.
  • Named for the late Rep. Jay Dickey of Arkansas, the provision specifies that "none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control." This amendment remains a huge obstacle to any group seeking to research gun violence.

References

Lankford A. Do the media unintentionally make mass killers into celebrities? An assessment of free advertising and earned media value. Celebr Stud. 2018;9(3):340-54.

Knoll IV JL and GD Annas. Mass shootings and mental illness. In: Gold LH and RI Simon (eds). Gun Violence and Mental Illness. Arlington, Va.: American Psychiatric Association Publishing, 2016.

Silver J et al. Foreshadowing targeted violence: Assessing leakage of intent by public mass murderers. Aggress Violent Behav. 2018;38:94-100.

Metzl JM and KT MacLeish. Mental illness, mass shootings, and the politics of American firearms. Am J Public Health. 2015;105(2):240-9.

Swanson JW et al. Gun violence, mental illness, and laws that prohibit gun possession: Evidence from two Florida counties. Health Aff (Millwood). 2016 Jun 1;35(6):1067-75.

Van Dorn R et al. Mental disorder and violence: is there a relationship beyond substance use? Soc Psychiatry Psychiatr Epidemiol. 2012;47(3):487-503.

Rahman T et al. Anders Breivik: extreme beliefs mistaken for psychosis. J Am Acad Psychiatry Law. 2016;44(1):28-35.

National Council for Behavioral Health. Mass violence in America: Causes, impacts, and solutions. 2019 Aug.

Mass shooters and murderers: Motives and paths. National Collaborating Centre for Mental Health. Violence and aggression: Short-term management in mental health, health and community settings.2019 Apr 1.

Betz ME and GJ Wintemute. Physician counseling on firearm safety: A new kind of cultural competence. JAMA. 2015;314(5):449-50.

District of Columbia v. Heller (2008).

Rostron A. The Dickey amendment on federal funding for research on gun violence: A legal dissection. Am J Public Health. 2018 Jul;108(7):865-7.

"More research could help prevent gun violence in America." Rand Review. 2018 Jul 10.

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Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, interviews the psychiatry residents who produce the PsychEd podcast, which as they put it, is "created by medical learners, for medical learners."

Dr. Norris speaks with some of the members of PsychEd podcast team: Sarah Hanafi, MD, a first-year resident in psychiatry at McGill University, Montreal; Alex Raben, MD, a fourth-year resident in psychiatry at the University of Toronto; Lucy Chen, MD, a fourth-year psychiatry resident at the University of Toronto; and Bruce Fage, MD, a fifth-year psychiatry resident at the University of Toronto.

And later, in the "Dr. RK" segment, Renee Kohanski, MD, discusses the role of the placebo in the modern setting. Dr. Kohanski is a member of the MDedge Psychiatry Editorial Advisory Board and is a psychiatrist in private practice in Mystic, Conn.

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

Why podcasting?

• The PsychEd podcast originated when the team identified a gap in podcast-mediated learning for psychiatry trainees.
• In psychiatry, there have been podcasts that reviewed recent publications, but none that examined foundational topics. Other specialties, such as emergency medicine, have several podcasts covering basic topics aimed at trainees.
• Podcasts are identified as an asynchronous educational material. They are a medium that can be used in "downtime," especially because many trainees commute or have other time during which they can consume information.
• At the American Psychiatric Association's 2019 Annual Meeting, the PsychEd team presented on the integration of podcasting into medical education.
• Materials should focus on digital natives vs. digital immigrants.
• In 2015, one research group polled emergency medicine residents and found a differential in the use of podcasts; 90% of users were residents and 45% were program directors.

Podcasts are a supplement to other types of learning

• Podcasts can distill information as well as engage with information and experts in an alternative fashion.
• Podcasts are efficient in their use of time and broaden listeners' exposure to information and experts.
• Podcasts offer one modality of learning and are not meant to replace other sources.
• Resources should focus on what information is needed and be tailored to where students, residents, and all learners spend their time.

PsychEd beginnings

• After the team identified the need for a psychiatry education–focused podcast, they started meeting to create an environment for collaboration.
• Learning how to podcast – using the equipment, editing the recording, and uploading to relevant platforms – was the hardest part.
• All PsychEd podcasting is done "live." The team takes their recording equipment to the experts they interview. Presently, their guests are located in Toronto. The team has expanded to Montreal with a new team member, Sarah Hanafi, a first-year psychiatry resident at McGill University.

Formatting

• The podcast started with a case-based format, using a composite case presented to an expert, followed by a junior learner asking questions. Now the team does more prep work to create a structured script that includes educational objectives.
• Using a script allows for the interview to flow in a more organized structure, which makes for easier editing. Meeting and preparing the script with experts demands time and preparation in order to create the milieu for a generative interview.
• Most often, the "pearls" come from the unscripted questions that elicit reflections.
• Experts have been willing and excited to participate in the podcast and to disseminate their knowledge in a format that will reach trainees.

PsychEd topics

• So far, PsychEd has covered basic topics of psychiatry, including major depressive disorder, schizophrenia, bipolar disorder, and anxiety, and it is now expanding to more complex topics.
• An initial idea was to incorporate the patient perspective to add nuance to the foundational-level topics. Listeners were indifferent to this idea since they already encounter the patient experience on a regular basis and incorporating the patient voice did not necessarily target the educational content.
• This scenario illustrates in difficulty of choosing topics: Subject matter that will draw in listeners but also are creative and add meaning.
• There is space for societal topics in psychiatry such Big Data, climate change, technology, and loneliness.
• PsychEd has been awarded a grant through the University of Toronto to expand subject matter focused on clinical skills to target priorities identified by the Royal Board of Canada through its "Competency by Design" initiative.

Other challenges in podcasting

• Choosing topics is a balance of identifying cutting-edge topics vs. issues universal to all psychiatrists. Should popular topics be revisited?
• Deciding how to identify topics that can enhance learning but are also professionally enriching to the psychiatrist as an individual.

What personal growth has come from podcasting?

• Learning leadership skills: Leading a small team to create a quality podcast and then expanding to research about the impact.
• Providing a creative outlet both in content and thinking about the scope of scholarship within psychiatry.
• Enhancing time management and learning how to juggle interests outside of clinical work.
• Understanding how to access rich local resources, ranging from experts to other trainees who want to podcast and contribute.
• Broadening one's vision and perspective by talking with thought leaders: As psychiatrists, our work resonates with similar themes, and it's inspiring to talk to others about universal themes.

References

The PsychEd podcast: https://www.psychedpodcast.org/

Mallin M et al. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014 Apr;89(4):598-601.

Matava CT et al. eLearning among Canadian anesthesia residents: A survey of podcast use and content needs. BMC Med Educ. 2013 Apr 23;13:59.

Riddle J et al. A survey of emergency medicine residents' use of educational podcasts. West J Emerg Med. 2017 Feb; 18(2): 229-234.

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Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych