Psychcast

Welcome to this bonus episode of the MDedge Psychcast. In this episode, as a tribute to the late Carl C. Bell, MD, we would like to replay highlights from the interview that Lorenzo Norris, MD, did with him last year at the annual IPS (Institute on Psychiatric Services) Mental Health Services conference in Chicago.

Dr. Norris, host of the MDedge Psychcast, is assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Bell, who died Aug. 1, was a psychiatrist at Jackson Park Hospital in Chicago and an emeritus professor of psychiatry at the University of Illinois at Chicago. He spoke with Dr. Norris in episodes 26 and 27 about identifying and preventing fetal alcohol spectrum disorders.

Conceptualizing intellectual disabilities in children

• In the late 1960s, African American children had twice the rates of mild intellectual disabilities as did white children.
• Some clinicians thought that the intellectual disabilities they were seeing among African American children were the result of social-cultural mental retardation, but that conclusion did not make sense to Dr. Bell.
• Julius B. Richmond, MD, former surgeon general, cocreated Head Start as a way to address some of the educational disadvantages faced by low-income children.
• African American psychologists began to suggest that standardized tests were biased against certain racial and low-income groups.
• Bell thought some African American and low-income children might have knowledge that their counterparts in other communities might not have.

Fetal alcohol exposure emerges as an explanation

• A few years ago, Dr. Bell was talking with a woman patient with three children in the Illinois Department of Children and Family Services. The children had poor tempers, social/emotional skills. And when he looked at their mother, he saw fetal alcohol facies.
• After talking with the patient longer, he learned that she had not gotten far in school. She also had problems with simple subtraction. At that point, he thought that the patient might have had fetal alcohol exposure.
• He then began looking at family medicine patients at Jackson Park Hospital in Chicago. The question at that time was: "Were you drinking while you were pregnant?" That question did not explain why patients had children who could not do basic subtraction and had ADHD, for example.
• Bell realized that the right question was: When did you realize you were pregnant? In many cases, they would say that they had learned they were pregnant at 4-6 weeks.

Choline deficiency and fetal alcohol exposure

• The Institute of Medicine recommended that pregnant women consume 450 mg/day of choline each day.
• Robert Freedman, MD, and his colleagues found that higher amounts of choline as a prenatal supplement are tied to more self-regulation among infants who had common maternal infections during gestation.
• Bell began giving choline to patients. In one example, a patient's ability to relate to others improved dramatically after taking choline over an 18-month period.
• The American Medical Association passed a resolution supporting the addition of adequate amounts of choline to prenatal vitamins.

References

Freedle RO. Correcting the SAT's ethnic and social-class bias: A method for reestimating SAT scores. Harvard Educ Rev. 2003. 73(1):1-42.

Bell CC and J Aujla. Prenatal vitamins deficient in recommended choline intake for pregnant women. J Fam Med Dis Prevent. 2016. 4(2):1-3.

Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders: A randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2015 Nov;102(5):1113-25.

Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders(FASD) has high feasibility & tolerability. Nutr Res. 2013. Nov;33(11):897-904.

Zeisel SH and KA da Costa. Choline: An essential nutrient for public health. Nutr. Res. 2009. Nov;67(11):615-23.

Freedman R et al. Higher gestational choline levels in maternal infection are protective for infant brain development. J Pediatr. 2019 May. 208:198-206.

Velazquez R et al. Maternal choline supplementation ameliorates Alzheimer's disease pathology by reducing brain homocysteine levels across multiple generations. Mol Psychiatry. 2019 Jan 8. doi: 10.1038/s41380-018-0322-z.

Wilhoit F et al. Fetal alcohol spectrum disorders: Characteristics, complications, and treatment. Community Ment Health J. 2017 Aug;53(6):711-8.

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Show Notes

Last week, Igor Galynker, MD, PhD, spoke with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about how to identify suicide crisis syndrome. This week, he explores the kinds of "gut feelings" that clinicians can access to help them identify when a patient might have the syndrome.

Dr. Galynker has been a guest on the Psychcast twice before, once to discuss the impact of suicide on physicians and a second time to talk about his research on the arguments for adding a suicide-specific diagnosis to the DSM-5. He is associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel in New York. In addition, Dr. Galynker is founder and director of the Richard and Cynthia Zirinsky Center for Bipolar Disorder, and professor of psychiatry at the Icahn School of Medicine, both at Mount Sinai.

Later, Renee Kohanski, MD, discusses the ability of psychiatrists to help patients realize that they can choose what matters in their lives. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

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

The "gut feelings" -- emotional reactions to the patient in suicide risk assessment -- also will elicit behaviors from a clinician.

Behavioral signs of the four emotions are pertinent for clinicians who are burned out or may have limited emotional awareness. Examples include:

• Anxious overinvolvement manifested as going above and beyond for a patient; doing things that are out of character, such as answering phone calls/texts on the weekend; reluctance to set boundaries.
• Dislike and distancing: The patient in suicide crisis syndrome will be the last one the clinician sees on the inpatient unit or the one he/she postpones or forgets to see; the clinician experiences dread tied to the prospect of seeing a patient all day, shortens sessions, or does not answer phone calls.

How to combine emotional response and the suicide crisis syndrome.

• New research from Dr. Galynker and colleagues suggests that the predictive validity for suicide risk doubles if the patient meets criteria for suicide crisis syndrome and the clinician has an emotional response as described above.
• The emotional response is elicited not just from the suicide crisis syndrome but also from the suicidal narrative.
• The narrative of a suicidal person describes an intolerable present with no future. This type of aberrant narrative triggers an emotional response in the clinician.
• One could argue the electronic medical record makes it difficult to understand the patient's narrative, which can impede the clinician's ability to have an emotional response to the patient's suffering.

Why has psychiatry not focused on suicide over other mental health diagnoses?

• As a transdiagnostic phenomenon, one could argue that suicide must be a primary focus of assessment and treatment by psychiatrists.
• Suicide elicits a variety of cultural responses, ranging from shame, disgust, and a sense of weakness to empathy for the pain and suffering of a suicidal person.
• It is difficult to connect with someone who is suffering from a desire to die, but this might be what the patient wants.
• Clinical excellence is the ability to connect with a variety of patients in different settings, and it's about demonstrating how one cares.

References

Olfson M et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-26.

Galynker I et al. Prediction of suicidal behavior in high-risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb;34(2):147-58.

Cohen LJ et al. The suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav. 2018 Oct;48(5):613-23.

Suicide rising across U.S. Centers for Disease Control and Prevention. Vital Signs. 2018 Jun.

Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: Advantages outweigh limitations. World Psychiatry. 2014 Jun;13(2):128-30.

Fawcett J. "Diagnosis, traits, states and comorbidity in suicide" in The Neurobiological Basis of Suicide. Boca Raton, Fla.: Taylor & Francis, 2012.

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Show Notes

Igor Galynker, MD, PhD, talks with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about suicide crisis syndrome.

Dr. Galynker has been a guest on the Psychcast twice before, once to discuss the impact of suicide on physicians and a second time to talk about his research on the arguments for adding a suicide-specific diagnosis to the DSM-5. He is associate chairman for research in the department of psychiatry at Mount Sinai Beth Israel in New York. In addition, Dr. Galynker is founder and director of the Richard and Cynthia Zirinsky Center for Bipolar Disorder, and professor of psychiatry at the Icahn School of Medicine, both at Mount Sinai.

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

Later, in the "Dr. RK" segment, Renee Kohanski, MD, tells the story of a patient who found a way to rediscover his value system against great odds. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Suicide crisis syndrome: A suicide-specific mental state

• Until recently, there was no differentiation between the mental state associated with lifelong suicide risk versus the mental state associated with imminent suicide risk.
• Jan Fawcett, MD, distinguished these mental states for the first time by differentiating acute risk of imminent death and lifelong risks and traits of suicidal behavior.
• Lifetime suicide risk factors include mental illness, history of suicide attempts, depression, and substance abuse.
• Imminent suicidal behavior risk factors include panic, acute anhedonia, agitation, and insomnia.

Dr. Galynker and colleagues have identified a condition they call suicide crisis syndrome, which they define as a mental state that predicts imminent suicidal behavior in days to weeks. The predictive validity has been replicated across several cultures and populations.

Suicide crisis syndrome: To be identified as having suicide crisis syndrome, the patient must meet both criterion A and two criteria of B.

• Criterion A: Frantic hopelessness or state of entrapment defined as being stuck in a life situation that is painful and intolerable, and a feeling that all routes of escape are blocked. The risk of suicide within 1 month is 13% for people who meet criteria for suicide crisis syndrome.
• Criterion B:
  • Affective dyscontrol, including emotional pain or mental pain; severe panic with agitation, and dissociation; rapid mood swings that can include happiness; and acute anhedonia.
  • Cognitive dyscontrol, which can include ruminative flooding associated with headache or head pressure; cognitive rigidity; and inability to suppress the ruminative thoughts. (For example, you might assess by asking: "Do you control the thoughts or do the thoughts control you?")
  • Overarousal with insomnia and agitation.
  • Social withdrawal and isolation, and evading communication.

Why are suicide-specific diagnoses necessary?

• 75% of people who die by suicide do not report suicidal ideation to a clinician, psychiatrist, or primary care physician.
• Notably, suicide crisis syndrome does not include suicidal ideation in the criteria, because not all people within imminent risk feel suicidal until the moment strikes. Some patients will hide their suicidal ideation from their clinician to prevent having their plan foiled.
• Suicide crisis syndrome creates a fuller picture of patient risk. Assessment of the criteria help a clinician consider more risk factors for imminent risk than simply a patient's self-report about suicidal ideation.

Approach suicidality with a different framework

• Suicide-specific diagnoses represent a profound shift in approach, because suicide is a transdiagnostic phenomenon for depression, bipolar disorder, and schizophrenia.
• A person can be at imminent risk for suicide without meeting criteria for other DSM diagnoses.
• Other suicide-specific diagnoses: Maria A. Oquendo, MD, PhD, and colleagues have put forward "suicidal behavior disorder," which is a diagnosis that captures the propensity of suicidal behavior and urges to kill oneself.
• Suicidal behavior disorder and suicide crisis syndrome provide clinical targets for treatment of suicide.
• Without a diagnosis, clinicians cannot test treatment or teach the assessments.

Use emotional reactions to the patient in suicide risk assessment

• Clinicians can identify "gut feelings" that help hone their assessments.
• Galynker and colleagues have identified four emotions that can help clinicians identify suicide risk:
  • Distress.
  • Dislike with distancing.
  • Anxious overinvolvement, with a paradoxical combination of hope and distress.
  • Collusion/abandonment/rejection, which includes a type of hopelessness and calm.
• Clinicians can be trained to identify these emotions, which they may have been taught to suppress.
• Recognition of these emotions can be cultivated through "emotional awareness rounds."

Dr. Fawcett is a professor of psychiatry at the University of New Mexico, Albuquerque. Dr. Oquendo is the Ruth Meltzer Professor of Psychiatry at the University of Pennsylvania, Philadelphia.

References

Olfson M et al. Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry. 2016 Nov 1;73(11):1119-26.

Galynker I et al. Prediction of suicidal behavior in high-risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb;34(2):147-58.

Cohen LJ et al. The suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life Threat Behav. 2018 Oct;48(5):613-23.

Suicide rising across U.S. Centers for Disease Control and Prevention. Vital Signs. 2018 Jun.

Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: advantages outweigh limitations. World Psychiatry. 2014 Jun;13(2):128-30.

Fawcett J. "Diagnosis, traits, states and comorbidity in suicide" in The Neurobiological Basis of Suicide. Boca Raton, Fla.: Taylor & Francis, 2012.

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Show Notes

Elspeth Cameron Ritchie, MD, MPH, talks with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about averting disruptions in psychiatric medications after short- and long-term disasters.

Dr. Ritchie is a psychiatrist who works in Washington.

Show Notes by Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Later, in the "Dr. RK" segment, Renee Kohanski, MD, discusses the potential impact of pharmacogenomics on the practice of psychiatry. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Dr. Ritchie and disaster psychiatry

• She entered disaster psychiatry through her many years as a military psychiatrist.
• She had to think about how to plan and treat psychiatric emergencies during deployments to an austere environment, such as Somalia and Iraq.
• She was on active duty during Sept. 11, 2001, and helped coordinate the disaster response during that period and then completed a fellowship in disaster psychiatry at the Uniformed Services University in Bethesda, Md.
• Ritchie says that the field has changed immensely, from the way in which it once handled debriefings to the current use of psychological first aid. Yet, she thinks that psychiatric medications are a neglected area of planning.

Minor, major disasters can cause disruptions in psychiatric medications

• Access/continuity of psychiatric medications is overlooked in planning.
• Disruption in psychotropic medications will affect many populations, including people with serious mental illness (SMI), first responders, and patients dependent on controlled substances such as methadone, buprenorphine and naloxone, and benzodiazepines.
  • Especially for those with SMI in a disaster that creates increased stress, the absence of medications can have longer negative consequences, such as changes in behavior as hospitalizations or that may lead to contact with the legal system.
• Plans need to be made in advance with patients to prevent disruption in medications.
• Small disasters could include a weather event, such as a snow or rainstorm. These can create barriers to medication at the basic level, such as a lack of electricity affecting computer systems, a pharmacist cannot make it to work, etc.
• Larger disasters, such as hurricanes, can have effects that last months to years, such as loss of psychiatrists or lack of other infrastructure related to mental health.

Population-specific planning during disasters

• Patients with SMI: Some might be homeless and affected by weather conditions; there often may be a robust citywide response aimed at creating a safety net for these individuals.
• First responders: It is essential to have medications available for sleep, such as trazodone or zolpidem, to mitigate the effects of long, stressful workdays that make it hard to "turn off" and get rest.
• Working professionals: Many people balance busy lives on a routine basis, so it's important to help these patients maintain their medications and functioning. Psychiatrists should make sure that these patients have adequate supplies of medications, such as SSRIs.

How can psychiatrists help to prepare?

• They can ensure that patients can have an adequate supply of medications in several locations in case of disaster or emergency.
• They can provide a 90-day supply of medication in the event of a large disaster with lasting effects.
• They can determine that patients have a printed up-to-date list of all their medications in case they need to change pharmacies or have medications refilled by another clinician, such as a primary care physician.
  • Patients and doctors rely on the electronic health records for medication lists, which may fail during a disaster.
• They can identify at-risk patients, such as those on controlled substances (opiates and benzodiazepines), and refill any medications that, if missed, can result in withdrawal syndromes.

Disaster planning has come a long way over the last 30 years

• Disaster planning often takes into consideration food supply and medications. However, psychiatric medications often are forgotten as being essential to patients.
  • For example, the Centers for Disease Control and Prevention does not stockpile psychotropic medications, other than valium, for emergencies.
• Psychiatrists can advocate within their cities or states to ensure that disaster plans include a contingency for psychiatric care, such as stockpiles of psychotropic medications.
• Psychiatrists can help in disaster planning by consulting on formularies for disasters and suggesting versatile psychotropic medications that can be used in multiple settings or for different patient types.
  • Examples of versatile medications include mirtazapine for sleep and depression, bupropion for depression and ADHD, medications for sleep, antipsychotics, and such key SSRIs as fluoxetine.
• Psychiatrists also must plan for themselves and consider their own self-care as well as emergency planning for their offices and their families.

References

Ritchie EC et al. When a disaster disrupts access to psychiatric medications. Current Psychiatry. 2019 May;18(5):22-6.

Kenardy J. The current status of psychological debriefing: It may do more harm than good. BMJ. 2000 Oct 28;321(7268):1032-3.

Rodriguez JJ and R Kohn. Use of mental health services among disaster survivors. Curr Opin Psychiatry. 2008 Jul;21(4):370-8.

Redd SC and TR Frieden. CDC's evolving approach to emergency response. Health Secur. 2017 Jan/Feb;15(1):41-52.

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Ep. 70

Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

In this episode, Richard Balon, MD, returns to the MDedge Psychcast to discuss benzodiazepines. This time, Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, interviewed Dr. Balon about prescribing benzodiazepines for patients with serious medical illnesses. They also examine some of the controversies around benzodiazepines and common mistakes that some clinicians make when prescribing these drugs.

Dr. Balon is professor of psychiatry at Wayne State University in Detroit.

And later, in the "Dr. RK" segment, Renee Kohanski, MD, explores the need for psychiatrists to challenge the distorted thinking patterns of patients, particularly in light of the growing influence of social media. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn.

Benzodiazepines can be used for patients with serious mental illness across several areas of medical illness, including those with cardiovascular, gastrointestinal, and sleep disorders, as well as for those with generalized anxiety disorder (GAD) and panic disorder.

Cardiovascular illness

• Patients with cardiovascular illness might have just encountered a near-death experience and present with somatic symptoms of their cardiovascular illness and anxiety.
  • This overlap of symptoms makes cardiovascular illness a reasonable comorbidity in which to use benzodiazepines for anxiety.
• A naturalistic study of patients with heart failure showed patients on benzodiazepines had a small decrease in mortality. The reason is unknown, but it could be from a decrease in anxiety and stress, both of which affect the heart.
• Older studies show that some benzodiazepines can be used in addition to antihypertensives.

Gastrointestinal illness

• Benzodiazepines also are useful for such gastrointestinal (GI) illnesses as peptic ulcer disease, inflammatory bowel disease, irritable bowel syndrome, etc.
• The symptoms of GI illness, such as constipation, diarrhea, and nausea, can complicate the use of SSRIs or tricyclic antidepressants for anxiety.
• Older studies suggest that adding benzodiazepines to the regimen of these patients, especially those without substance use disorder, can improve outcomes.

Sleep disorders

• Five benzodiazepines have been approved for sleep disorders: triazolam, flurazepam, temazepam, estazolam, and quazepam.
• These medications are used infrequently despite having a long half-life, which is useful for sleep initiation and maintenance.
• Quazepam is designed specifically for insomnia and has activity at a different part of the alpha subunit on the GABA receptor.
• Clonazepam also is useful, especially for patients with comorbid anxiety and sleep issues, because it contributes to sedation, and as a result of its long half-life, it continues to relieve anxiety throughout the day.

Generalized anxiety disorder (GAD) and panic disorder

• Many clinicians are leery about using alprazolam for several reasons.
• The medication's short half-life contributes to patients using the drug several times a day.
• Immediate relief of anxiety has a reinforcing effect, which in turn, increases the risk of abuse.
• There are no well-designed trials comparing benzodiazepines with SSRIs. Many of the recommendations about how to use benzodiazepines come from clinical experience.
• Some patients with GAD without substance use benefit from benzodiazepines such as clonazepam.
• It is possible for some patients to stay on long-term treatment with benzodiazepines and not need higher doses because of tolerance.

Clarity is needed about the true impact of benzodiazepines on patients

• Benzodiazepines are an integral part of the psychopharmacology armamentarium yet are underused.
• Their use is increasingly discouraged, and trainees are not getting enough experience with prescribing benzodiazepines.
• Benzodiazepines are rarely abused on their own.

Common mistakes in using benzodiazepines

• Patients who might need or benefit from treatment with benzodiazepines are not adequately assessed.
• Dose escalation with benzodiazepines often is avoided. When patients ask for an increase in the dose, this is not necessarily sign of abuse. A dose increase might be a sign that the patient is still anxious.
• Trainees are not getting proper guidance in prescribing benzodiazepines; they need to be familiar with prescribing all classes of psychotropics.

References

Slee A et al. Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. Lancet 2019 Feb 23;393(10173):768-77.

Guina J, Merrill B. Benzodiazepines I: Upping the care on downers: The evidence of risks, benefits, and alternatives. J Clin Med. 2018 Jan 30. doi: 10.3390/jcm7020017.

Salzman C. The APA task force report on benzodiazepine dependence, toxicity, and abuse. Am J Psychiatry. 1991 Feb;148(2):151-2.

Fava GA et al. Benzodiazepines in anxiety disorders. JAMA Psychiatry. 2015;72(7):733-4.

Tully PJ et al. The anxious heart in whose mind? A systematic review and meta-regression of factors associated with anxiety disorder diagnosis, treatment, and morbidity risk in coronary heart disease. J Psychosom Res. 2014 Dec;77(6):439-48.

Colussi GL et al. Benzodiazepines: An old class of new antihypertensive drugs? Am J Hypertension. 2018 Apr;31(4):402-4.

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Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

In this episode, Lorenzo Norris, MD, host of the MDedge Psychcast, interviews Jonathan M. Meyer, MD, about prescribing clozapine and understanding barriers of use.

Dr. Meyer is clinical professor of psychiatry, University of California, San Diego, and a psychopharmacology consultant with the California Department of State Hospitals.

Overview of clozapine

• Clozapine is an effective medication for treatment-resistant schizophrenia and lethality/suicide.
• Clozapine is underused by clinicians for many reasons.
• Clinicians have less comfort with prescribing clozapine.
  • Too few trainees are exposed during residency to prescribing clozapine.
• Using clozapine during training provides the knowledge and comfort necessary to prescribe it once out in practice.
  • Fear of prescribing clozapine outweighs the benefits to patients who need it.
  • Other barriers include monitoring burdens in confluence with systems issues.

Indications for use

• Treatment-resistant schizophrenia is defined as an inadequate response to two antipsychotic trials, and treatment-resistant schizophrenia occurs in about 30% of patients with schizophrenia.
  • People with treatment-resistant schizophrenia have a 5% chance of responding to other antipsychotic medications, while the response rate to clozapine is about 40%.
• In light of those statistics, getting patients with schizophrenia on clozapine should be a priority.
• Everyone benefits when a patient with treatment-resistant schizophrenia is started on clozapine.
• Clozapine treatment leads to decreased symptoms and suffering, improved quality of life, decreased suicidality and aggression, and lower hospitalization rates, which in turn, lead to decreased health care costs.

Barriers to using clozapine

• Education is key to empowering physicians to start prescribing clozapine and overcoming the initial resistance to prescribing.
• SMI Adviser is a website sponsored by the American Psychiatric Association (APA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) that provides access to education, data, and consultations for clinicians who treat serious mental illness.
• SAMHSA also has sponsored "centers of excellence" in New York state and the Netherlands that provide consultation and on-demand answers to questions about prescribing.
• The Clozapine Handbook, written by Dr. Meyer and Stephen M. Stahl, MD, PhD, is another centralized resource for prescribers.
  • Dr. Meyer and Dr. Stahl wrote the handbook to educate and encourage clinicians to prescribe clozapine and improve patient outcomes.

Adverse events and monitoring

• Myocarditis: Rate of myocarditis ranges from 0.5% to 3% (most rates from Australia), an adverse event that happens primarily within the first 6 weeks of clozapine therapy.
  • Symptoms suggesting myocarditis include fever and elevated troponin level more than twice the upper limit of normal. Clinicians can order a C-reactive protein test, which can help rule in myocarditis if troponins are elevated but not at twice the upper limit range.
  • In the first 6 weeks of therapy, clinicians are encouraged to order a troponin test during the patients' weekly labs.
• Isolated fever does not mean myocarditis, because fever is a common side effect during titration, and clinicians can complete the fever work-up.
• Cigarette smoke can induce cytochrome P450 (CYP) enzyme, including CYP1A2.
• It is not necessary to have patients stop smoking when they start clozapine.
  • Clinicians can adjust the clozapine dose based on response and clozapine level.
• Induction of CYP1A2 enzyme happens only when people smoke or burn the actual leaf of tobacco or marijuana.
  • Vaping or e-cigarettes will not induce CYP1A2 and change clozapine levels.
• Threshold of response is 350 ng/mL, however levels that lead to response differ with each individual and will be influenced by smoking habits.
• Other common side effects include orthostasis, sedation, and sialorrhea.

New technologies are available to reduce barriers of prescribing clozapine and to improve patient adherence to hematologic monitoring.

• Athelas is a company that manufactures a Food and Drug Administration–cleared point-of-care device to measure neutrophil count by way of a finger stick.
  • Results are dispensed real time.
  • Athelas also will take care of medication dispensing.
• A point-of-care device is in development for plasma clozapine levels with fingerstick, which will allow clinicians to make titration decisions in real time instead of 1 week after levels.
  • The device already is available in Europe.

Creating a system that allows for adherence

• Using case managers to improve clozapine adherence is cost effective when the amount saved from avoiding hospitalization is taken into account.
• Clozapine can lead to a functional recovery in terms of how a patient interacts with family, friends, and society at large.
• Clozapine has the ability to improve productivity leading to employment, which is another way the benefits of creating a system to improve clozapine adherence outweigh financial costs.

References

Kane JM et al. Clinical guidance on the identification and management of treatment-resistant schizophrenia. J Clin Psychiatry. 2019 Mar 5;80(2): doi: 10.4088/JCP.18com12123.

Suskind D et al. Clozapine response rates among people with treatment-resistant schizophrenia: Data from a systematic review and meta-analysis. Can J Psychiatry. 2017 Nov;62(11):772-7. doi: 10.1177/0706743717718167.

Kelly DL et al. Addressing barriers to clozapine underutilization: A national effort. Psychiatr Serv. 2018 Feb 1;69(2):224-7.

Bui HN et al. Evaluation of the performance of a point-of-care method for total and differential white blood cell count in clozapine users. Int J Lab Hematol. 2016 Dec;38(6):703-9.

Other resources

SMI Adviser: Clozapine Center of Excellence, sponsored by the APA and SAMHSA.

The Clozapine Handbook (Cambridge University Press, 2019).

Clozapine and smoking cessation (NSW Health, Australia).

Point of care neutrophil measurement.

https://athelas.com/fda/.

https://curesz.org/.

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Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Show Notes

In this episode, we revisit three of our best episodes on preventing suicide. In episode 46, Lorenzo Norris, MD, host of the MDedge Psychcast, interviewed Igor Galynker, MD, about how to assess suicide crisis syndrome. Dr. Norris is editor in chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Galynker is associate chairman for research in the department of psychiatry at Mount Sinai, New York.

In episode 42, Dr. Norris interviewed Caroline Bonham, MD, and Avi Kreichman, MD, about addressing suicidality in rural communities and strategies for enhancing resilience. Dr. Bonham and Dr. Kreichman work together at the University of New Mexico, Albuquerque. She serves as vice chair of the department of psychiatry and behavioral sciences at the university, and he is an assistant professor there.

In episode 54, Sidney Zisook, MD, who directs the residency training program at the University of California, San Diego, conducted a Masterclass on the many causes of physician suicide and how this might be prevented.

And stay tuned for our Dr. RK segment, where Renee Kohanski, MD, who talks about making mistakes while caring for patients and granting ourselves full and complete forgiveness. Dr. Kohanski has a private practice in Mystic, Conn.

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

Email the show: [email protected]

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Headline: Update on the American Psychiatric Association – Part 2

Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Lorenzo Norris, MD, interview with Saul Levin, MD, MPA, CEO and medical director of the American Psychiatric Association (APA). Dr. Levin also is clinical professor at George Washington University.

Improving access to care and impact of psychiatrists is imperative.

• Finding a doctor: More physicians need to be trained. Increasing the number of physicians can be accomplished through initiatives funded by the government and by private medical centers.
  • Innovation in training at both undergraduate and graduate levels is needed to increase the number of physicians across all specialties.
  • Debt repayment: The APA is encouraging the federal government to diversify its loan repayment options, such as by making it possible for psychiatrists to practice in more diverse but underserved places in exchange for loan repayment.
• Getting to a doctor: Telepsychiatry and collaborative care are means of increasing access.
  • Collaborative/integrative care: The psychiatrist acts as an adviser to a whole team and then offers direct patient care in more complex cases.
  • Telepsychiatry improves access by decreasing stigma and reducing commute time to and from patient visits.
    • Both psychiatrists and patients save time and gain convenience.
• Using evidence-based treatments (EBT) is important in psychiatry.
  • One goal is to advance the use of EBT to enhance the impact of psychiatric treatment, especially by using quality measures (for example, the nine-item Patient Health Questionnaire) to validate the impact of treatment.
  • The Centers for Medicare & Medicaid Services has given grants to medical associations such as the APA to create quality measures to quantify/validate the impact of treatments in an effort to foster more EBT in psychiatry.

Conclusion: Advocating on behalf of people with psychiatric disorders requires a broad approach.

• The APA lobbies for fairness, parity, and quality treatment.
• The group works to advance EBTs and new treatments.
• Recruitment of diverse individuals to psychiatry is important.
• "Moonshot" level research is integral to the advancement of psychiatry and the mental health of the patients.
• The APA strives to balance a mission of government advocacy and individual psychiatrist education.

References

APA Innovation Lab

Mental health parity advocacy

Advocacy and APAPAC

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Update on the American Psychiatric Association – Part 1

Show Notes

By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Lorenzo Norris, MD, interview with Saul Levin, MD, MPA, CEO and medical director of the American Psychiatric Association (APA). Dr. Levin also is clinical professor at George Washington University.

In 2019, the American Psychiatric Association celebrated its 175th anniversary.

• The APA was the first medical association formed in the United States.
• The 2019 APA annual meeting in San Francisco attracted 13,000 psychiatrists and mental health professionals, and hosted 650 sessions covering all topics in psychiatry, including subjects related to private, community, and academic psychiatry.
• Highlights of the 2019 meeting included:
  • A Gala at San Francisco City Hall, which allowed generations of psychiatrists to celebrate the progress of the APA.
  • Sessions at the meeting, which focused on the latest basic, clinical, service, and psychopharmacology research.
  • Additional sessions focused on minority and underrepresented populations, both within APA membership and patient populations.
• Major networking opportunities at the APA were available, allowing peers and experts in the field to create lifelong professional relationships.
  • A burgeoning networking opportunity is the Psychiatry Innovation Lab, which is "an incubator at the American Psychiatric Association that aims to catalyze the formation of innovative ventures to transform mental health care."

The APA's role in advocacy: The organization is not just a guild that seeks to support psychiatrists.

• Part of the APA's mission is to advocate for patients with mental health illness with a focus on improving treatment and outcomes.
• For members, the APA sponsors a National Advocacy Day on Capitol Hill and state advocacy days, in which the APA helps fund people to come talk to their elected representatives.

Major areas of advocacy by the APA as a medical association are numerous.

• Mental health parity: Advocating for equal pay to psychiatrists for treating mental health diagnoses as well as the provision of equal coverage of psychiatric diagnoses by insurance companies.
• Augmentation of the workforce: Supporting measures aimed at making sure that there are enough psychiatrists to treat patients with mental illness in the United States.

Examples of advocacy initiatives by the APA are numerous. The group is active in the following areas:

• Advocates for legislation that advances telepsychiatry by supporting laws aimed at reducing barriers to the technology.
• Promotes integrative mental health care models.
• Explains the concept of prior authorization on Capitol Hill and helps to craft sensible guidelines.
• Promotes evidence-based treatments for substance use disorders, especially opioid use disorders.
• Lobbies for appropriations for agencies such as the Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health, and the National Institute on Alcohol Abuse and Alcoholism.
• Helps construct smart loan repayment plans aimed at allowing psychiatrists to practice in low-resource areas.

The APA recommends several research initiatives.

• "Moonshots" should be a goal in in psychiatry, much like those taken with illnesses such as HIV and breast cancer.
• Stigma must be reduced, and money must be appropriated to mental illness research in the same way it is for other medical illnesses.

References

APA Innovation Lab

Mental health parity advocacy

Advocacy and APAPAC

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Email the show: [email protected]

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Show Notes

Lorenzo Norris, MD, interview with Robert McCarron, DO, at the American Psychiatric Association meeting (#APAAM19)

Dr. McCarron is vice chair of education and integrated care at University of California, Irvine, department of psychiatry. He is also trained as an internist.

Shortage of psychiatrists, other mental health providers

• About 70% of all psychiatrists are over the age of 50 years and looking toward retirement.
• This also pertains to other mental health providers, such as psychologists.

Implications of shortage

• People with severe mental illnesses (SMIs) are not getting the care they need. On average, they die 10-15 years younger than people who do not have SMIs. Patients with SMIs have a higher risk of death from illnesses such as heart disease, hypertension, and osteoarthritis because they are not getting preventive/primary care.
• Patients with chronic pain issues are not getting care.
• In California, physician assistants provide care to many patients, but they get only 2 weeks of instruction in psychiatry.
• About 80% of all antidepressants are prescribed by nonpsychiatrists. About 60% of all mental health care is delivered in the United States by clinicians who do not specialize in mental health. This care is delivered in primary care settings. About 40%-45% of patients seen in primary care offices are treated for behavioral health issues, such as depression, anxiety, or substance use disorders.
• Suicides are up more than 20% over the last decade. On average, 25 veterans die by suicide each day.

Training primary care colleagues in psychiatry

• Primary care physicians have a core baseline in biomedical sciences. Giving them a booster in behavioral health is a way to address the shortage.
• The Train New Trainers Primary Care Psychiatry Fellowship was launched at University of California, Davis, and the University of California, Irvine. It has 125 fellows throughout the country, and the hope is to double that number.
  • The program lasts 1 year, including two intensive weekends.
  • It teaches fellows how to conduct motivational interviewing; short, targeted, and brief psychotherapies that are effective and evidence based.
  • The Fellowship includes Web-based presentations two to three times per month.
  • It also includes small group mentorship meetings in which fellows discuss patients and learn how to navigate complex cases.
• A combined residency program might be another way to address the need for more training in psychiatry.

References

Price S. Front line: Using primary care to prevent suicide. Tex Med. 2018 Nov 1;114(11):16-21.

Santiani A et al. Projected workforce of psychiatrists in the United States: A population analysis. Psychiatr Serv. 2018 Jun;69(6):710-3.

Huff C. Shrinking the psychiatrist shortage. Manag Care. 2018 Jan;27(1):20-2.

Wilkins KM et al. Integration of primary care and psychiatry: a new paradigm for medical student clerkships. J Gen Intern Med. 2018 Jan;33(1):120-4.

McGough PM et al. Integrating behavioral health into primary care. Popul Health Manag. 2016;19(2):81-7.

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