Psychcast

Show Notes

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

Guest

George T. Grossberg, MD: Samuel W. Fordyce Professor; director, geriatric psychiatry at Saint Louis University.

Dr. Grossberg spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.

New developments in Alzheimer's research

• The Systolic Blood Pressure Intervention Trial, also known as the SPRINT MIND Study, showed that tightly controlled systolic blood pressure (SBP) of 120 mm Hg, compared with an SBP of 140 mm Hg, resulted in a 20% reduced risk of developing mild cognitive impairment.
  • The SPRINT study was terminated early at the median follow-up of 3.26 years as its results showed that tightly controlled SBP significantly reduces the risk of stroke and heart disease.
  • The Alzheimer's Association has agreed to fund an additional 2 years of the SPRINT MIND Study to evaluate whether tightly controlled BP is effective in reducing the risk of Alzheimer's disease.
• In the brain, the glymphatic system was discovered in 2012 and is similar to the lymphatic system in its role as a drainage system for removing toxins.
  • Glial cells mediate toxin removal, and the glymphatic system removes toxins that eventually can cause cell death in the brain.
  • Because the glymphatic system is involved in removing the beta-amyloid plaques that contribute to cell death in AD, the glymphatic system is another area of investigation in the pathogenesis of AD.
• Novel treatment of moderate to advanced AD involves using plasma infusion.
  • Infusion of plasma products from healthy, nonimmunocompromised 18-year-old individuals into older patients with AD is a potential treatment for AD.
  • Precedent for this intervention comes from animal studies investigating parabiosis, a procedure in which two animals are connected so that they share each other's blood stream.
    • When such a circulatory exchange occurs between a younger mouse and an older mouse with AD, the older AD model mouse regains cognitive abilities and is able to complete mazes that it was unable to complete before.
• How can this model be adapted to humans? One possibility might involve infusing plasma from young healthy individuals into older adults with advanced AD.
• • A safety proof-of-concept study, published recently, found that plasma products can be safely infused. The next step is an efficacy study.
• A relationship has been found between AD and periodontal disease.
  • The primary bacteria related to periodontal disease, Porphyromonas gingivalis, is found in close proximity in the brain to the plaques and tangles of AD.
  • One theory posits that the presence of this bacteria is related to inflammation that may contribute to the causality of AD.
  • Could AD be treated with the antibiotics used to treat periodontal disease? The answers remain unclear.
• Aducanumab, a monoclonal antibody targeting the beta-amyloid plaques of AD, initially showed favorable changes in imaging studies of the brains of people with AD.
  • In March 2019, the study was halted because of futility.
  • An independent data-monitoring committee determined that the early results seen on imaging did not result in clinically meaningful changes, compared with placebo.
  • Some AD researchers consider this drug failure the "final nail in the coffin" of the amyloid hypothesis, and the pathogenesis of AD is most likely related to tau neurofibrillary tangles and other mediators, such as the immune system and inflammation.

References

SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 26 Nov 2015;373:2103-16.

Jessen NA et al. The glymphatic system: A beginner's guide. Neurochem Res. 2015 Dec;40(12):2583-99.

Dominy SS et al. Porphyromonas gingivalis in Alzheimer's disease brains: Evidence for disease causation and treatment with small-molecule inhibitors. Science Advances. 23 Jan 2019;5(1): doi: 10.1126//sciadv.aau3333.

Conese M et al. The fountain of youth: A tale of parabiosis, stem cells, and rejuvenation.

Open Med (Wars). 2017;12:376-83.

Phase 3 study of aducanumab in early Alzheimer's disease. ClinicalTrials.gov Identifier: NCT02477800.

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Part I of II (episode 62)

If you have lost a patient to suicide, or if you simply want to be part of the conversation, we strongly encourage you to email us at [email protected] your email will be read and discussed in a future episode. You can also tweet at us at @MDedgePsych.

If you're someone struggling with suicide in need of care, the national suicide hotline is 800-237-8255.

Part I of II (episode 62)

If you have lost a patient to suicide, or if you simply want to be part of the conversation, we strongly encourage you to email us at [email protected]. Your email will be read and discussed in a future episode. You can also tweet at us at @MDedgePsych.

If you're someone struggling with suicide in need of care, the national suicide hotline is 800-237-8255.

In this masterclass, Charles L. Raison, MD, returns to the MDedge Psychcast to discuss the risks and benefits of antidepressants. He previously appeared on the Psychcast in episodes 15 and 16.

Dr. Raison is Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families and professor, School of Human Ecology, and professor, department of psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison.

Later, Renee Kohanski, MD, discusses the need for psychiatrists to take care of and nourish their communities.

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

Treatment with antidepressants

• The STAR-D trial, a large effectiveness trial (n = 4,000), looked at the effect of SSRIs and other medications for the treatment of depression.
• As an effectiveness trial, STAR-D looked at "real" patients with comorbidities (as opposed to efficacy trials, which use "perfect patients" with no comorbidities to minimize confounding effects).
  • Only 30% of patients went into complete remission with first step of treatment with an SSRI (citalopram) at the highest tolerated dose.
  • Almost 50% experienced a response (a 50% reduction in symptoms of depression on standardized scale).

Cynicism and hope for antidepressants

• To obtain Food and Drug Administration approval, a medication requires two positive studies (showing that the drug beats placebo), and on average, an SSRI requires five to seven studies to get the two positive studies.
  • A meta-analysis of negative SSRI studies that were "filed away" found only a 1.8-point difference on Hamilton Depression Rating Scale score between SSRI vs placebo.
  • The difference between SSRI and placebo in treatment disappeared among patients who were less depressed.
• Geddes et al., presented a more balanced view in a published meta-analysis of 522 trials that included more than 100,000 patients.
  • Antidepressants had a modest benefit, compared with placebo.
  • In head-to-head studies, some antidepressants were better than others, such as amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine.

Predictors of response

• Poor response to antidepressants: Presence of comorbid anxiety disorder, failure of first or subsequent antidepressant trials.
  • Within STAR-D, among those who failed three treatment steps, only 13% responded to the next treatment.
• Good response to antidepressants: An acute response to an antidepressant predicts long-term response.
  • A 20% or greater improvement within 2 weeks of treatment resulted in a higher chance of remission, compared with those who don't initially respond, who then had a less than 5% chance of remission.

Are antidepressants good for everyone?

• The difference between active antidepressants and placebo is small.
• A latent growth curve analysis of placebo vs. antidepressants for depression showed that there are two separate trajectories with antidepressants: 70% will respond and are vastly improved, while 30% actually do worse.
• A National Institute of Mental Health study from 1980s randomized patients to two types of psychotherapy vs. tricyclic antidepressants (TCAs) vs. waitlist control group. Treatment took place for 16 weeks, and patients were followed for 18 months.
  • People who went into remission on TCAs were more likely to relapse than those who went into remission on psychotherapy.
• Epidemiological Catchment Area (ECA) trial: Prospective data of 92 people from the total 3,500 in the study.
  • Of the 92 with a first major depressive episode, 50% had a second major depressive episode.
  • Of those who were treated into complete remission, even after 5 years, more than 50% had a relapse of their depression.

Conclusion: Relapse of depression is common when patients come off antidepressants

• To stay well, a patient with depression should continue to receive an antidepressant.
• Clinicians must ask: Do the antidepressants increase the risk of relapse of depression?
• Depression is a disabling disease, so treatment is necessary. But clinicians should question for whom and when antidepressants should be used.

References

Turner EH et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358:352-60.

Cipriani A et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet. 2018 Apr 7:391(10128):1357-66.

Penninx BW et al. Two-year course of depressive and anxiety disorders: Results from the Netherlands study of depression and anxiety (NESDA). J Affect Disord. 2011 Sep;133(1-2):76-85.

Perlman K et al. A systematic meta-review of predictors of antidepressant treatment outcome in major depressive disorder. J Affect Disord. 2019 Jan 15;243:503-15.

For more MDedge Podcasts go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

For more MDedge Podcasts go to mdedge.com/podcasts

In part II of this Psychcast Masterclass, Patricia Westmoreland, MD, returns to discuss severe, enduring eating disorders, including management and ethical questions.

In Dr. RK this week, Renee Kohanksi explores the impact of censorship and self-censorship.

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Show Notes

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

Guest

Patricia Westmoreland, MD, a forensic psychiatrist at the University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; adjunct assistant professor of psychiatry at the University of Colorado Denver.

Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.

Harm reduction, palliative care, and futility

• Harm reduction model: A focus on returning to reasonable level of functioning without focus on full weight restoration, especially if full weight restoration has not proven sustainable with previous treatment.
  • Harm reduction is managed an as outpatient with regular check-ups. Team collaborates for attainable, mutual treatment goals.
  • Patients are allowed to stay at a lower body mass index (BMI) and are able to partially function and do things they enjoy, such as living with family and working part time.
  • Patients maintain an agreed-upon weight and regularly check labs.
• Inpatient hospitalization is pursued only to restore weight back to previously agreed-upon goal:
  • BMI is a marker of risk; BMI greater than 15 kg/m2 is lower risk, and BMI less than 13 kg/m2 is higher risk (lower BMI is tied to higher immunocompromised risk, more fractures, and other illnesses, as well as a greater risk of suicide, etc.)
• Palliative care is offered when patients have failed harm reduction and cannot sustain an acceptable body weight (not weight restored):
  • Palliative care is NOT hospice, and therefore, there are no specific expectations.
  • Treatment goal is comfort care, i.e., analgesics for fractures and decubitus ulcers, anxiolytics for refractory anxiety.

Ethics and futility:

When to say "enough is enough"? In anorexia nervosa (AN), frequently, many treatments have been implemented, and there may be no cure.

• Some think that anorexia should never be an end-stage diagnosis.

Cynthia Geppert, MD, MPH, a health care ethicist and a professor of psychiatry and internal medicine at the University of New Mexico, Albuquerque, who wrote in the American Journal of Bioethics: "Futility and chronic anorexia nervosa: A concept whose time has not yet come," argues against futility:

• AN does not meet definition of a terminal illness:
  • The patient's depleted weight renders a patient as having a life-threatening illness.
  • Can a patient be terminal and is care futile if there is hope for long-term recovery?
• Legally: Cognitive distortions make up the core of AN as an illness. Do patients with AN have the capacity to decide that further treatment is futile?
  • Cognitive impairments often normalize with treatment. Are physicians obligated to treat first in order to restore a patient's decision-making capacity before allowing them to choose palliative care?
  • People with AN may lack capacity because they cannot appreciate the consequences of their decision, which is one of the four components of capacity.

In support of futility, Cushla McKinney, PhD, of the biochemistry department at University of Otago (New Zealand), argues against the complete rejection of the concept of futility, saying it risks forcing a small and chronic group of patients into an intolerable situation.

• Arguments for futility: Not EVERY individual with AN lacks capacity.
  • Some argue for futility, and allowing patients to make choices in line with what they value in life.
  • Prognosis, even with treatment, is poor, especially for older individuals with years of failed treatments and medical comorbidities.
  • Are we doing harm by forcing an invasive treatment that patients don't want – especially after much treatment?

Illustrative case of AG, a 29-year-old female with chronic AN, who had a guardian for medical decision making:

• The guardian had decided in favor of tube feedings many times; AG had suffered complications such as heart failure.
• AG wanted to enter palliative care, arguing that she did not want to die, but if death were the result of AN, then "so be it."
• The judge ruled she could refuse treatment. He did not comment on capacity, but ruled she could make this decision to die on her terms.

Emerging concerns:

Is anorexia nervosa an end-stage illness or not? How will physician aid-in-dying overlap with AN? Do eating disorder patients have the capacity to request aid-in-dying, and what is the physician obligation?

References

Eddy J. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. Clin Psychiatry. 2017 Feb;78(2):184-9.

Sjostrand M et al. Ethical deliberations about involuntary treatment: Interviews with Swedish psychiatrists. BMC Med Ethics. 2015;16:37.

Geppert C. Futility in chronic anorexia nervosa: A concept whose time has not yet come. Am J Bioethics. 2015. 15(17):34-43.

Cushla M. Is resistance (n)ever futile? A response to "Futility in chronic anorexia nervosa: A concept whose time has not yet come," by Cynthia Geppert. Am J Bioethics. 2015 Jul 6. 15(7):53-4.

In Episode 59 Patricia Westmoreland, MD, gives a masterclass lecture on managing severe and enduring eating disorder (SEERS).

Renee Kohanksi, MD, poses the question, "What do we want?"

Contact us: [email protected]

Twitter: @mdedgepsych

Show Notes

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

Guest

Patricia Westmoreland, MD: forensic psychiatrist at University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; and adjunct assistant professor at University of Colorado Denver in department of psychiatry.

Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.

Introduction, definition, role of involuntary treatment, and novel treatment options

Introduction:

• Prognosis: Anorexia nervosa (AN) has the highest mortality of any psychiatric disorder.
  • Risk factors for death: Older age at first presentation, lower weight at presentation, greater duration of illness, comorbid alcohol or diuretic abuse, comorbid mood disorder, history of psychiatric hospitalization and suicide attempts, and self-harm.
    • Less than 50% recover completely, about 30% improve somewhat but require frequent hospitalizations or treatments, and 20% develop a SEED.
  • Eddy et al. longitudinal study of eating disorders (EDs): AN patients can recover over the long term. Overall, 31% were better at 9 years; 63% better at 22 years of follow-up.

Treatment:

• Treat ASAP, especially if patient is seen at a young/pediatric age before symptoms are fully developed and weight loss is profound.
  • Weight gain as the central treatment: Many patients are reluctant to get treatment that focuses only on food intake and weight gain.
  • Predictors of improvement: Weight gain that is parallel to improvement in physical and psychological well-being, diagnosis at a younger age, and shorter duration of illness.
• Medications: Fluoxetine is the only Food and Drug Administration-approved treatment for EDs, including bulimia, at doses of 60 mg and above.
  • Patients with EDs have poor response to selective serotonin reuptake inhibitors because of starvation and limited production of serotonin and serotonin receptor abnormalities.

Severe and enduring eating disorders (SEED) definition:

• 6-12 years of an ED can qualify as chronic.
• Lower likelihood of recovery with symptoms substantially interfering with quality of life.

Role for involuntary treatment in EDs: Few treatment centers do involuntary treatment of ED.

• Involuntary treatment can involve guardianship for medical decisions.
  • Guardianship is useful for medical treatment and admission to a medical ward, for example, when a patient requires forcible tube feeding for life-threatening starvation.
• Commitment or certification is required for involuntary treatment in a psychiatric hospital.
  • Commitment is sought by a psychiatrist and is a tool in cases when the patient is dangerous to self or others and is gravely disabled.
    • It is useful to commit a patient who is refusing care and has not been sick for long. Often, commitment/certification is used as a last resort, and the patient is too sick to truly recover.
  • Pros and cons of involuntary treatment:
    • Pro: No difference in weight restoration in voluntary vs. involuntary treatment, and patients are often grateful after involuntary treatment.
    • Cons: Involuntary tube feeding has unclear long-term outcomes.
      • Some studies show poor outcomes for people who are treated involuntarily, though this is likely because of their comorbidities.

Novel treatment options:

• Ketamine has been used in EDs. Concerns remain about the drug's addictive potential and inability to clearly change eating disorder pathology.
• Oxytocin: There are reduced cerebrospinal fluid levels of oxytocin in AN, and oxytocin restores during recovery.
  • Experimentally in rats, oxytocin may reduce the fear and social phobias related to eating.
• Electroconvulsive therapy does not reduce ED symptoms such as restricted eating and fear of fatness, but it can improve depression.
  • People with ED are often medically ill, so the patient must be physically able to undergo treatment.
  • Because of medical comorbidities, AN patients are more likely to have complications like delirium.
• Transcranial magnetic stimulation: Dorsolateral prefrontal cortex involved in self-regulatory control, inhibitory control, and cognitive flexibility.
  • Some studies show promising results of using this intervention with ED and mild side effects like syncope and headache.
• Deep brain stimulation (DBS): Treatment targets the nucleus accumbens and the subcallosal cingulate gyrus, which theoretically alter balance between reward and cognitive inhibitory and control systems that are related to pathological eating behaviors.
  • DBS has strongest theoretical rationale in terms of neurocircuitry targets.

References

Eddy J. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. Clin Psychiatry. 2017 Feb;78(2):184-9.

Sjostrand M et al. Ethical deliberations about involuntary treatment: Interviews with Swedish psychiatrists. BMC Med Ethics. 2015;16:37.

Geppert C. Futility in chronic anorexia nervosa: A concept whose time has not yet come. Am J Bioethics. 2015. 15(17):34-43.

Cushla M. Is resistance (n)ever futile? A response to "Futility in chronic anorexia nervosa: A concept whose time has not yet come," by Cynthia Geppert. Am J Bioethics. 2015 Jul 6. 15(7):53-4.

In part 2, Dr. Westmoreland will discuss harm reduction, palliative care, and futility.

Show Notes

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

Masterclass guest

Richard Balon, MD: professor of psychiatry and training director at Wayne State University, Detroit.

In March, Dr. Balon spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.

Physician burnout and effective interventions

• The scales (for example, the Maslach Burnout Inventory) do not necessarily represent the full extent of burnout:
  • If physicians work 12 hours but find fulfillment in work, they will be tired but not necessarily burned out. However, if physicians work 12 hours a day feeling frustrated by the systemic problems, then burnout can ensue.
• Common contributors to provider burnout:
  • Excessive workload: Pressures of working with an electronic medical record, extensive time spent on documentation; lack of work satisfaction and job control; lack of respect for the work; student loan burden.
  • "Moral injury": The emotional burden, which occurs when physicians cannot deliver ideal care/treatment to patients, especially when limited by resources (such as insurance or poverty), or other systemic health care issues.
  • Work environment and organizational culture: These factors also contribute to physician burnout.

Burnout is a problem for health care organizations as a whole

• Two main ways to address burnout: Physician-directed interventions (focused on individuals) and organization-directed interventions.
• Organization-directed burnout prevention strategies include:
  • Reducing workload; reducing time spent on documentation, such as decreasing time spent in front of EMRs; cultivating effective teamwork; fostering a sense of job control.
• Organizations prefer individual-focused interventions over systemic changes.
  • Examples include mindfulness teaching, yoga, cognitive-behavioral therapy techniques, education about burnout, and education.
  • Individual-focused interventions are great, but they are not realistic for changing the culture that contributes to burnout.

Interventions for burnout

In a systematic review and meta-analysis in JAMA Internal Medicine, Maria Panagioti, PhD, and colleagues found that:

• Burnout interventions focused on individual physicians have small, significant effect on physician burnout.
• Organizational-directed approaches result in greater treatment effects, especially when interventions focus on promoting healthy individual-organization relationships.
  • The impact of individual interventions can be improved when supported by organizational interventions.
  • Interventions targeted at more experienced physicians within primary care settings show greater treatment effect than interventions targeted at less experienced physicians within secondary treatment settings.
• Approaches identified by staff, as outlined in a New England Journal of Medicine article, can lead to meaningful change.
  • A Hawaiian health care system queried individuals (physicians, mid-levels, and nursing staff) to identify parts of EMR documentation that are poorly designed and unnecessary, and lead to unintended burdens contributing to burnout.
  • This type of survey improves efficiency of a system and shows that the health care organization cares about preventing clinician burnout.

References

Panagioti M et al. "Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis." JAMA Intern Med. 2017 Feb 1;777(2):195-205.

Ashton M. "Getting rid of stupid stuff." N Engl J Med. 2018 Nov. 8;379(10):1789-91.

Host Lorenzo Norris, MD, returns this week for a dual-specialty episode on the opioid crisis and how it can be mitigated. He welcomes psychiatrist Martin Klapheke, MD, and family practice physician Magdelena Pasarica, MD, PhD, to talk about education, strategies, and collaboration between psychiatry and family practice medicine.

In Dr. RK this week, Renee Kohanski, MD, talks about whether something is indeed better than nothing.

You can contact the Psychcast by emailing us at [email protected] or you can follow us on Twitter at @MDedgePsych.

Show Notes

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

Guests

Dr. Martin M. Klapheke: psychiatry residency program director; assistant dean, medical education; and professor of psychiatry at University of Central Florida, Orlando

Dr. Magdalena Pasarica: associate professor of medicine; medical director, KNIGHTS (Keeping Neighbors in Good Health Through Service) student-run free clinic; family medicine chair, Family Medicine Interest Group adviser at University of Central Florida, Orlando

How to address the opioid crisis during training

• The opioid crisis looms large over the medical field:
• • 130 deaths from opioid overdoses per day.
  • 11 million people misuse opiate prescriptions and 2.1 million people have an opioid use disorder.
• In 2018, the Department of Health & Human Services released a 5-point strategy in response to the opioid crisis:

1. Access: Providing better prevention, treatment, and recovery services.
2. Data: Offering timelier, more specific public health data and reporting.
3. Pain management: Mitigating risk while prescribing with healthy, evidence-based methods of pain management.
4. Overdoses: Targeting overdose-reversing drugs better.
5. Research: Doing better research on pain and addiction.

Educating the next generation of medical professionals to address the opioid crisis

• From the family medicine and resident education point of view:
  • Mitigate the risk when prescribing opiates.
  • Identify opioid use disorder (OUD).
  • Use the interdisciplinary approach to know when to refer to psychiatry and pain medicine.
• • Primary care providers are on the front lines of the crisis, as 11% of patients report chronic pain.
  • PCP will have to treat pain and:
• From the psychiatric and medical education point of view:
• • Before opioid crisis, there was little instruction in how to treat acute or chronic pain.
  • Medical education now teaches about pain management: Information about non-narcotic analgesics, nonmedication pain treatments, and addiction and its treatment.
  • Medical students: Focus on working with family members of those with OUD and especially on using naloxone to reverse opioid overdose.

Interprofessional approach is most effective with communication with shared priorities

We can collaborate effectively by understanding our shared priorities and offering all providers the opportunity to working toward these priorities in their own ways.

From Dr. Klapheke: The opioid crisis crosses all specialties of medicine, and doctors will reach the limit of their expertise.

• Work interprofessionally by communicating and knowing what resources are available.
• Communicate what each party is doing for the epidemic and for the patient.
• This means knowing about resources in the hospital, clinics, city, county, law enforcement, etc.

From Dr. Pasarica: Again, we must acknowledge the limits of our expertise and work interdisciplinarily in a team-based approach.

• Each team member needs to be responsible for the follow-up, even if the patient is referred to another person such as a counselor or a psychiatrist.
• Each team member must share information and what has been done for the patient.

How is addressing the opioid epidemic being integrated into medical student and resident education?

From Dr. Klapheke: At University of Central Florida, the medical school uses vertical and horizontal integration of information into the curriculum.

• During the preclinical years: Write OUD and pain management into standardized patient work.
  • Focus on the pharmacology of opiates and understanding neuroscience of addiction.
• During clinical rotations: Discuss OUD and the opioid epidemic during every specialty rotation and in lectures:
  • Use simulations: For example, during the third year, treat a patient experiencing opioid overdose.
• Medical schools should take advantage of already created online resources to teach about substance use disorder and opioid use disorder.
• Educating medical students and residents to incorporate family members in treatment:
  • Give family members information on chronic pain, addiction, and refer them to support groups.

From Dr. Pasarica: There also is a focus on interdisciplinary care in clerkships and in the student-run free clinic. It is important to teach interdisciplinary care in clerkships and volunteer settings.

• Work with counseling students and pharmacy students to screen and manage substance use disorder.
• Visit treatment and recovery sites during medical school to see interdisciplinary work in action.

General ways to teach about the opioid epidemic in medical education:

• Focus on longitudinal educational experiences about pain and treatment.
• Focus on interdisciplinary care.
• Talk about pain in all different settings.
• Create simulations and online training modules.
• Use the medical school and GME network: Collaborate with other medical schools and hospitals about education and treatment.
• Address the stigma that occurs in the health care setting:
  • Stigma is a barrier to patients and family accessing treatment.
  • Nonjudgmental education about opioids, the crisis, and treatment can decrease stigma from health care providers.

References

Department of Health & Human Services: 5-point Strategy to Combat the Opioid Crisis

Association of American Medical Colleges News: "Responding to the opioid epidemic through education, patient care, and research."

MDedge Psychiatry live Twitter chat on the aftermath of losing a patient to suicide. April 24th, 6 - 7 p.m. EST. @MDedgePsych, #MDedgeChats

Episode 54

Donald Black, MD, gives a masterclass lecture on behavioral addictions and Renee Kohanski talks about what normal is.

Show Notes By Jacquiline Posada, MD.

• Gambling disorder (previously pathological gambling) is widespread, though not commonly assessed
• Patients may not volunteer information related to gambling unless asked, so questions about gambling should be included in routine questioning
• Assessment should include questions about legal and illegal gambling
• • Explore extent: Ask about the level of financial burden; impact on home life, such as marital problems and divorce; legal complications like bankruptcy. Finally, ask about suicide risk related to gambling
• Treatment: There is strong data for SSRI medications and naltrexone for urges
• • Therapy is more efficacious, such as CBT therapy and Gamblers Anonymous
  • In certain states, such as Iowa, a person can ask for "self-exclusion," which is essentially banning oneself from a casino or lottery. Also, participation in gambling results in arrest

Behavioral addictions: Behavior that is out of control and has qualities and consequences similar to drug and alcohol addiction

• Examples include gambling disorder, compulsive buying, compulsive sexual behaviors (hypersexuality), and Internet addiction
• • Gambling disorder is similar enough to substance addictions that it is included in the DSM-5 in the "substance-related and addictive disorder"
  • Addiction neurocircuitry active in these behavioral addictions: Dopamine driven in the nucleus accumbens
• Compulsive shopping: primarily a female disorder, onset in late 20s, with shopping and spending that are chronic and problematic
• • CBT programs developed to target compulsive shopping, studies about medications for this disorder are mixed
• Compulsive sexual behavior: Primarily a male disorder affecting 5% of the population; onset late teens, early 20s. The addiction will combine conventional sexual behaviors taken to extremes often combined with an addiction to pornography
• • This disorder will often overlap with an Internet addiction
  • No evidence-based treatments exist, though CBT-driven models and 12-step programs exist
  • SSRI or TCA antidepressants may be helpful in dampening sex drive
• Internet addiction has developed in our technologically enabled world; most psychiatrists have encountered this addiction.
• • Most data come from Asia, where children are exposed to technology at an even earlier age than in the U.S.
  • China has developed residential treatment programs involving individual and group therapies.

References

• Black DW. Can J Psychiatry. 2013 May;58(5):249-51. "Behavioral addictions as a way to classify behaviors"
• Dell'Osso B et al. Eur Arch Psychiatry Clin Neurosci. 2006 Dec;256(8):464-75. "Epidemiologic and clinical updates on impulse control disorders: a critical review"
• National Council on Problem Gambling. State by state help for problem gambling
• Zajac K et al. Psychol Addict Behav. 2017 Dec;31(8):979-94. "Treatments for Internet gaming disorder and Internet addiction: A systematic review"

In this episode of the MDedge Psychcast, Sidney Zisook, MD, gives a Masterclass lecture on physician suicide and Dr. RK talks about what can be spoken into existence.

If you have ideas, suggestions, questions for Dr. Norris or Dr. RK, or feedback for the show, please email us at [email protected]. You can also follow us on Twitter @MDedgePsych.

Show NotesBy Jacqueline Posada, MD

Introduction

• Suicide in general population increased by 30% since 1999. The suicide rate was 14 people in every 100,000 up from 10.5 people per 100,000 in 1999.
• 400 physicians die per year. However, there is not great data collection about profession-specific suicide
• Suicide is the leading cause of death in male residents and the 2nd leading cause of death in female residents
• This represents a serious loss of the medical profession as well as the thousands of patients who lose their physician as well

Risks factors for physician suicide

Psychological:

• Physicians tend be contentious, perfectionistic, and compulsive. They are able to cope with delayed gratification, and this may lead to a false sense of ability to cope with all obstacles, without failures.
• Medicine presents physicians with many obstacles such as the deaths of our patients and human frailty. Human imperfection and physician failures are juxtaposed against these traits listed above

Historical and genetic risk factors:

• Past suicide attempt and presence of mood disorder
• Untreated depression is an especially high risk for physicians as they may leave their mental illness untreated due to stigma
• As of 2017, 32 of 48 state licensing boards continue to question doctors about their mental health history.
• There is increased risk of suicide with the presence of the long arm version of the serotonin transporter gene and history of childhood trauma

Workplace risk factors:

• Physicians identify electronic medical records (EMR) and increased documentation demands as contributing to burnout and less job satisfaction
• EMR means that doctors feel like they spend more time with records than face to face with patients. With EMR there is less eye contact and direct connection with patients so it's hard to foster relationships
• Physicians feel the stress of increased use of technology and connectivity via cell phones and the need to "keep up"

Change in culture

• As a profession we are starting to talk about physician suicide; acknowledgment of the issue can lead to change.
• ACGME and other workplaces are starting to integrate physician wellness into curriculums and culture.

References:

• NCHS Data Brief No. 330. 2018 Nov."Suicide mortality in the United States, 1999-2017"
• Yaghmour, NA et al. Acad Med. 2017 Jul. 92(7):976-83."Causes of death of residents in ACGME-accredited programs 2000 through 2014" Implications for the learning environment"
• Babbott S et al. J Am Med Inform Assoc. 2014 Feb;21(e1):e100-61. Electronic medical records and physician stress in primary care: Results from the MEMO Study"
• Gold KJ et al.Gen Hosp Psychiatry. 2013 Jan-Feb;35(1):45-9. "Details on suicide among U.S. physicians: Data from the National Violent Death Reporting System"
• ACGME Symposium on Physician Well-Being