Psychcast

Brian Holoyda, MD, MPH, MBA, conducts a Masterclass on the history of psychedelic research and how the renaissance of this drug class could affect psychiatric patients.

Dr. Holoyda, a forensic psychiatrist, practices in the San Francisco Bay Area. He also provides psychiatric consultations across the country. Dr. Holoyda has no disclosures.

Take-home points

• The effects of psychedelics are dose dependent and difficult to predict. The impact of psychedelic treatment on violent behaviors was studied since the 1960s with varying results. More recent studies suggest that psychedelic use (excluding phencyclidine, or PCP) is associated with less violent crime.
• Dr. Holoyda recommends that, before psychiatrists treat patients with psychedelic-assisted psychotherapy, patients should be screened for history of violence or aggression while using psychedelics (and in general) and a history of serious mental illness. Patients require informed consent about the risk of violence and interventions used to control aggressive behaviors.

Summary

• In 1960, the Harvard Psilocybin Project included a study in the Concord (Mass.) Prison in which researchers hypothesized that using psychedelic-assisted psychotherapy in prisoners would reduce risk of violent recidivism. The original authors, including Timothy Leary, PhD, published varying results of the study – including that psychedelic use reduced recidivism. However, some argue the overly positive results from the first analysis were attributable to a halo effect. A recent reanalysis showed that the base rate for recidivism in the intervention group was 34%, and not significantly different from that of the control group.
• Psychiatrists have continued to use psychedelic-assisted therapy for patients with psychopathology and treatment-resistant sexual offenders to investigate whether the transcendent experiences can change their personalities, including the development of insight and empathy.
• Dr. Holoyda published a review of all published cases in medical literature discussing psychedelic use and violent behavior. Most of the cases were published in the 1960s-1970s, when psychedelics were viewed negatively as a product of the counterculture era.
• More recent observational studies identified that psychedelics use is associated with a greater likelihood of carrying a firearm as well as intimate partner violence, but these newer studies are fraught, because PCP is sometimes classified as a psychedelic. Other epidemiological studies have identified reductions in violent behaviors associated with psychedelics use, compared with other illicit substances. Those reductions in violent behaviors include a lower probability of supervision failure, and a lower risk of intimate partner violence and drug distribution.
• Peter S. Hendricks, PhD, and associates analyzed data from 225 million individuals who took the National Survey on Drug Use and Health from 2002 to 2014 with a focus on psychedelics use, excluding PCP. They found that a lifetime history of psychedelic use decreased the odds of theft, assault, and arrest for property and violent crime. Studies such as this suggest that individuals who favor psychedelics may be less prone to violent crime rather than a direct effect of psychedelics on decreasing violent crime.
• As psychedelics enter the clinical sphere, clinicians must keep in mind that experiences on these agents are unpredictable. In a study of unmonitored psychedelic use, individuals report putting themselves or others at risk. Others reported behaving aggressively or violently, and others sought help at a hospital.
• Before using psychedelics in a therapeutic environment, clinicians should assess patients' past use and experience on psychedelics. They also should screen for history of "bad trips," leading to aggression, agitation, paranoia, and risky behaviors. In clinical trials with psychedelics, individuals with history of bipolar and psychotic disorders have been excluded to reduce the risk of triggering an episode. For medicolegal protection, psychiatrists should engage in a thorough informed consent process before using psychedelic-assisted therapy.

References

Holoyda B. Psychiatric Serv. 2020;71(12): 1297-99.

Holoyda B. J Am Acad Psychiatry Law. 2020 Mar;48(1):87-97.

Hendricks PS et al. J Psychopharmacol. 2017 Oct 17. doi: 10.1177/0269881117735685.

Carbonaro TM et al. J Psychopharmacol. 2016;30(12):1268-78.

Metzner R. Reflections on the Concord prison project and the follow-up study. Bulletin of the Multidisciplinary Association for Psychedelic Studies/MAPS. Winter 1999/2000. 9(4).

Arendsen-Hein GW. LSD in the treatment of criminal psychopaths, in "Hallucinogenic Drugs and Their Psychotherapeutic Use." (London: H. K. Lewis & Co, 1963).

Leary T. Psyched Rev. 1969; 10:20-44.

Leary T and Metzner R. Brit J Soc Psychiatry. 1968;2:27-51.

Leary T et al. Psychother. 1965;2:61-72.

Doblin R. J Psychoactive Drugs. 1998; 30:419-26.

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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

Email the show: [email protected]

Dost Öngür, MD, PhD, joins host Lorenzo Norris, MD, to discuss the emerging mental health effects of the pandemic.

Dr. Öngür is chief of the Center of Excellence in Psychotic Disorders at McLean Hospital in Belmont, Mass. He also serves as the William P. and Henry B. Test Professor of Psychiatry at Harvard Medical School, Boston. Dr. Öngür has no disclosures.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.

Take-home points

• Without a doubt, the COVID-19 pandemic will have a lasting mental health impact on society.
• Öngür discusses the role of trauma, grief, mourning, and social isolation during the pandemic.

Summary

• One emerging mental health effect of the pandemic is lasting psychiatric symptoms after infection and inflammatory response, including anxiety, depression, insomnia, and fatigue.
• Many individuals have lost loved ones or witnessed someone close to them experience severe illness and prolonged hospitalizations.
• Early in the pandemic, in a 2020 Centers for Disease Control and Prevention representative survey, 30% of Americans reported symptoms of depression and anxiety, 13% reported increased substance use, and 11% thought about suicide.
• Individuals report greater distress, substance use, and suicidal ideation in the United States, but deaths from suicide did not increase dramatically, compared with 2019. A recent study in JAMA Psychiatry noted, however, that emergency department visits for social and mental health emergencies such as suicide attempts, overdoses, and intimate partner violence were higher in mid-March through October 2020 during the COVID-19 pandemic, compared with the same period a year earlier.
• One possible resilience factor for individuals with mental illness may be the protective nature of family ties. Though the shutdown led to social isolation and detachment from some networks, certain individuals came to rely more on nuclear relationships, such as family.
• With the pandemic, mental illness and mental health treatment have entered the public consciousness and conversation more than ever before. After the pandemic, more people will need mental health services as the social effects continue to ripple for years to come.

References

Czeisler ME et al. Mental health, substance use, suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1049-1057.

Faust JS et al. Suicide deaths during the COVID-19 stay-at-home advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021 Jan 21;4(1):e2034273.

John A et al. Trends in suicide during the COVID-19 pandemic. BMJ. 2020;371:m452.

Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. Nat Hum Behav. 2021 Jan 15;5:229-38.

Holland KM et al. Trends in U.S. emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. 2020 Feb 3. doi: 10.1001/jamapsychiatry.2020.4402.

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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

Email the show: [email protected]

In this week's installment of Clinical Correlation, Renee Kohanski, MD, offers some of her treasured nonpharmacologic pearls and discusses the power in practicing what we preach while forgiving our own human foibles.

Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at [email protected], and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Pete Simi, PhD, joins host Lorenzo Norris, MD, to discuss some of the factors that lead people to join hate groups, and strategies that have enabled some to leave the life of extremism behind.

Dr. Simi, associate professor of sociology at Chapman University in Orange, Calif., has studied extremist groups and violence for more than 20 years. His research has received external funding from the National Institute of Justice, the Department of Homeland Security, the Department of Defense, the National Science Foundation, and the Harry F. Guggenheim Foundation.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. Dr. Norris has no disclosures.

Take-home points

• Dr. Simi discusses how many of the White supremacists he studied live mundane, ordinary lives organized around extremist, violent beliefs. These individuals may be socialized in early life through exposure to beliefs consistent with White supremacy, such as racist ideas, slurs, and jokes, but they are not usually raised within a White supremacist family.
• The biggest challenge of leaving White supremacy is finding a new overarching identity, which ultimately requires redefining one's emotional habits when it comes to engaging with society. White supremacist programming not only includes hateful beliefs but an emotional orientation that influences how an individual interprets the world around them.
• White supremacist violence and terrorism have long been a U.S. problem, and Dr. Simi said his awareness of the problem grew after the Oklahoma City bombing in 1995. Dr. Simi hopes that, through research and initiatives, the United States will address the root causes of White supremacist beliefs rather than focus on specific groups.

Summary

• Dr. Simi first started studying White supremacists by evaluating their engagement on early Internet forums. Eventually, he made contact with a group that allowed him to observe their daily lives, including staying in their homes and attending collective events, such as music festivals. More recently, he has been evaluating and researching individuals who leave the White supremacist movement.
• As with many individuals who find solace in extremist groups, the childhood and adolescence of those who become White supremacists usually contain adverse childhood experiences and instability, such as physical and emotional abuse, and substance use in the home. These events cultivate vulnerability to White supremacy, because these adolescents and young adults are searching for a stabilizing force.
• In the Internet age, it's much easier for vulnerable individuals to have chance encounters with extremist groups and beliefs, and even brief exposures are an opportunity for some to be recruited into White supremacist groups. A selling point of White supremacy is the sense of "fellowship" and "family," which is attractive for individuals who feel disillusioned and isolated from society at large.
• In Dr. Simi's research, half of his sample participants of White supremacists reported mental health diagnoses and similarly high rates of suicidal ideation. Mental illness is not an excuse for the behaviors and beliefs, but an example of another vulnerability that makes these individuals susceptible to strong support groups that often hold extremist beliefs.

References

Simi P et al. Am Sociol Rev. 2017 Aug 29. doi: 10.1177/00031224177282719.

Bubolz BF and Simi P. Am Behav Sci. 2019. doi: 10.1177/0002764219831746.

Simi P et al. J Res Crime Delinquency. 2016. doi: 10.1177/002242781567312.

Windisch S et al. Terrorism Polit Violence. 2020. doi: 10.1080/09546553.2020.1767604.

Ask a researcher: Pete Simi. What domestic groups pose the largest threats? University of Nebraska, Omaha. 2021 Jan 14. National Counterterrorism Innovation, Technology, and Education Center. A U.S. Department of Homeland Security Center of Excellence.

McDonald-Gibson C. 'Right now, people are pretty fragile.' How coronavirus creates the perfect breeding ground for online extremism. Time. 2020 Mar 26.

Garcia-Navarro L. Masculinity and U.S. extremism: What makes young men vulnerable to toxic ideologies. NPR. 2019 Jan 27.

Life After Hate. Larry King Now. 2019 Jan 23.

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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

Email the show: [email protected]

Frank Chen, MD, joins host Lorenzo Norris, MD, to discuss the impact of the COVID-19 pandemic on patients with schizophrenia.

Dr. Chen is the chief medical director for Houston Behavioral Healthcare Hospital and Houston Adult Psychiatry. He is a speaker for Alkermes and Otsuka. Dr. Chen has served on advisory boards for Alkermes, Intracellular Therapies, Otsuka, and Teva Pharmaceuticals.

Dr. Norris is associate dean of student affairs and administration at George Washington University. He has no disclosures.

Take-home points

• Schizophrenia is associated with an increased risk of death from COVID-19, even when controlling for other medical comorbidities.
• Individuals with schizophrenia have many biological and situational risk factors for COVID-19, including an elevated risk of metabolic syndrome from antipsychotic medications, higher rates of nicotine addiction, a greater likelihood of living in a group setting, limited access to medical care, and the underlying inflammatory state of schizophrenia.

Summary

• An article published in JAMA Psychiatry in January 2021 evaluated a large cohort of patients in a New York health system and identified schizophrenia as the second most highly associated risk factor for 45-day mortality from COVID-19, after the risk factor of advanced age.
• The study controlled for other medical comorbidities to avoid confounding the results. However, it is essential to remember that individuals with schizophrenia have environmental and biological factors that increase their risk of infection and complications from COVID-19, such as metabolic syndrome, cigarette smoking, limited access to health care, and living in a group or institutional setting.
• Dr. Chen points out that many patients with schizophrenia already have skills to adapt to the stresses of the pandemic. For example, individuals with schizophrenia might already be accustomed to living with a certain level of fear and uncertainty inherent to their thought disorder. He also comments that negative symptoms make social distancing easier for individuals with schizophrenia than for other people.
• Dr. Chen notes that telepsychiatry has been a boon to treating individuals with schizophrenia, because using this tool is almost like making a "home visit." Telemedicine removes the barriers to care, such as transport and resistance to coming to the office.
• Adaptation to telepsychiatry has varied among different patient populations. Dr. Chen says some of his "higher functioning" patients with more controlled and stable lives did not want to see their clinician via video. They preferred the "secure" and more private setting of an office.
• Ultimately, psychological flexibility and ability to adapt influence the amount of stress people experience during crisis.

References

Nemani K et al. JAMA Psychiatry. 2021 Jan 27. doi: 10.1001/jamapsychiatry. 2020.4442.

Mazereel V et al. Lancet. 2021 Feb 3. doi: 10.1016/S2215-0366(2)30564-2.

Muruganandam P et al. Psychiatry Res. 2020 Jun 29. doi: 101016/j.psychres.2020.113265.

Kozloff N et al. Schizophr Bull. 2020 Jul;46(4):752-7.

Smith BM et al. J Contextual Behav Sci. 2020 Oct;18:162-74.

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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

Email the show: [email protected]

We are still experiencing the direct hit in addition to the aftermath of the SARS-CoV-2 coronavirus, especially its devastating psychiatric impact. It's always darkest before dawn, isn't it? Let's lighten the path, shall we, in episode 12 of Clinical Correlation.

Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at [email protected], and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

John Koo, MD, and Scott A. Norton, MD, MPH, join host Lorenzo Norris, MD, for this special edition of the Psychcast. This is a crossover episode with our sister podcast, Dermatology Weekly.

Dr. Koo is a psychiatrist and a dermatologist at the University of California, San Francisco. He has no disclosures. Dr. Norton is a dermatologist with the Uniformed Services University of the Health Sciences in Bethesda, Md., and with George Washington University, Washington. He has no disclosures.

They are featured in an article on this topic online at MDedge.com/Psychiatry.

Dr. Norris is associate dean of student affairs and administration at George Washington University. He has no disclosures.

Take-home points

• Delusional infestation or delusions of infestation, also known as delusional parasitosis, is a fixed false belief that one has an infestation of animate or inanimate pathogens, despite strong evidence against infestation. Common precipitants of delusional infestation include previous exposure to external or internal parasites, stress, and travel. The condition is more common among highly functional older women.
• A recent study estimated the prevalence of delusional infestation as 1.9/100,000, though the condition is an area of limited study. Delusional infestation is poorly recognized by physicians, therapists, and families, which leads patients to search for an external cause of the symptoms and contributes to distress for patients and their loved ones.
• Patients with delusional parasitosis often lack insight into their disease, and it can be difficult to persuade them to take the recommended treatment of antipsychotics.
• Low-dose pimozide, a first-generation antipsychotic, is the most common treatment for delusional infestation, particularly because it does not have Food and Drug Administration approval as a treatment for psychosis. Therefore, patients are less biased against taking this medication.

Summary

• Delusions of infestation are a monosymptomatic hypochondriacal psychosis in which the only delusion present is one of infestation, and patients do not have other symptoms of psychotic spectrum illness. Secondary delusions of infestation may occur in individuals who use drugs, such as methamphetamine or cocaine, or who have a primary psychotic disorder, such as schizophrenia.
• Delusions of infestation is related to Morgellons disease, which is defined as a skin condition characterized by the presence of "threads" or filaments that patients believe are embedded in their skin and might be accompanied by stinging and itching sensations.
• Patients with delusions of infestation usually present to a primary care physician or ED with symptoms of abnormal sensations of their skin, including crawling sensations. In addition, patients usually bring personal proof of their condition, such as a small bag of "specimens," including pieces of lint, threads, or scabs. Some patients also bring in journals detailing the timing and associated factors of their symptoms.
• Dr. Norton advises that physicians treating the patients with delusions of infestation should mentally prepare themselves against initial bias and set aside time for longer visits or several follow-up visits. Dr. Norton starts with the premise that the patient has an actual infestation or other underlying cause of their pruritus and performs a thorough, full-body exam for dermatologic conditions, and examines the materials patients bring with them using a double-headed microscope – so that he and the patient can look at the specimens together.
• Dr. Koo often tells patients that they have Morgellons disease because it does not include the stigmatizing term of "delusional." He reframes Morgellons as an infestation that cannot be cured by internal or external antiparasitic medications. He then pivots away from etiology to validation of their emotions and eventually to treatment.
• Dr. Koo usually often starts treatment with pimozide because it is an antipsychotic with FDA approval for Tourette syndrome – not schizophrenia. This perceived absence of a connection of the medication to psychiatric illness allows patients to be more open to taking the medication.
• For primary delusional infestation, Dr. Koo starts with pimozide. The dose, which is daily and taken orally, starts low at 0.5 mg and goes up by 0.5 mg every 2-4 weeks. The aim is to get up to 3 mg per day. Low doses of pimozide and other antipsychotics lead to decreased sensation of itching and formication. Dr. Koo refers to his treatment plan as a "trapezoid-like dosage strategy." Once he gets the patient to 3 mg, he continues the medication until all the symptoms disappear and then continues the medication for an additional 3 months. Dr. Koo then slowly tapers the dosage over an additional few months.
• The keys to successful treatment include communicating with patients and working collaboratively with them. This approach builds trust and rapport.

References

Brown GE et al. J Clin Exp Dermatol Res. 2014;5:6. doi: 10.4172/2155-9554.1000241.

Kohorst JJ et al. JAMA Dermatol. 2018 May 1;154(5):615-7.

Lepping P et al. J Am Acad Dermatol. 2017 Oct;77(4):778-9.

Middelveen MJ et al. Clin Cosmet Investig Dermatol. 2018;11:71-90.

Lepping P et al. Acta Derm Venereol. 2020 Sep 16. doi: 10.2340/00015555-3625.

Freudenmann RW et al. Br J Dermatol. 2012 Aug;167(2):247-51.

Wolf RC et al. Neuropsychobiology. 2020;79:335-44.

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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

Email the show: [email protected]

George T. Grossberg, MD, conducts a Masterclass examining emerging treatment options for Alzheimer's disease that are tied to the new research on the microbiome.

Dr. Grossberg is the Samuel W. Fordyce professor and director of geriatric psychiatry in the department of psychiatry and behavioral neuroscience at Saint Louis University.

He disclosed that he is a consultant for Acadia, Alkahest, Avanir, Axovant, Axsome Therapeutics, Biogen, BioXcel, Genentech, Karuna, Lundbeck, Novartis, Otsuka, Roche, and Takeda; receives research support from the National Institute on Aging, Janssen, and Genentech/Roche; performs safety monitoring for ANAVEX, EryDel, Intra-Cellular Therapies, Merck, and Newron; and serves on the data monitoring committee of ITI Therapeutics. Dr. Grossberg also serves on the speakers' bureau of Acadia.

Take-home points

• Dr. Grossberg discusses burgeoning research about treatment of Alzheimer's disease (AD) by altering the microbiota using diet and medications.
• The microbiome refers to the entirety of microorganisms that live throughout the body. Microbiota are those organisms that live within the gut. Dysbiosis refers to a microbial imbalance, which has been linked to numerous disorders, including inflammatory diseases, psychiatric illness, obesity, diabetes, and more recently, AD.
• The gut-brain axis describes the impact of microbiota and GI tract health on the brain. Periodontal disease, as a marker of inflammation and as part of the microbiome, is linked to AD.
• Increasing research into the role of the microbiome, inflammation, and AD has revealed promising treatments. Sodium oligomannate, a drug approved for mild to moderate AD in China, has been shown to slow the progression of AD by remodeling the microbiota and suppressing the production of specific amino acids that promote neuroinflammation.

Summary

• The microbiota has many purposes, including digestion, communication with the immune system, generation of signaling peptides, refining vitamins, and producing antioxidants. Many factors influence the microbiome, including diet, use of antibiotics, exposure to breast milk as an infant, stress, and old age.
• The gut microbiota can be altered by consuming "prebiotics," which are food sources that influence the composition of the microbiota. These foods include fermented foods such as yogurt, kombucha, sauerkraut, and kimchi. The Mediterranean diet also has good sources of prebiotics.
• Birthing method (C-section versus vaginal birth) also influences the microbiota; a recent study shows that an infant's microbiota after C-section can be altered by giving them an early fecal transplantation from the mother.
• As further proof of the link between periodontal disease and AD, a recent study identified the presence of Porphyromonas gingivalis, a bacteria that causes gum disease, in the brain in close proximity to the tau tangles of AD. Gingipain, the toxin secreted by this bacteria, is found in high concentrations in brains of individuals with AD.
• Dr. Grossberg reviewed his "recipe" for AD prevention and treatment:
• Recommend adequate activity in four spheres: Physical, mental, social, and spiritual.
• Treat and control all cardiovascular risk factors, including smoking, obesity, diabetes, hypertension, and hyperlipidemia.
• Recommend good oral hygiene based on the increasing research about the link of periodontal disease and AD.
• Recommend dietary changes, including a prebiotic or probiotic, and the Mediterranean diet. Dietary changes may also include supplements such as curcumin, B-complex multivitamin, and vitamin E.
• Control exposure to air pollution as possible.
• Use a combination pharmacotherapy of an N-methyl-D-aspartate antagonist and a cholinesterase inhibitor for individuals with AD.

References

Jones ML et al. Gut Microbes. 2014 Jul 1;5(4):446-57.

Askarova S et al. Front Cell Infect Microbiol. 2020;10:104.

Beydoun MA et al. J Alzheimers Dis. 2020;75(1):157-72.

Wang X et al. Cell Res. 2019 Oct;29(10):787-803.

Korpela K et al. Cell. 2020 Oct 15;183(2):324-34.

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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

Email the show: [email protected]

In episode 11 of Clinical Correlation, Dr. Kohanski offers more pearls to approaching that seemingly innocent chief complaint of insomnia. She welcomes listener commentary as always.

Clinical Correlation is published every other Monday on the Psychcast feed. You can email the show at [email protected], and you can learn more about MDedge Psychiatry here: https://www.mdedge.com/podcasts/psychcast.

Rebecca W. Brendel, MD, JD, and Allen R. Dyer, MD, PhD, join guest host Carol A. Bernstein, MD, to discuss the ethical challenges that have been occurring during the COVID-19 pandemic.

Dr. Brendel is director of law and ethics at the Center for Law, Brain, and Behavior at Massachusetts General Hospital, Boston. She also serves as director of the master of bioethics degree program at Harvard Medical School, Boston. Dr. Brendel has no disclosures.

Dr. Dyer is professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as vice chair for education at the school of medicine and health sciences. Dr. Dyer has no disclosures.

Dr. Bernstein, a past president of the American Psychiatric Association, is vice chair for faculty development and well-being at Montefiore Medical Center/Albert Einstein College of Medicine, New York. She has no disclosures.

Take-home points

• Medical ethics often deal with decisions between doctors and patients, but during the COVID-19 pandemic, the medical community has been forced to reckon with ethics on a population scale. Examples of ethical challenges include issues of scarcity, justice, transparency, and navigating distrust of the medical system.
• In the beginning of the pandemic, individuals such as Dr. Brendel and Dr. Dyer participated in ethical planning so that hospital systems would be prepared to deal with scarcity of resources that could result in some individuals going without lifesaving interventions. During times of scarcity, transparency and accountability are necessary, because the community will ask questions about the fairness and justice of specific outcomes.
• The philosophy of utilitarianism is a reason-based decision-making model that strives to maximize the greatest good for the greatest number, and it has been commonly used as a template for ethical discussions during the pandemic. Yet, utilitarianism calculus is complicated by questions of how to define "good" and the challenge of accurately predicting the outcomes.

Summary

• In situations of urgency, demand, and scarcity, ethics usually turns to utilitarianism with the intention of maximizing the greatest good for the greatest number. Inevitably, people or populations are harmed. Especially in the beginning of the COVID-19 pandemic, American society grappled with the issue of scarcity and allocation of medical resources, ranging from personal protective equipment, ventilators, medical staff, ICU space, and the vaccine.
• Now we must think about the ethical decisions influencing COVID-19 vaccination, including weighing the risks and benefits of who gets the vaccine and when – and how certain vaccine schedules forestall the spread in the population. For example, institutionalized individuals are at great risk of contracting COVID-19, yet society debates the "good" of vaccinating elderly in nursing homes versus incarcerated individuals. Question of defining good and grappling with the consequences are present throughout the entire vaccination algorithm. Communities contend with the question of who in their ranks are essential workers: Health care workers? Teachers? Restaurant staff? Factory workers?
• Justice and transparency are commonly discussed ethical principles, especially when we think about the algorithms created to allocate resources. Transparency is required to foster trust in the public health system, and actors within the system must demonstrate their accountability through being honest about the evidence behind policy decisions, following set parameters, and acknowledging historical reasons for distrust.
• The pandemic has pushed society to think about the ethics of community solidarity and reflect on governmental and individual responsibility of protecting the health and well-being of the community. As the pandemic ravaged the U.S. economy and further disadvantaged already vulnerable communities, we must use this opportunity to reexamine the ethics of how health care is distributed in the United States, and work toward a just and equitable system.

References

Ethics and COVID10: Resource allocation and priority-setting. 2020 World Health Organization.

AMA Journal of Ethics. COVID-19 Ethics Resource Center.

Emanuel EJ et al. N Engl J Med. 2020 May 21. doi: 10.1056/NEJMsb2005114.

Dyer AR and Khin EK. Int Encycl Soc Behav Sci. 2015;63-70.

The principles of medical ethics with annotations especially applicable to psychiatry, 2013 edition. American Psychiatric Association.

American Psychiatric Association. Ethics.psychiatry.org.

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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

Email the show: [email protected]