Psychcast

Ruth S. Shim, MD, MPH, joins Carol A. Bernstein, MD, to discuss how to understand systemic racism within psychiatric institutions and the implications for patient care.

Dr. Shim is the Luke & Grace Kim Professor in Cultural Psychiatry in the department of psychiatry and behavioral sciences at the University of California, Davis. She 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

• Dr. Shim discusses her editorial published by statnews about why she left the APA, and describes her frustration about what she sees as the APA's failure to prioritize mental health inequity and structural racism within the organization.
• Dr. Shim describes systemic racism and oppression as generational traumas that must be recognized and processed if our professional organizations and country are to move forward with equity. Psychiatry plays a role in healing societal trauma, so psychiatrists need to understand and address the damage of structural racism in our own system.

Summary

• After psychiatry training, Dr. Shim became faculty at Morehouse School of Medicine, one of the few historically Black medical schools. During her clinical work in Atlanta, Dr. Shim noted the difference in health outcomes of inpatients at Emory University Hospital, which treated majority White patients, compared with those of Grady Memorial Hospital, which treated majority Black patients. This observation propelled her research into health disparities, which continues to inform her academic work.
• Dr. Shim's decision to leave the APA occurred during the presidential term of Altha J. Stewart, MD, who, even as the first African American president of the organization, was thwarted in her attempt to push the APA to focus attention and resources on addressing mental health disparities, inequity, and systemic racism within the organization and psychiatry, according to Dr. Shim.
• Dr. Shim observes that systemic racism occurs when the structures of an organization, not individuals, perpetuate the inequity. An example within the APA is the disconnect and power disparity between the group's executive leadership structure and its elected officials. This disconnect and power disparity stymie progressive voices and interventions, Dr. Shim said.
• Addressing systemic racism within an organization is challenging because it may not be considered a problem by all members, and usually the leadership of an organization caters to its majority. As an example, Dr. Shim discussed the APA's systematic attempt to reduce resources and cancel the Mental Health Services Conference (formerly Institute for Psychiatric Services, or IPS meeting), which focuses on health care delivery to the most vulnerable populations. As observed by Dr. Bernstein, the IPS meeting might have incurred financial losses, but investment in such a meeting demonstrated the APA's concern for mental health equity. (The Mental Health Services Conference was not held in 2020 but is scheduled to be held virtually Oct. 7-8, 2021).

References

Shim RS and Vinson SY, eds. Social (In)Justice and Mental Health. Washington, D.C.: American Psychiatric Association Publishing, 2021.

Shim RS. Structural racism is why I'm leaving organized psychiatry. Statnews.com. 2020 Jul 1.

Marmot M et al. Lancet. 2008 Nov 8;372(9650):1661-9.

Okun T. White supremacy culture. Dismantlingracism.org.

APA apologizes for its support of racism in psychiatry. psychiatry.org. 2021 Jan 18.

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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.

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The Beatles aren't the first group to write about sleep and surely won't be the last. In these next two programs, Dr. Kohanski shares some of her pearls, pharmacologic and nonpharmacologic, on those gymnastic, jumping sheep.

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.

David H. Rosmarin, PhD, joins Lorenzo Norris, MD, to discuss how to think about the concept of denial and its role in the sociopolitical challenges of our society.

Dr. Rosmarin is a clinical psychologist and director of the spirituality and mental health program at McLean Hospital in Belmont, Mass. He also is an assistant professor of psychiatry at Harvard Medical School, Boston.

Dr. Rosmarin has no disclosures. Dr. Norris has no disclosures.

Take-home points

• Denial is defined as a cognitive and emotional process by which a person avoids facing aspects of reality, especially when it is difficult to assimilate the details of reality into one's current thinking.
• Arguably, denial is a coping or defense mechanism meant to address the tension that arises from trying to change an individual's current way of thinking and understanding of reality.
• Another form of denial is choosing to focus only on one's perception of reality and struggling to see the other side of an argument. We can see this form of denial play out in COVID-19 pandemic denial and in certain political narratives.
• Denial in its most potent form causes individuals to disconnect from any conversation around the salient topic, which can make denial even worse.

Summary

• Denial can be adaptive in its role of protecting a person's psyche. When the midbrain and limbic system are activated, the frontal lobe needs time to process and integrate the information. For example, people will deny the presence of an event they regret or fear until they have enough emotional capacity to integrate new facts into their current model of reality.
• Yet, denial can be harmful when there are "side effects." The classic example of pathologic denial is an individual who has experienced trauma, and through continued denial of its impact and poor integration of the event, starts to experience somatic symptoms. Dr. Rosmarin says the problem with denial is that people who are experiencing denial are often the last to recognize their need for treatment or an intervention.
• Dr. Rosmarin discusses how, with certain topics, we must value and preserve relationships over persuading certain social contacts, such as family and friends, to overcome their denial. Validating emotions and finding the validity in a person's beliefs and grievances can go a long way toward preserving relationships that are challenged by denial of certain facts.

References

Rosmarin DH et al. Lancet Psychiatry. 2021 Feb;8(2):92-3.

Hall C and Pick D. Hist Workshop J. 2017 Oct;84(1):1-23.

Miller BL. JAMA. 2020 Dec 8;324(22):2255-6.

Rosmarin DH. Spirituality, Religion and Cognitive-Behavioral Therapy: A Guide for Clinicians. New York: Guilford Press, 2018.

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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

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Guest host Eva Ritvo, MD, interviews Dorothy Otnow Lewis, MD, about her more than 40-year career in studying death row inmates as examined in the HBO documentary "Crazy, Not Insane."

Dr. Lewis is clinical professor of psychiatry at Yale University, New Haven, Conn. She has no disclosures.

Dr. Ritvo is a psychiatrist in private practice in Miami Beach, Fla. She has no disclosures.

Take-home points

• Dr. Lewis has an extensive archive of taped interviews with death row inmates that she has used to inform her work as an expert witness.
• While doing her child psychiatry training at the Yale Child Study Center and sitting in at the juvenile court, she began to see that some of the children had psychiatric and neurologic problems that had not been addressed.
• The parents of these children sometimes had psychotic or bipolar disorders. After seeing these themes, Dr. Lewis started a clinic at the court.
• Dr. Lewis and her team were able to study approximately 15 inmates in four states, including Texas and Florida, both of which had the greatest number of condemned juveniles. One key theme that emerged is that all of the inmates had been sentenced to death as juveniles.
• Eventually, the Supreme Court ended the death penalty for convicted killers who committed their crimes before age 18.
• Digging deeper and asking more questions of child and adolescent patients who commit violent acts can help clinicians identify environmental stressors that might underlie behavior that is aggressive and antisocial. In some cases, the psychiatric and neurologic impairments identified are treatable.
• Dr. Lewis would like to study whether identifying child abuse early might prevent future violence.

References

Yaeger CA, Lewis DO. Mental illness, neuropsychologic deficits, child abuse and violence. Child Adolesc Psychiatr Clin N Am. 2009;(4):793-813.

Lewis DO. Ethical Implications of what we know about violence. Child Adolesc Psychiatr Clin N Am. 2000 Oct 9(4):833-91.

Lewis DO et al. Ethics questions raised by the neuropsychiatric, neuropsychological, educational, developmental, and family characteristics of 18 juveniles awaiting execution in Texas. J Am Acad Psychiatry Law. 2004;32(4):408-29.

Griffith EEH et al. Re: Ethics questions raised by characteristics of 18 juveniles awaiting execution in Texas. J Am Acad Psychiatry Law. 2006;34(2):143-4.

Lewis DO et al. Some evidence of race bias in the diagnosis and treatment of the juvenile offender. Am J Orthopsychiatry. 1979 Jan;49(1):53-61.

Lewis DO. Guilty by Reason of Insanity: A Psychiatrist Explores the Minds of Killers. New York: Fawcett Columbine, 1998.

Roper v. Simmons, 543 U.S. 551 (2005).

Thompson v. Oklahoma, 487 U.S. 815 (1988) .

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In this week's installment, Dr. Renee Kohanski explores the identity crisis facing many physicians today.

Clinical Correlation is a bimonthly drop 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.

Regina James, MD, tells her personal story and discusses how to understand health equity with guest host Carol A. Bernstein, MD.

Dr. James is deputy medical director and chief of the division of diversity and health equity at the American Psychiatric Association. She also serves on the advisory board of The PACT group (Pan African Clinical Trials) and receives no income from the group.

Dr. Bernstein, a past president of the APA, 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

• The Robert Wood Johnson Foundation defines health equity as: "Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care." Equity embraces the idea of inclusiveness and evaluates a whole health care system instead of focusing only on individual marginalized communities. For example, it is essential to understand the social determinants that lead to groups being medically underserved and then to understand the impact of the medically underserved on the entire system.
• Dr. James led a 20-year career in research and leadership within the National Institutes of Health, including the National Institute of Mental Health, the National Institute on Minority Health and Health Disparities, and the Eunice Shriver National Institute of Child Health and Human Development. She later transitioned to 2M, a research consulting agency, and then to the APA.
• Within the APA, Dr. James has developed a 5-point strategic plan with the vision that all APA members will be culturally competent and sensitive, and able to provide mental health care for any individual regardless of age, race, gender, or sexual orientation.
• The strategic plan focuses on raising awareness about mental health equity and destigmatization and leveraging the expertise of the APA membership in their communities. A cornerstone of the plan is an educational agenda, including materials on health equity in psychiatry and outreach to APA members and their community partners. In addition, Dr. James and her office partner with APA leadership to lobby the government for mental health equity and inclusion.
• Dr. James describes structural racism as current policies within an organization that lead to racial inequalities. Separate from the Office of Diversity and Health Equity, the APA established a Presidential Task Force to Address Structural Racism Throughout Psychiatry to identify the scope and targets of structural racism within organized psychiatry, including the APA. It also seeks to identify how structural racism affects practicing psychiatrists and their patients.

References

Braveman P et al. What is health equity? Robert Wood Johnson Foundation. 2017 May 1.

American Psychiatric Association. Diversity and health equity.

American Psychiatric Association. Mental health disparities: Diverse populations.

APA Presidential Task Force to Address Structural Racism Throughout Psychiatry. https://www.psychiatry.org/psychiatrists/structural-racism-task-force

Rosenkranz KM et al. J Surg Education. 2020. doi: 10.1016/j.surg.2020.11.013.

Simonsen KA and Shim RS. Psychiatr Clin North Am. 2019 Sep;42(3):463-71.

Alves-Bradford J-M et al. Psychiatr Clin North Am. 2020 Sep;43(3):415-28.

Aggarwal NK et al. Patient Educ Couns. 2016 Feb;99(2):198-209.

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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]

As we begin 2021, Renee Kohanski, MD, muses about the roller coaster journey she and her listeners have been on during the challenging times of 2020.

Clinical Correlation is a bimonthly drop 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.

Bradford L. Frank, MD, MPH, MBA, conducts a Masterclass on how to provide nursing home consultations for psychiatrists. The documents Dr. Frank refers to during this Masterclass are available at (https://bit.ly/3rWqfcK)

Dr. Frank is a board-certified geriatric psychiatrist who provides consultations for more than 30 nursing homes in North Dakota. He has no disclosures.

Take-home points

• Dr. Frank reviews practical information about documentation, prescribing, and diagnoses for psychiatric clinicians who treat individuals living in nursing homes.
• The Centers for Medicare & Medicaid Services has many rules and regulations governing the psychiatric treatment of individuals in nursing homes, including special mental status testing, a policy of gradual dose reduction, and restrictions on how long certain medications can be used.

Documentation

• Even for geriatric patients who live in nursing homes, a full past psychiatric history, including substance abuse and social history, is essential to diagnosis and treatment. To obtain these histories, Dr. Frank sends documents to the nursing home to be completed ahead of time, and then, while he starts to make his differential diagnoses, he talks with the nursing staff about why they want the consultation.
• The Brief Interview for Mental Status (BIMS) is a 15-item mental status exam mandated by the CMS during nursing home evaluations. A score of 13-15 indicates that a patient is cognitively intact, 8-12 indicates moderately impaired, and Patient Health Questionaire–9 and have labs done as they would in a clinic.
• The assessment must also address gradual dose reduction using language from the CMS (see below).

Prescribing and medications

• Gradual dose reduction is a CMS policy defined as "the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued." In collaboration with nursing home staff, prescribers must attempt to taper the doses of psychotropic medications during at least two quarters during the first year of the prescription and at least annually thereafter.
• The Food and Drug Administration has provided a black-box warning for the use of atypical antipsychotics in geriatric patients with dementia, and their use in such patients is audited by the CMS. To avoid censure and low ratings, nursing home clinicians must prescribe antipsychotics only for psychotic symptoms, such as hallucinations and delusions, and not for "dementia" or "agitation."
• As-needed (PRN) antipsychotic medications can only be used for 14 days, and to extend the period another 14 days, the patient must be evaluated in person by the primary prescriber. PRN medications from other drug classes, such as benzodiazepines, can be used for longer without an exam, but their timeline must be specifically documented.
• Psychiatrists are most commonly consulted in nursing homes for agitation, and antipsychotics are not supposed to be used solely for agitation. Dr. Frank recommends citalopram (maximum dose of 20 mg), then escitalopram, Nuedexta (dextromethorphan HBr and quinidine sulfate), and pimavanserin for agitation associated with Alzheimer's disease (AD).

Diagnosis

• Research based on autopsy findings has concluded that mixed etiology dementia is the most common type of dementia. On autopsy, AD is concurrently found with either vascular dementia, as evidenced by cerebral infarcts, or Lewy body dementia. To use cognitive enhancers that are FDA approved only for AD, Dr. Frank will update the diagnosis to multiple etiologies with a severity specifier.
• Frank discusses that nursing homes are reimbursed at a higher rate for the diagnoses of restlessness and agitation (R45.1), noncompliance (Z91.19), and wandering (V40.31), and these are helpful diagnoses because they describe behaviors. Nursing homes use ICD-10 codes to diagnoses dementia with or without behavioral disturbance. For psychosis not attributed to delirium or severe dementia, Dr. Frank uses psychotic disorder with delusions or hallucinations because of a known physiological condition (F06.2 and F06.0). Regulatory agencies recommend against use of the unspecified diagnoses.

References

Center for Clinical Standards and Quality/Survey & Certification Group. Centers for Medicare and Medicaid Services. 2016 Mar 25: 21-5.

Minimum Data Set – Version 3.0. Resident Assessment and Care Screening. Brief Inventory Mental Status exam: 7-8.

Bennett DA et al. Curr Alzheimer Res. 2012 Jul 9(6):646-63.

Yunusa I et al. JAMA Netw Open. 2019;2(3):e190828.

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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.

Three of our favorite masterclasses back-to-back-to-back. The Psychcast will return with new content in 2021.

1. Bulimia nervosa (01:53) Episode 104
2. Telepsychiatry (12:58) Episode 111
3. Cannabis (39:17) Episode 137

Email the show at [email protected]

Richa Bhatia, MD, conducts a Masterclass on how to identify medical and neurologic illnesses that present with psychiatric symptoms and mimic psychiatric diagnoses.

Dr. Bhatia is a board-certified general and child and adolescent psychiatrist in private practice. She has no disclosures.

Take-home points

Psychiatric diagnoses are diagnoses of exclusion. Psychiatric clinicians must maintain a high level of clinical suspicion for medical and neurologic illnesses that present with psychiatric symptoms and mimic psychiatric diagnoses. When patients have a "strange" presentation of their psychiatric illness, including being out of the usual age range, a fast progression, or an unusual constellation of symptoms, clinicians should pursue a medical work-up and think broadly about other diagnoses that might mimic the psychiatric diagnosis.

Dr. Bhatia provides an overview of common medical and neurologic illnesses that mimic psychiatric diagnoses, including hypothyroidism, delirium, HIV/AIDS, Addison disease, autoimmune encephalitis, temporal lobe epilepsy, frontotemporal dementia, Wilson's disease, and Parkinson's disease.

Summary

Hypothyroidism is an endocrine disease that can mimic depression. The physical symptoms include constipation, edema, dry skin, hair loss, weight gain, and cold intolerance. Individuals with comorbid hypothyroidism and depression report inadequate response to antidepressants, so psychiatrists should check the patient's thyroid-stimulating hormone or refer them to their primary care physician if they suspect hypothyroidism with elevated TSH.

Delirium is a common yet underdiagnosed syndrome that occurs secondary to medical illness and can produce an array of neuropsychiatric symptoms, including psychosis, irritability, and disorganized behaviors, which can lead to misdiagnosis as schizophrenia or mania. Delirium presents as an abrupt change in cognition with disorientation and significantly impaired attention. Hypoactive delirium presents with lethargy, apathy, and decreased alertness, and is often mistaken for depression in the hospital setting. Simple beside tests such as the Confusion Assessment Method can be used to quickly aid in diagnosing delirium.

HIV/AIDS can mimic psychiatric disease through direct effect on the nervous system, opportunistic disease, intracranial tumors, cerebral vascular disease, and medication adverse effects. HIV can mimic depression by causing neurovegetative symptoms; apathy, psychomotor slowing, and working memory deficits are more characteristic of the neuropsychiatric impairment from HIV rather than a primary depressive disorder. In late-stage HIV/AIDS, dementia can cause bizarre behaviors, delusions, and mood disturbance such as euphoria and irritability.

Addison disease is characterized by low blood pressure, hyperpigmentation, nausea, vomiting, weakness, fatigue, hypokalemia, and hyponatremia. Addisonian crisis can present with neuropsychiatric symptoms of delirium, anxiety, agitation, cognitive impairment, and auditory and visual hallucinations.

Autoimmune encephalitis, with anti–N-methyl-D-aspartate receptor encephalitis as the most common type, often masquerades as a primary psychotic symptom. Notable symptoms include subacute onset with fast progression and no clear prodrome, working memory impairment, agitation, or lethargy. Other presenting symptoms include focal neurologic deficits, new-onset or rapidly developing catatonia, fever, headaches, flu-like illness, and autonomic disturbance.

Temporal lobe epilepsy also can mimic a primary psychiatric disorder. The symptoms of seizure-like staring, blinking, lip-smacking, and behavioral arrest are precipitated by a sensation of fear or epigastric sensation and depersonalization, which can lead to misdiagnosis as a panic attack.

Frontotemporal dementia (FTD) can be mistaken for a primary psychiatric diagnosis in the initial stages. Hallmark symptoms include progressive behavioral change with disinhibition and a decline in executive functioning and language skills such as verbal learning and reasoning. FTD is the second most common dementia in people aged younger than 65 years. Patients with FTD struggle to give a history, and often lack a psychiatric history or exposure to psychotropic drugs. Clinicians should maintain a high degree of clinical suspicion for FTD in new-onset psychiatric syndromes in older individuals.

Stroke can lead to poststroke depression and anxiety, apathy, emotional lability, and personality changes. Depression after stroke, occurring hours to days after the insult, is associated with greater cognitive impairment and increased mortality. The diagnosis of poststroke depression is challenging because of impairments in language and cognition after stroke. Apathy can occur separately from depression and diminish recovery.

Wilson's disease results in copper deposits in the brain and liver. The psychiatric symptoms, including psychosis, occur before neurologic changes. Parkinson's disease also can result in depression-like symptoms, given the motor and neurovegetative symptoms from the neurodegeneration. Fatigue, psychomotor slowing with diminished facial expression, postural changes, and sleep disturbance are common conditions that can mimic depression.

References

Carroll VK. Current Psychiatry. 2009 Aug;8(8):43-54.

Welch KA and Carson AJ. Clin Med (Lond). 2018 Feb;18(1):80-7.

Scarioni M et al. Ann Neurol. 2020;87(6):950-61.

Evans DL et al. Neuropsychiatric manifestations of HIV-1 infection and AIDS, in "Neuropsychopharmacology: 5th Generation of Progress." Philadelphia: Lippincott Williams & Wilkins, 2002, pp. 1281-99.

Deng P and Yeshokumar A. Psychiatric Times. 2020 Jan. (37):1.

Kumar A and Sharma S. Complex partial seizure, in "StatPearls [Internet]." Treasure Island, Fla.: StatPearls Publishing, 2020 Jan. (Updated 2020 Nov 20).

Rao V. Neuropsychiatry of stroke. Geriatric Workforce Program. Johns Hopkins Medicine.

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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]