Psychcast

In this week's installment of Clinical Correlation, Dr. Renee Kohanski reminds listeners of our inherent desire to help one another and problem solve while cautioning against those who would place our most vulnerable populations at risk.

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.

Eliza W. Menninger, MD, spoke with Psychcast host Lorenzo Norris, MD, about how to help patients deal with anxiety related to the COVID-19 pandemic.

Dr. Menninger is medical director of the behavioral health partial hospital program at McLean Hospital in Belmont, Mass. She treats patients with major depression, bipolar disorder, schizophrenia, and schizoaffective disorder. Dr. Menninger also treats patients in McLean's Schizophrenia and Bipolar Disorder Outpatient Clinic. She has no disclosures.

Dr. Norris has no disclosures.

Take-home points

• Anxiety related to stress, fear, worry, and grief has spiked in all phases of the pandemic. Initially, we faced uncertainty not knowing how to adapt to restrictions, and we assumed that the adaptations would be short term. Six months into the pandemic, we've moved into questions about maintaining these adaptive processes over the long term.
• As the medical director of a partial hospitalization program, Dr. Menninger created an acronym, "MASK," to help people cope with the stress of the pandemic.
• MASK stands for Make boundaries, Avoid the virus, Stay connected, Keep the faith.

Summary

• Making boundaries refers to encouraging people to use similar behaviors from their past routines to maintain normalcy. For example, for people who work from home, Dr. Menninger suggests getting dressed and ready for work as though you're actually going, and taking breaks from screens to reduce virtual platform fatigue. People are feeling socially and physically restricted by the pandemic, and she emphasizes going outside regularly. Boundaries that help delineate physical spaces and emotional responsibilities can alleviate the physical and mental clutter that compounds stress.
• Avoiding the virus is a constant chore, so Dr. Menninger came up with a humorous song aimed at helping her patients remember their role in avoiding exposure to the coronavirus.
• Staying connected means focusing on the social connection and feeling the presence of the other person instead of just sensing the temporary connection provided through the virtual platform. Dr. Menninger suggests imagining that the person with whom you're connecting is in the room with you. Self-care through maintaining routines; exercising; maintaining healthy nutrition; seeking out humor; and enjoying art, music, and other stimuli helps people connect with themselves and others.
• Keeping the faith means remembering that the pandemic will end, and we have the tools to build resilience in ourselves and patients. Dr. Menninger finds hope in the way her clinical staff has been creative to make a difference in the patients' life amid the constant changes. She and Dr. Norris cite examples of patients using creativity to overcome overwhelming life circumstances, build on their strengths, and reframe the pandemic to find the silver lining.

Reference

Marcus PH et al. Current Psychiatry. 2020 Dec;19(12):28-33.

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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

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Oliver Freudenreich, MD, talks with Lorenzo Norris, MD, about principles of pandemic management among patients with serious mental illness.

Dr. Freudenreich reported receiving grant or research support from Alkermes, Avanir, Janssen, and Otsuka. He has served as a consultant to the American Psychiatric Association, Alkermes, Janssen, Neurocrine, Novartis, and Roche.

Dr. Norris has no disclosures.

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In this week's installment of Clinical Correlation, Dr. Renee Kohanski tackles the very difficult and painful realities of a postelection country.

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.

This week, we revisit four shows that offer guidance to clinicians for addressing the mental health fallout from COVID-19.

Lisa W. Coyne, PhD, founder of the McLean OCD Institute for Children and Adolescents in Belmont, Mass., focuses on helping children and adolescents with anxiety and obsessive-compulsive disorder. She disclosed receiving royalties from New Harbinger and Little Brown Publishing.

Christine Moutier, MD, describes interventions that can prevent patients from ending their lives by suicide. She is chief medical officer of the American Foundation for Suicide Prevention. Dr. Moutier reported no disclosures.

Sanjay Gupta, MD, offers a Masterclass on how to determine which medication works best for geriatric patients with symptoms of dementia. Dr. Gupta, chief medical officer at BryLin Hospital in Buffalo, N.Y., disclosed serving on the speakers' bureaus of AbbVie, Acadia, Alkermes, Intra-Cellular Therapies, Janssen, and Otsuka.

Peter Yellowlees, MBBS, MD, wraps up the podcast with perspective about permanent changes that could be in the offing to the practice of psychiatry because of the pandemic. He is a professor of psychiatry at the University of California, Davis. Dr. Yellowlees has no disclosures.

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Diana M. Martinez, MD, conducts a Masterclass on marijuana's effects on psychiatric disorders.

Dr. Martinez, a professor of psychiatry at Columbia University, New York, specializes in addiction research. She disclosed receiving medication (cannabis) from Tilray for one study and has no other financial relationships with this company.

Take-home points

• The use of cannabis, recreationally and medically, has been a controversial topic for ages, and the classification of cannabis as a schedule I controlled substance has made it all the more difficult to research and meaningfully understand its harms and benefits.
• Based on information from the National Academies of Sciences publication Health Effects of Marijuana: An Evidence Review and Research Agenda, Dr. Martinez presents a sweeping overview of the role of cannabis in two domains: Its ability to worsen psychiatric symptoms, and its role in causing psychiatric disorders.
• The cannabis plant has 100 cannabinoids. The two most commonly studied are tetrahydrocannabinol (THC), which creates the "high," and cannabidiol (CBD), which does not create a high and has many subjective effects.
• Cannabis is researched and used in several forms, including the smoked plant or flower form, and prescription cannabinoids based on THC – namely dronabinol (Marinol), nabilone (Cesamet), and CBD.
• Research suggests that both benefits and risks are tied to using cannabis and cannabinoids.
• Clinicians should have rational discussions with their patients about the use of cannabis. If patients are no longer responding to psychiatric treatment, and the clinician wants to talk about their cannabis use, it is important to understand the common reasons patients use cannabis, including for chronic pain, anxiety, and insomnia.

Benefits

• There is substantial evidence supporting the use of cannabis and cannabinoids for the treatment of chronic pain. Most studies evaluated the smoked or vaporized form. Research suggests a dose of 5-20 mg of oral THC is about as effective as 50-120 mg of codeine, although there are few head-to-head studies to reinforce this finding.
• Cannabis will likely have a role in the pain treatment armamentarium. The risks of use include intoxication and development of an addiction.
• Cannabinoids may have a role in achieving abstinence from addiction to cannabis and other substances.
• THC in the form of cannabinoids shows some promise for its use in disorders such as PTSD and obsessive-compulsive disorder, but larger controlled studies are needed. In addition, cannabinoids have an effect when combined with other behavioral interventions, such as exposure therapy.

Risks

• There is substantial evidence that cannabis has a moderate to large association with increased risk of developing psychotic spectrum disorders in a dose-dependent fashion, particularly in patients who are genetically vulnerable.
• Moderate evidence suggests that cannabis causes increased symptoms of mania and hypomania in people with bipolar disorder who use it regularly.
• Cannabis can cause addiction. About 9% of people who use it will develop a substance use disorder, and the risk of developing a substance use disorder increases to 17% in people who start using cannabis in their teenage years. Frequent cannabis use is associated with withdrawal symptoms, such as irritability, sleep problems, cravings, decreased appetite, and restlessness.

References

National Academies of Sciences, Engineering, and Medicine. Health Effects of Marijuana: An Evidence Review and Research Agenda. Washington, DC: National Academies Press, 2017.

Whiting PF et al. JAMA. 2015;313(24):2456-73.

Fischer B et al. Am J Public Health. 2017 Jul 12. doi: 10.2105/AJPH.2017.303818.

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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.

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

Email the show: [email protected]

In this week's installment of Clinical Correlation, Renée Kohanski, MD, ponders the loss of professional courtesy and the larger implications of medicine-shifting paradigms.

Clinical Correlation is a bi-monthly 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.

Lisa W. Coyne, PhD, spoke with Psychcast host Lorenzo Norris, MD, about strategies that can be used to help children and adolescents deal with anxiety and obsessive-compulsive disorder amid COVID-19.

Dr. Coyne, a clinical psychologist, is founder of the McLean OCD Institute for Children and Adolescents in Belmont, Mass. She also is director with the New England Center for OCD and Anxiety in Cambridge, Mass. Dr. Coyne disclosed receiving royalties from New Harbinger and Little Brown Publishing.

Dr. Norris has no disclosures.

Take-home points

• Much of the anxiety experienced by some children and adolescents is caused by uncertainty about the future.
• Some children and adolescents also are watching cases of COVID-19 tick up across the country and are concerned about the mixed messages they are receiving from adults.
  • Different cultures exist around belief in science.
• Rates of anxiety in general are on the rise as are demands for more mental health services.
  • Clinicians are supporting each other to support their patients.
• Anxiety in young patients might present as disruptions in sleep and appetite. Look for an increase in oppositional behavior. Young patients with anxiety also might resist going to bed.
• Clinicians also are seeing increases in depressed mood and nonsuicidal self-injury.
• Acceptance and commitment therapy, a type of cognitive-behavioral therapy that is exposure based, is a strategy that can be used to help patients develop psychological flexibility and put distance between themselves and their thoughts.

References

Mazza MT with foreword by Coyne LW. The ACT Workbook for OCD: Mindfulness, Acceptance, and Exposure Skills to Live Well With Obsessive-Compulsive Disorder. Oakland, Calif.: New Harbinger Publications, 2020.

Allmann AE et al. Acceptance and commitment therapy-enhanced exposures for children and adolescents. Exposure Therapy for Children and Adolescents with Obsessive-Compulsive Disorder: Clinician's Guide to Integrated Treatment. Academic Press, 2020.

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

Email the show: [email protected]

*** There is a transcript available for this episodes at https://www.medscape.com/viewarticle/940969

Yuan Chang Leong, PhD, spoke with Psychcast host Lorenzo Norris, MD, about his research into the neural underpinnings of right- and left-leaning individuals.

Dr. Leong is a postdoctoral scholar in cognitive neuroscience at the University of California, Berkeley. He has no disclosures.

Dr. Norris has no disclosures.

Take-home points

• Dr. Leong and colleagues looked for further evidence of "neural polarization," which is defined as divergent brain activity based on conversative versus liberal political attitudes.
• The prefrontal cortex is the part of the frontal lobe responsible for executive and higher-order brain function that makes sense and organizes what a person is seeing, hearing, and experiencing.
• Participants were shown news clips about immigration policy and their brain activity showed differences in activity of their dorsomedial prefrontal cortex (DMPFC), which is active in interpreting narrative content. The findings suggest there is a neural basis for the way in which individuals with different political attitudes interpret political information and news.
• The research suggests that words related to threat, morality, emotions, anger, and differentiation/community drive neural polarization.

Summary

• Dr. Leong and colleagues asked participants to watch news clips about immigration policy while undergoing functional MRI with the goal of identifying the neural correlates of neural polarization, which is thought to parallel the behavioral aspects of political polarization.
• Dr. Leong and colleagues identified an association of divergence in connectivity to the DMPFC to the ventral striatum, a structure involved in reward processing and sensing the valence and tone of information. Their study, published in the Proceeding of the National Academy of Sciences, suggests that information from the ventral striatum is transmitted differently to the DMPFC between groups.
• The findings suggest that our political beliefs might influence our interpretation of other information, as the DMPFC helps humans interpret narrative content.
• Dr. Leong pointed out that this study provides evidence about why it is so difficult to bridge the partisan divide. He also discussed the psychology of social identity theory and how any categorization of people makes individuals think along the lines of in-group and out-group, and how the human drive is to protect the in-group.

References

Leong YC et al. PNAS. 2020 Oct 20. doi: 10.1073/pnas.2008530117.

McLeod S. Social identity theory. Simply Psychology. Updated 2019.

University of Texas, Austin. Ethics unwrapped. In-group/out-group (video).

Brooks M. Brain imaging reveals a neural basis for partisan politics. Medscape.com. 2020 Oct 27.

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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.

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

Email the show: [email protected]

Renee Kohanski, MD, discusses managing difficult referrals from trusted colleagues.

Clinical Correlation is a bi-monthly 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.