Psychcast

Christine Moutier, MD, joins Lorenzo Norris, MD, to discuss how clinicians can scale up interventions to reduce suicide rates amid the pandemic.

Dr. Moutier is chief medical officer of the American Foundation for Suicide Prevention. She reported no disclosures.

Dr. Norris also reported no disclosures.

Take-home points

• Death by suicide is a health outcome, which means that there is always a place to intervene, whether clinically, socially, or through research.
• Risks for suicide during the pandemic are known to increase; however, it is not a foregone conclusion that suicide deaths will rise during or afterward.
• Mental health diagnoses are a risk factor for suicide, and there will be interplay with stressors such as unemployment, financial stress, grief, and socioeconomic disparities.
• The basics of suicide prevention include screening for suicidal ideation at behavioral health appointments. If a change in risk is identified, clinicians should use a patient-centered intervention, such as a safety plan.

Summary

• The U.S. suicide rate has risen by 35% from 1999 to 2018, and the rates of suicide are particularly increasing in middle-aged populations as well as among youths of color.
• Evidence-based efforts are underway to mitigate suicide deaths through national suicide prevention plans. Yet, everyone has a role to play in suicide prevention, since part of prevention includes reducing stigma related to conversations about mental health and asking about crises and suicidal thoughts.
• In behavioral health settings, routine screening should be implemented for suicidal ideation and deterioration in any aspect of mental health. Asking about suicidal ideation is the bare minimum, and not all patients will admit to suicidal ideation when asked. Other risk factors for suicide include acute stressors such as decompensation and losses of relationships and employment.
• Most individuals with suicidal thoughts do not need to be psychiatrically hospitalized. Suicidal thoughts, as symptoms of a mental illness, can be treated with interventions other than hospitalization. The goal is to maintain safety and respond appropriately.
• In-office interventions include creating a safety plan or adding to an existing plan.
• As a silver lining, the pandemic has normalized conversations about mental health and reduced stigma around mental health experiences. Dr. Moutier discusses how, as the pandemic set in, the AFSP experienced a notable increase in requests for education about mental health and suicide prevention.

References

Moutier C. JAMA Psychiatry. 2020 Oct 16. https://bit.ly/34AF0Zq.

Chung DT et al. https://bit.ly/31RYxm9.

American Foundation for Suicide Prevention: https://bit.ly/2HK3S8j

Policy priorities: https://bit.ly/37IvO78

Safety plan worksheet: https://bit.ly/2HK3Vkv

Centers for Disease Control and Prevention suicide risk factors: https://bit.ly/3jyMu3i

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Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest.

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

Email the show: [email protected]

Philip Resnik, PhD, returns to the Psychcast, this time with his research partner and wife, Rebecca Resnik, PsyD, to discuss the interface between language, psychiatry, psychology, and health.

Dr. Philip Resnik appeared on the show previously to discuss artificial intelligence, natural language processing, and mental illness. He is a professor in the department of linguistics at the University of Maryland, College Park, and has a joint appointment with the university's Institute for Advanced Computer Studies.

Dr. Philip Resnik has disclosed being an adviser for Converseon, a social media analysis firm; FiscalNote, a government relationship management platform; and SoloSegment, which specializes in enterprise website optimization. Some of the work Dr. Philip Resnik discusses has been supported by an Amazon AWS Machine Learning Research Award.

Dr. Rebecca Resnik is a licensed psychologist in private practice who specializes in neuropsychological assessment. In 2014, she served as cofounder of the Computational Linguistics and Clinical Psychology workshop at the North American Association for Computational Linguistics. She continues to serve as a workshop organizer and clinical consultant to the cross-disciplinary community. She has no disclosures.

Dr. Norris disclosed having no conflicts of interest.

Take-home points

• Dr. Rebecca Resnik and Dr. Philip Resnik are interested in finding measurable, observable features to apply to the assessment of psychological and psychiatric diagnoses. They point out that finding an objective measure is essential for scaling up mental health evaluations and treatment.
• Natural language processing (NLP) is focused on analyzing language content. NLP technology has generated tools such as Siri, Alexa, and Google Translate, and NLP allows computers to do things more intelligently with human language.
• Individuals are using machine learning and NLP to analyze language data sets to evaluate diagnostic criteria. The goal is to create or use language sets that can be analyzed outside of the clinic.
• Dr. Rebecca Resnik imagines a world where a patient gives a "language sample" to an app or an avatar that would be evaluated by NLP that would, in turn, offer some overarching hypotheses about the person. So much of evaluations is trying to home in on the correct signal, explicit and implicit, from the patient. In addition, neuropsychiatric tests/scales are standardized against a limited scope of the population, so NLP would be matched to the individual.
• Dr. Philip Resnik looks at signals in text and speech content, acoustics, microexpressions, and even biometric data. Machine learning can process and distill a huge amount of data with various signals more easily than any human.
• Dr. Rebecca Resnik revisits the idea of clinical white space, which is the "space" or the time between clinical encounters, and this is where decompensation and high-risk suicidal behaviors occur. She suggests that NLP software could be used to fill this white space by using apps to collect text samples from patients, and the software would analyze the samples and warn of patients who are at risk of decompensation or suicide. If clinicians were to use text or speech samples from people's smart technology, we could assess an individual's risk in the moment and use nudge-type interventions to prevent suicide.
• Finally, Dr. Philip Resnik emphasizes that there are technologists who have the skills and technology that is on the verge of helping clinicians, but the key to progress is collaborating with clinicians.

References

Resnik P et al. J Analytical Psychol. 2020 Sep 10. doi: 10.111/sltb.12674.

Coppersmith G et al. Biomed Inform Insights. 2018;10:1178222618792860.

Zirikly A et al. CLPsych 2019 shared task: Predicting the degree of suicide risk in Reddit posts. Proceedings of the Sixth Workshop on Computational Linguistics and Clinical Psychology. 2019 Jun 16.

Yoo DW et al. JMIR Mental Health. 2020;7(8):e16969.

American Medical Informatics Association and Mental Health: https://www.amia.org/mental-health-informatics-working-group

Selanikio J. The big-data revolution in health care. TEDxAustin. 2013 Feb.

CLPsych: Computational Linguistics and Clinical Psychology Workshop. 2019 Program.

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

Email the show: [email protected]

Dr. Renee Kohanski discusses how important personal and professional development is among physicians in the workplace. Is your current job worth it?

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

Sanjay Gupta, MD, conducts a Masterclass on treating geriatric patients with symptoms of dementia, particularly amid the restrictions tied to COVID-19.

Dr. Gupta is chief medical officer at BryLin Hospital in Buffalo, N.Y. He is also is a clinical professor in the department of psychiatry at the State University of New York, Syracuse, and is affiliated with SUNY at Buffalo. Dr. Gupta attends at 8-10 nursing homes.

He disclosed serving on the speakers' bureaus of AbbVie, Acadia, Alkermes, Intra-Cellular Therapies, Janssen, and Otsuka.

Take-home points

• Common neuropsychiatric symptoms in patients with dementia include agitation, aggression, delusions, insomnia, anxiety, and depression. One-third of community-dwelling elders and between 60%-80% of nursing facility patients have these neuropsychiatric symptoms.
• The most common medication class Dr. Gupta uses is antipsychotics. The use of these medications in individuals with dementia is off label. The Food and Drug Administration maintains a black-box warning on the use of antipsychotics for geriatric patients because of the increased risk of sudden death.
• Risperidone is supported by the most data, then olanzapine, then aripiprazole, and finally quetiapine. Quetiapine has very limited data to support its efficacy. Most antipsychotics have modest efficacy data for their use in this population. The riskiest adverse effects are cardiovascular adverse events, which are higher in risperidone.
• Dr. Gupta starts risperidone at a low dose of 0.25 mg taken by mouth b.i.d. and titrates to a maximum dose of 2 mg/24 hours. The starting dose for olanzapine is 2.5 mg up to a maximum dose of 10 mg. The starting dose of aripiprazole is 1 mg, and maximum dose 5 mg or less.
• Selective serotonin reuptake inhibitors (most commonly sertraline or citalopram), the atypical antidepressant mirtazapine, and anticonvulsants (valproic acid) are also used for agitation in dementia but there is limited evidence for their efficacy. Melatonin and trazodone have a positive effect on sleep that can have downstream improvement on aggressive behaviors.

Summary

• To choose an effective treatment, it's essential to obtain a detailed history of the symptoms from patients and collateral, such as relatives and staff members from the facility. Staff members can be educated about what information is most important to the clinician, or they may provide vague information, such as "the patient is confused." Specific symptoms that can be used guide treatment include the presence of disorganized thoughts, delusions and paranoia, or visual and/or auditory hallucinations; the timing of the behavior (day vs. night); and patterns of aggressive behaviors.
• Dr. Gupta emphasizes that it's important to rule out delirium as the cause of agitation by evaluating underlying medical issues with laboratory evaluations, and when possible, a physical exam.
• Antipsychotics work best in the context of aggression driven by paranoia and/or delusions of persecution. Antipsychotics seem to work less well for general agitation that may be driven by triggers that need to be uncovered through investigation of the history and environment. Reasons for agitation and aggression might include sensory or activity deprivation, difficulty emptying bladder or bowels, or depression and loneliness, both of which are prevalent during the pandemic.
• Adverse effects of antipsychotics will be greater in older adults, and include sedation, gait problems that increase the risk of falls, and extrapyramidal or Parkinsonian symptoms. In a geriatric patient, tardive dyskinesia can occur with as little as 1 month of exposure to an antipsychotic, compared with 3 months in younger adults.
• Before starting an antipsychotic, the clinician must obtain informed consent from the health-care proxy and inform them that using antipsychotics in a patient with dementia is a non–FDA-approved treatment with a black-box warning.
• Gradual dose reduction, a Medicare policy about the use of psychotropic medications within nursing homes, is defined as "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." Dr. Gupta addresses this policy by assessing which medications are essential and often stopping some medications once the patient is started on antipsychotics.

References

Steinberg M, Lyketsos CG. Am J Psychiatry. 2012 Sep;169(9):900-6.

Maher AR et al. JAMA. 2011 Sep 28;306(12):1359-69.

Schneider LS et al. JAMA. 2005 Oct 19;294(15):1934-43.

Seitz DP et al. Cochrane Database Sys Rev. 2001 Feb 16;(12):CD0089.

Ballard C et al. Cochrane Database Sys Rev. 2006 Jan 25. doi: 10.1002/14651858.

Ballard C, Waite J. Cochrane Database Sys Rev. 2006 Jan 25;(1):CD003476.

Department of Health & Human Services. State Operations Manual Surveyor Guidance Revisions Related to Psychosocial Harm in Nursing Homes. CMS.gov. 2016 Mar 25.

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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]

David Henry, MD, host of the Blood & Cancer podcast, joins Psychcast host Lorenzo Norris, MD, to discuss steps clinicians can take to alleviate the distress associated with receiving a diagnosis of cancer.

Dr. Henry is clinical professor of medicine at the University of Pennsylvania, Philadelphia. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures.

Take-home points

• Cancer patients have always been susceptible to developing depression and anxiety after receiving their distressing diagnoses. During the COVID-19 pandemic, the risk for depression and anxiety are even greater because patients face separation from their oncology treatment teams and for some, delays in treatment.
• Major depressive disorder (MDD) occurs in up to one-third of cancer patients, and any depressive disorder can be seen in about half.
• Another concern is how to screen for depression in the context of cancer. Dr. Norris suggests using the Patient Health Questionnaire–2 (PHQ-2) screener, or the question: "Are you sad or depressed?" Answering those questions can give patients the opportunity to open up about their emotions.
• Signs of depression in cancer include nonadherence to treatment, changes in mood and anxiety affecting daily functioning at home or work, and demoralization, which is defined as helplessness, isolation, and despair in the face of overwhelming stressors.

Summary

• An emotional upset, such as disbelief, despair, or even denial, might occur immediately after receiving a cancer diagnosis. A depressive disorder, however, is a persistently depressed, sad mood with changes in functioning that affect the patient, his/her family, and even engagement with treatment.
• Findings of studies about the prevalence of depression in patients with cancer vary depending on the type of screening and/or diagnostic tool used. In general, the prevalence of MDD is up to 38%, and the prevalence of any depressive disorder is up to 58%. The prevalence of depression is even greater in patients with advanced cancer. In the general population, the 12-month prevalence of MDD is 6%, and the lifetime prevalence is 16%.
• It's useful to think about stress along a continuum of diagnoses ranging from a normal expected stress syndrome, an adjustment disorder, MDD triggered by the event, depression secondary to a general medical condition as can occur in central nervous system and pancreatic cancer, or even a substance-induced mood disorder from either prescribed medications or perhaps a form of coping that has turned maladaptive.
• Cognitive-behavioral therapy (CBT) can be explained as examining the way thoughts influence emotions and behavior. When using CBT with cancer patients, a good place to start is checking in on their understanding of their diagnosis, their prognosis, and current and future treatments. The goal is to see whether they have unnecessary cognitive distortions that may be affecting their emotions and behaviors. During periods of extreme stress, CBT can help patients by emphasizing the use of adaptive thoughts, and identifying maladaptive thoughts and behaviors as opportunities for intervention.
• To screen for depression, it may be enough to ask: "Are you depressed?" As a screening tool, the PHQ-2 asks only two questions: "Over the last 2 weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things, or been feeling down, depressed or hopeless? The PHQ-2 score ranges from 1 to 6, and even at the lowest score, it has a sensitivity and specificity of 90.6% and 65.4%, respectively, in detecting any depressive disorder.

References

Krebber AMH et al. Psycho-oncology. 2014 Feb;23(2)121-30.

Walker J et al. Ann Oncol. 2013 Apr 1;24(4):895-900.

Trinidad AC et al. Psychiatr Ann. 2011;4(9):439-42.

Daniels S. J Adv Pract Oncol. 2015 Jan-Feb;6(1):54-6.

Other resources

PHQ-2: https://www.hiv.uw.edu/page/mental-health-screening/phq-2

National Cancer Institute: Depression–Health Professional Version: https://www.cancer.gov/about-cancer/coping/feelings/depression-hp-pdq

Dr. Renee Kohanski, MD, uses a proverb to discuss how she talks to patients about face masks, and how she talks to patients with face masks on. What's hiding behind the mask?

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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

Psychcast host Lorenzo Norris, MD, talks with members of the Group for the Advancement of Psychiatry's Media Committee about how to help patients navigate the uncertainties associated with educating K-12 and college students during the pandemic. The discussion is moderated by Jack Drescher, MD.

Dr. Norris is assistant professor of psychiatry and behavioral sciences and assistant dean of student affairs at George Washington University in Washington. He also serves as medical director of psychiatric and behavioral sciences at George Washington University Hospital. Dr. Norris has no conflicts of interest.

Dr. Drescher is clinical professor of psychiatry at Columbia University in New York, adjunct professor at New York University, and a training and supervising psychoanalyst at the William Alanson White Institute. He has no conflicts of interest.

Joining Dr. Norris and Dr. Drescher are Carol Bernstein, MD; Jeffrey Freedman, MD; Gail Saltz, MD; and Peter Kramer, MD. None of the guests have a conflict of interest.

Summary

• Questions about school reopenings are fraught with uncertainty for children, parents, and teachers, with concerns for safety as well as the quality of the school experience. Constant communication between parents and schools with families is warranted; however, without a clear plan, too much communication can generate anxiety.
• The pandemic and school reopenings affect most sectors of society, including the economy, and vulnerable and elderly populations. The pandemic puts pressure on families because the distribution of work often is in the home.
• Women in particular are struggling with the ongoing need to manage work demands with those tied to their children's school schedules.
• School reopening plans have ramifications for the workplace as parents struggle to meet their usual schedule and productivity standards.
• School reopening is another aspect of the pandemic that underscores class and financial disparities, because some school systems can afford widespread testing to keep children in school. These decisions, in turn, have a ripple effect on parents' ability to return to work.
• School reopenings also affect young adults at colleges and universities. The social milieu of college targets the development of young adults as they accomplish social and emotional milestones by interacting with peers. Yet, to reopen safely, colleges have been forced to change their structure and limit social interactions between students and faculty. In addition, college is a common time and place for mental illnesses to surface or be exacerbated in young people; it's unclear whether there will be enough mental health services for this group, which is now under even more stress. Colleges are trying to fill the mental health gap by using adjunctive tools, such as apps, and broader telehealth and virtual psychotherapy services.
• Children at every age are facing developmental challenges, including a "failure to launch." Presently, 52% of young adults reside with one or both of their parents, the largest proportion since the Great Depression.

References

Bushwick S. Schools have no good options for reopening during COVID-19. Scientific American. 2020 Sep 5.

Simpson BW. The important and elusive science behind safely reopening schools. https://www.jhsph.edu/covid-19/articles/the-important-and-elusive-science-behind-safely-reopening-schools.html. Johns Hopkins School of Public Health. 2020 Aug 14.

Johns Hopkins School Reopening Plan Tracker. https://bioethics.jhu.edu/research-and-outreach/projects/eschool-initiative/school-policy-tracker/.

Fry R et al. A majority of young adults in the United States live with their parents for the first time since the Great Depression. Pew Research Center. FACTTANK: News in the Numbers. 2020 Sep 4.

Marcus J and Gold J. Colleges are getting ready to blame their students: As campuses reopen without adequate testing, universities fault young people for a lack of personal responsibility. The Atlantic. 2020 Jul 21.

Will M. Keeping COVID-19 rates low in schools: Advice from an expert. Education Week. 2020 Sep 28.

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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]

Richard Balon, MD, returns to the Psychcast, this time to conduct a Masterclass on the impact of marijuana use on patients, particularly adolescents.

Dr. Balon is professor of clinical psychiatry and anesthesiology and associate chair of education at Wayne State University in Detroit. He has no disclosures.

Take-home points

• Marijuana remains a controversial topic as potential legalization looms large in public policy and various groups espouse the positive benefits of marijuana.
• Current marijuana formulations are more potent than formulations used in previous years. Formulations used today have a higher tetrahydrocannabinol content, with up to 80% THC content achieved through artificial selection.
• Clinicians are rightly concerned about the well-established negative effects of marijuana on specific populations, particularly adolescents. They also worry about the effect of marijuana on brain development, which could affect educational outcomes, and the significant risk of developing psychosis and/or schizophrenia after using marijuana.
• Newer research on marijuana use is also suggesting other negative health outcomes, including a potential link between marijuana use and an increased risk of developing various types of cancer.

Summary

• Research over the past 20 years has elucidated the negative effects of marijuana on brain health and development. Marijuana use undermines cognitive function, including executive function and educational outcomes. Longitudinal and twin studies show a decline in the IQ of adolescents who have used marijuana. This is congruent with other established research and public health guidelines urging individuals to avoid the use of psychoactive drugs before the brain finishes maturing at approximately age 25 years.
• In 2016, Nora D. Volkow, MD, director of the National Institute on Drug Abuse, and other leading investigators in the field published a review of the literature discussing the impact of marijuana cognitive capacity, amotivational syndrome, and the risk of psychosis. Ample evidence based on neuropsychological testing demonstrates a negative impact of marijuana on learning and working memory. Cannabis amotivational syndrome manifests as apathy, reduced concentration, and an inability to follow routines or master new material. Evidence demonstrates that long-term heavy cannabis use is associated with educational underachievement and impaired motivation.
• Marijuana use is considered a preventable risk factor for the development of psychosis and schizophrenia. Any use of marijuana is estimated to double the risk of schizophrenia, accounting for 8%-14% of cases, and those at greatest risk include adolescents who start at an early age, engage in heavy use, and use high-potency THC.
• There is limited evidence about the effect of marijuana on PTSD, and a study using a large Veterans Affairs database suggests that marijuana may worsen PTSD symptoms and increase the risk of violence.
• A well-established physical outcome of heavy cannabis use is cannabis hyperemesis, defined as recurrent nausea, vomiting, and cramping abdominal pain tied to marijuana use.
  • The symptoms may improve temporarily by taking a hot shower or bath.
• Though more research is required, low-strength evidence suggests that regular marijuana use may be associated with development of testicular germ cell tumors. The association of marijuana use with lung and oral cancer is unclear, partly because marijuana smokers often also smoke cigarettes.
  • Given that we know the smoke in cigarettes is a major risk factor for heart disease, the same concerns must be investigated for individuals who smoke only marijuana.

References

Fischer B et al. Am J Public Health. 2017 Jul 12;107(8):e1-12.

Volkow ND et al. JAMA Psychiatry. 2016;73(3):292-7.

Lorenzetti V et al. Eur Neuropsychopharmacol. 2020 Jul;36:169-80.

Fried P et al. CMAJ. 2002 Apr 2;166(7):887-91.

Meier MH et al. Addiction. 2017 Jul;113:257-65.

McAlaney J et al. Eur Addict Res. 2020 May 6;1-8.

Ben Amar M, Potvin S. J Psychoactive Drugs. 2007;39:131-42.

Wilkinson ST et al. J Clin Psychiatry. 2015 Sep;76(9):1174-80.

Steenkamp MM et al. Depress Anxiety. 2017 Mar;34(3):207-16.

Chocron Y et al. BMJ. 2019;366:l4336.

Ghasemiesfe M et al. JAMA Netw Open. 2019;2(11):e1916318.

Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. 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]

Introducing Clinical Correlation, a new podcast drop from the Psychcast.

Renee Kohanski, MD, began producing observational segments for the Psychcast since its inception in April 2018. Clinical Correlation episodes will be published on Mondays twice per month.

In this first edition, Dr. Kohanski recalls a poignant moment during her training when her mentor and then director, Donald Morgan, MD (https://bit.ly/35PAqY6), reconsidered his opinion prior to testifying in a court of law based on a simple question from a trainee. For Dr. Kohanski, this moment emphasized the importance of honest and open conversations.

You can email the show at [email protected] and you can learn more about the show at https://www.mdedge.com/podcasts/psychcast

Jeffrey R. Strawn, MD, talks with host Lorenzo Norris, MD, about assisting children and adolescents with anxiety and anxiety disorders, particularly during the COVID-19 pandemic.

Dr. Strawn, a previous Psychcast guest, discusses ways for mental health clinicians to think about proportionate anxiety versus anxiety that is severe, continual, and persistent. He is director of the anxiety disorders research program at Cincinnati Children's Hospital Medical Center and an associate professor of psychiatry at the University of Cincinnati.

Dr. Strawn has received research support from several pharmaceutical companies and from the National Institute of Mental Health. He also has received royalties from Springer.

Dr. Norris is assistant dean of student affairs, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He has no conflicts of interest.

Take-home points

• Anxiety is a normal emotional reaction critical to survival. Yet, when the emotions become extreme, anxiety can negatively affect day-to-day functioning.
• With any event that may cause stress, the anxiety should be expected and proportional to the event.
• Clinicians and parents can support children and adolescents by pointing out different emotional reactions and discussing them to promote self-awareness, as well as maintaining routines while also acknowledging the loss of normalcy.
• Clinicians should keep in mind several dimensions of the child-parent relationship and how they interact with the ever-changing home and schooling environment. The dimensions to be considered include: Flexibility versus control, which is a spectrum that ranges from rigid to chaotic, and cohesion and support, which ranges from disengaged to enmeshed.

Summary

• If the triggering event is severe, persistent, and uncertain, such as the COVID-19 pandemic, the anxiety may last and become an anxiety disorder, which results in functional impairment.
• Anxiety (not yet a disorder) may provoke changes in emotions and behaviors, such as irritability, frustration, poor sleep, and so on, that are proportional and expected to the major changes produced by the pandemic. So, parents and clinicians need to monitor for impact on functioning.
• Clinicians and parents can support children by pointing out different emotional reactions and discussing them to promote self-awareness. Adults should acknowledge that children are going through loss and trauma and be open to discussing how life is different now but not lose sight of the future. Parents will have to balance trying to keep normalcy in place where possible and discussing when life feels far from the norm.
• In his clinical practice, Dr. Strawn has noticed more reports of irritability and frustration. These emotions need to be evaluated but not necessarily pathologized. Those emotions likely arise from the drastic changes in home environment. Also parents now have more opportunity to observe their children in the learning environment.
• The pandemic has come with certain benefits, such as more time at home together allowing families time to slow down and engage in different, more fulfilling activities. Yet, the pandemic has created chronic and variable stressors that can negatively affect physical and mental health. This combination of the dark and light has the potential to foster resilience as we reflect on our vulnerabilities and strengths. But we must also think about how to inoculate ourselves against loneliness, and the risks of how social distancing and societal discord may fray our social fabric.

References

Strawn JR. Current Psychiatry. 2020 May;19(5):9-10.

Brooks D. The pandemic of fear and agony. New York Times. 2020 Apr 9.

Delgado SV, Strawn JR. Difficult Psychiatric Consultations: An Integrated Approach. New York: Springer, 2013.

Strawn JR et al. Depress Anxiety. 2012;29(11):939-47.

Strawn JR et al. Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-39.

Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. 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]