Psychcast

Psychcast host Lorenzo Norris, MD, talks with Peter Yellowlees, MBBS, MD, about the changes to clinical practice forced by the COVID-19 pandemic and the likelihood that many of these changes are here to stay.

Dr. Yellowlees is a professor of psychiatry and chief wellness officer at the University of California, Davis. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures.

Take-home points

• Prior to the COVID-19 pandemic, 1%-2% of psychiatric consultations occurred on telepsychiatry modalities. During the pandemic, however, telepsychiatry has become the norm for psychiatric patient encounters.
• With the pandemic, the federal government relaxed many regulations that limited the use of telehealth.
• For many, telepsychiatry is now a preferred modality, because it confers high patient satisfaction, and many view it as more egalitarian, convenient, and less intimidating. Some even consider it more private, because the patient does not have to come to the office, and they can remain in a safe personal space.
• Telepsychiatry can be used within a hybrid model, where a patient can see the psychiatrist in person, using video, and the modality changes based on the needs of the patient and the clinician.
• Telehealth has expanded access to care to many populations, so the American Psychiatric Association and other professional associations are lobbying the federal government to keep certain telehealth regulations relaxed beyond the pandemic.

Summary

• Dr. Yellowlees sees telepsychiatry as the return of the home visit because the tool allows the clinician to see how the patient lives. He believes telepsychiatry fosters even more intimacy in the clinical relationship because of the extra distances created through the virtual space. In hybrid relationships, there are the physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. But the virtual space is convenient and provides a sense of physical and emotional space between the clinician and patient – which can make it easier to share intense emotions.
• The textbook that Dr. Yellowlees wrote with Jay H. Shore, MD, MPH, "Telepsychiatry and Health Technologies: A guide for mental health professionals," includes a chapter on clinical skills for seeing patients over video. Dr. Yellowlees points out that trainees need instruction about the work flow and clinical process, but most are savvy about how they should present themselves on screen.
  • Dos and don'ts: The clinical space for teleconferencing for both the clinician and the patient must be private and secure. Ensure that everyone in either room is introduced. The webcam should be placed on top of the computer screen so that eye contact is maintained.
  • The clinician's head should take up two-thirds of the screen. Use picture in picture setting, so you can monitor your body language during the session.

• The APA and other professional associations are lobbying the federal government to keep certain telehealth regulations relaxed beyond the pandemic. The changes would include removing the geographic restrictions on licensing, maintaining parity of reimbursement between telehealth and in-person visits, removing frequency limitations on telehealth services in nursing homes and inpatient settings, finalizing regulatory changes to the Ryan Haight Act, and allowing prescribers to continue to prescribe controlled substances without an initial in-person visit.

References

Yellowlees P, Shore JH. Telepsychiatry and Health Technologies: A guide for mental health professionals (Washington: American Psychiatric Association Publishing, 2018).

Yellowlees P. Physician Well-Being: Cases and Solutions (Washington: American Psychiatric Association Publishing, 2020).

Support for Permanent Expansion of Telehealth Regulations After COVID-19. American Psychiatric Association. 2020.

Telepsychiatry Toolkit. American Psychiatric Association

American Telemedicine Association

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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Psychcast host Lorenzo Norris, MD, meets Renee Kohanski, MD, to announce the launch of Clinical Correlation.

In Clinical Correlation, which will be released every other Monday, starting Sept. 14, Dr. Kohanski will expand on her "Dr. RK" segment and explore issues of interest to the practicing psychiatrist. And later, we will revisit four of Dr. Kohanski's "Best of" segments.

Next week, Dr. Norris will return with an interview with Peter Yellowlees, MD, about clinicians' embrace of telepsychiatry during the pandemic. They also discuss whether many of the COVID-19–related changes – including those tied to reimbursement – are here to stay.

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Anique K. Forrester, MD, joins host Lorenzo Norris, MD, to discuss the importance of continuing to work in academic medicine.

Dr. Forrester is assistant professor at the University of Maryland, Baltimore. She also serves as director of the consultation-liaison psychiatry fellowship at the university.

Dr. Norris and Dr. Forrester have no conflicts of interest.

Take-home points

• Dr. Forrester recently wrote an article in the New England Journal of Medicine discussing minority underrepresentation in academic medicine and the persistent labor of love required to stay in departments that do not explicitly value diversity.
• Underrepresented minority colleagues leave for many reasons, and Dr. Forrester highlights the issues of invisibility, lack of mentorship and support, and burden of microaggressions.
• Dr. Forrester focused her article on why she stays in academic medicine, feeling that it is critical her voice is heard; she knows her presence has changed the tone and outcome of issues. As she says: "One of the things about representation is that someone has to be there to represent."

Summary

• Staying in academic medicine with the presence of systemic racism is a difficult road; however, Dr. Forrester has stayed because of her desire to educate and mold the future of trainees.
• Underrepresented minority (URM) colleagues leave for many reasons, and Dr. Forrester highlights the issues of invisibility, lack of mentorship and support, and burden of microaggressions. The late Chester Pierce, MD, a psychiatrist and the first African American full professor at Massachusetts General Hospital, Boston, coined the term "microaggression" to describe subtle slights or snubs directed at minority and historically stigmatized groups. The cumulative effect of microaggressions is toxic and can lead to self-doubt, damaged self-esteem, and momentum that pushes a URM colleague to leave.
• When a URM colleague leaves a department, there is a short-lived conversation about what could have been done differently to retain them.
• Forrester speaks of the "double hit" that occurs when a URM colleague leaves because it is not just the loss of a colleague, but the additional connection about the shared sense of mission and about progressing conversations about equity and diversity in the department.
• Medical trainees at every level benefit from a diverse core faculty because such diversity provides different perspectives to situations and thus might also provoke an alternative response that is essential to growth. Research has also shown that patient outcomes improve in the presence of diverse medical teams.
• Dr. Forrester talks about using self-reflection to identify one's core mission as the commitment to stay in academic medicine and/or an underrepresented department. When we are stressed, it's instinctive to be reactive to negative situations. Identifying one's intention for being in academic medicine in the first place can reinforce the strength to stay and reach out for support.

References

Forester A. N Engl J Med. 2020 Jul 23;383:e24.

DeAngelis T. Unmasking 'racial microaggressions.' American Psychological Association. Monitor on Psychology. 2009;40(2):42.

Galinsky AD et al. Perspect Psychol Sci. 2015 Nov;10(6):742-8.

Gomez LE, Bernet P. J Nat Med Assoc. 2009 Aug;111(4):383-92.

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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Philip Resnik, PhD, joins host Lorenzo Norris, MD, to discuss the use of AI and natural language processing to help clinicians identify patterns in the behaviors of patients with mental illness.

Dr. Resnik is a professor in the department of linguistics at the University of Maryland, College Park. He also has a joint appointment with the university's Institute for Advanced Computer Studies.

Dr. 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. Resnik discusses has been supported by an Amazon AWS Machine Learning Research Award.

Dr. Norris disclosed having no conflicts of interest.

And don't miss the "Dr. RK" segment, with Renee Kohanski, MD.

Take-home points

• Artificial intelligence (AI) refers to the effort to get computers to develop capabilities that humans would consider intelligent when people do them. For example, a "smart" thermostat learns patterns of behaviors and changes the temperature accordingly.
• Natural language processing (NLP), an AI approach, focuses on the content of language from the words used and looks for cues within the content. NLP technology allows computers to do things more intelligently with human language, and NLP has generated technologies such as Siri, Alexa, and Google Translate.
• Much of clinical work is focused on language, and clinicians look for cues within the content. Dr. Resnik is a technologist who believes that NLP can help facilitate clinical progress, especially in the face of a shortage of mental health clinicians and the limited amount of time that clinicians are able to spend with their patients.
• Research aimed at using machine learning and NLP to analyze social media and other types of online presence to evaluate for suicide risk and the presence of mood disorders is underway.
• Dr. Resnik imagines an ecosystem in which computers and humans balance their efforts, with each "brain" doing what they are best at; he believes in technology's ability to save us time so we can prioritize our efforts.

Summary

• A common example of NLP is automatic dictation and transcription software embedded in medical records. Dr. Resnik thinks of technology as an enabler and augmentation strategy.
• Resnik and his wife, Rebecca Resnik, PsyD, completed a study using NLP to automatically detect clusters of language in the writing samples of college students. NLP software evaluated the natural patterns of language that might correlate with vegetative and somatic symptoms of depression and social isolation. His team was able to home in on language themes specific to college students that suggest specific symptoms of depression.
• Another example of NLP in mental health is using predictive modeling, taking in data, and then making a prediction about a pertinent variable to understand mental health outcomes. For example, Glen Coppersmith, PhD, and associates evaluated social media posts with NLP software and concluded that analysis of language in social media posts can accurately identify individuals at risk of suicide and facilitate earlier interventions.
• Resnik imagines a future in which speech and language samples are used to give a point-of-care evaluation of a patient's mood and suicide risk.
• "Clinical white space" is all the "space" (for example, the time between clinical encounters) and this is where decompensation occurs. Resnik suggests that NLP software could be used to fill this white space by using apps to collect text samples from patients. Software would analyze the samples and warn of patients who are at risk of decompensation or suicide.
• Barriers to using this technology include engaging the technologists and clinicians, and accessing data samples because of privacy concerns, especially because HIPPA was written before the emergence of mega data.

References

Coppersmith G et al. Natural Language Processing of Social Media as Screening for Suicide Risk. Biomed Inform Insights. 2018 Aug 27. doi: 10.1177/1178222618792860.

Zirikly A et al. CLPsych 2019 Shared Task: Predicting the Degree of Suicide Risk in Reddit Posts. In Proceedings of the Sixth Workshop on Computational Linguistics and Clinical Psychology. 2019 Jun 6. 24-33.

Lynn V et al. CLPsych 2018 Shared Task: Predicting Current and Future Psychological Health from Childhood Essays. In Proceedings of the Fifth Workshop on Computational Linguistics and Clinical Psychology: From Keyboard to Clinic. 2018. 37-46.

Selanikio J. The big-data revolution in health care. TEDx talk.

Graham S et al. Artificial Intelligence for Mental Health and Mental Illnesses: An Overview. Curr Psychiatry Rep. 2019 Nov 7;21(11):116. doi: 10.1007/s11920-019-1094-0.

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

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Abigail Kay, MD, MS, joins host Lorenzo Norris, MD, to discuss the treatment of patients with substance use disorders.

Dr. Kay is an addiction psychiatrist at Thomas Jefferson University Hospital in Philadelphia and is associate dean of academic affairs and medical student education at Sidney Kimmel Medical College. Dr. Norris is assistant dean of student affairs, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington.

Dr. Kay disclosed no conflicts of interest for the past year. Before that, she reported receiving payment from the American Society of Addiction Medicine, through a grant from the Substance Abuse and Mental Health Services Administration, to teach a free training to clinicians to be certified to prescribe buprenorphine. Dr. Norris, who also serves as medical director of psychiatric and behavioral sciences at George Washington University Hospital, disclosed no conflicts.

Take-home points

• Substance use disorders have genetic and environmental factors. The genetic component is sometimes overlooked because the environmental factor – the exposure to using a substance – is heavily focused as the only trigger for addiction.
• Methadone is a pure agonist at the mu-opioid receptor so the higher dose the greater the effect. The average dose of methadone to achieve blocking of cravings, withdrawal, and opiate intoxication is 80-120 mg.
• Buprenorphine is a partial agonist: At low doses, it acts as an agonist, and at high doses it acts as an antagonist with quite high affinity for the receptor. As a partial agonist, it has a ceiling effect with more than 90% of opiate receptors occupied at 24 mg.
• Dr. Kay suggests a helpful rule of thumb is to assume that, if patients have an addiction, there's a 50/50 chance that they have another psychiatric disorder and vice versa. With this in mind, all patients with substance use disorder should be evaluated for comorbid psychiatric disorders and underlying medical conditions.

Summary

• Dr. Kay breaks down human cognition into the primitive brain and thoughtful brain. The primitive brain keeps us alive by preferentially focusing on sleeping, drinking, and eating. Addiction to a drug hijacks the primitive brain, making it prioritize the substance of choice above all else.
• Methadone is the "gold-standard" treatment for opioid use disorder in the sense that all treatments are compared with its efficacy and mechanism of action. Methadone is a pure agonist at the mu-opioid receptor, meaning the higher dose the greater the effect; the average dose of methadone is 80-120 mg. The goal of treatment is to achieve a blocking dose, meaning a dose that blocks the craving, the withdrawal, and the high if people were to use illicit opiates on top of their methadone. Methadone is administered only at federally approved sites, and one advantage is that additional services, such as counseling, can be offered on site after daily administration.
• Buprenorphine as a partial agonist can play both "roles" on the mu-opioid receptor. At low doses, it acts as an agonist, and at high doses, it acts as an antagonist with quite high affinity for the receptor. In addition, as a partial agonist buprenorphine has a ceiling effect: At 24 mg of buprenorphine occupies 92% of opiate receptors and at 32 mg only an additional 1% of receptors are occupied. Buprenorphine must be administered when the person is already in withdrawal, because its affinity to the receptor dislodges other opiates from the mu receptor thus precipitating withdrawal. Buprenorphine works well for individuals who would require an average 40-60 mg of methadone to achieve their blocking dose. Because of the ceiling effect, some individuals continue to crave opiates while on buprenorphine. This means that, despite the greater convenience offered by buprenorphine, it is not the treatment of choice for everyone.
• Naltrexone is a pure opioid antagonist requiring 10-14 days of abstinence from opiates to prevent precipitating opioid withdrawal. Naltrexone can be given as a once-monthly injection to address cravings. The greatest risk with naltrexone is that, after 1 month of treatment, people lose their tolerance and are at risk of opioid overdose if they return to their previous amount of use.

References

Volkow ND. Hum Genet. 2012 Jun;131(6):773-7.

Volkow ND, Blanco C. J Clin Invest. 2020 Jan 2;130(1):10-3.

SAMHSA.gov. Overview of MAT: https://www.samhsa.gov/medication-assisted-treatment/treatment.

Jones HE et al. N Engl J Med. 2010;363:2320-31.

Kay A et al. J Addict Dis. 2010 Apr;29(2):139-63.

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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Derek M. Griffith, PhD, joints host Lorenzo Norris, MD, to discuss different ways to look at men's health within the context of COVID-19.

Dr. Griffith is founder and director of the Center for Research on Men's Health at Vanderbilt University, Nashville, Tenn. He also serves as professor of medicine, health, and society at the university. Neither Dr. Griffith nor Dr. Norris have disclosures.

And do not miss Renee Kohanski, MD, who offers a message of hope in the "Dr. RK" segment.

Take-home points

• The confluence of the COVID-19 pandemic, the death of civil rights leader Rep. John Lewis, and the death of Herman Cain from COVID-19 requires us to reflect on race, gender, personal identity, and our own vulnerability.
• Sometimes denial in the form of thinking "that won't happen to me" is a trope within masculinity, especially black masculinity, and can lead to men delaying preventive treatments and interventions, which makes them more vulnerable to excess morbidity and mortality from preventable diseases.
  • Some research suggests that men are more likely to suffer severe effects of COVID-19 than women.
• Personal preference and agency are hallmarks of the American ethos, and those attitudes made it difficult to accept new and challenging information during the beginning of the COVID-19 pandemic. Ironically, this fierce autonomy is celebrated and demonized in the male identity and will have an effect on their behavior in the environment. In terms of mental health, we must consider how schemas influence behavior, and one's ability to take in and act on relevant information.
• Any singular lens is limited when discussing an issue as complex as the current pandemic. Many perspectives must be examined if we are to work toward an effective solution. While society is examining COVID-19 morbidity and mortality through the lens of race, we may miss other essential perspectives, such as place, gender, age, etc.
• In a situation such as the COVID-19 pandemic, we must manage complexity by asking the hard questions. Dr. Norris asked Dr. Griffith to identify what factor in the pandemic we are missing from our current perspectives. Dr. Griffith suggested that our society continues to assume that we know more about COVID-19 than we actually know. Several times throughout the pandemic, we have assumed that we have it "figured out," only to be shown that the SARS-CoV-2 virus is more unpredictable than we realize.
• Race, gender, age, and health disparities also will be at play when it comes time to test and administer a COVID-19 vaccine.

References

Griffith DM et al. Prev Chronic Dis. 2020;17:E63.

Griffith DM et al. The COVID-19 elephant and the blind men of race, place, and gender. Gender & COVID-19.org. 2020 Jul 26.

Elder K and Griffith DM. Am J Public Health. 2016 Jul;106(7):1157. doi: 10.2105/AJPH.2016.303237.

Peters JW. Will Herman Cain's death change Republican views on the virus and masks? New York Times. 2020 Jul 30.

Cain H. This is Herman Cain!: My Journey to the White House. New York: Threshold Editions, 2011.

Sharma G et al. JACC Case Rep. 2020 Jul 15;2(9):1407-10.

Baker P et al. Lancet. 2020 Jun;395(10241):1886-8.

Indini A et al. Crit Rev Oncol Hematol. 2020 Sep;153:103059.

Chowkwanyun M and Reed AL. Racial disparities and COVID-19 – Caution and context. N Engl J Med. 2020 Jul 16;383:201-3.

Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. Updated 2020 Jul 24.

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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Episode 128 interview:

Philip G. Janicak, MD, joins MDedge Psychiatry Editor in Chief Lorenzo Norris, MD, to discuss device-based therapies for psychiatric patients.

Dr. Janicak is adjunct professor of psychiatry and behavioral sciences at Northwestern University in Chicago. He serves as an unpaid consultant to Neuronetics and has a financial relationship with Otsuka. Dr. Norris, medical director of psychiatric and behavioral services at George Washington University Hospital in Washington, has no disclosures.

Take-home points

• Therapeutic neuromodulation, including electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS), refers to the use of device-based therapies that alter neurocircuitry implicated in the pathophysiology of psychiatric disorders. Most available evidence is from studies in major depressive disorder, though more research is emerging for bipolar disorder and other diagnoses
• The advantage of TMS is minimal cognitive adverse effects, compared with ECT. Dr. Janicak recommends ECT over TMS when a patient requires inpatient psychiatric treatment, is acutely suicidal, has psychotic features, or is not taking care of basic needs.

Summary

• TMS originated in England when Anthony T. Barker, PhD, began using TMS as a probe for the peripheral and central nervous systems. Imaging studies showed that, in the context of depression, the left dorsolateral prefrontal cortex had less metabolism and blood flow, and when TMS was applied, those phenomena were reversed. One large randomized, controlled trial showed that TMS treatment could lead to remission of depression and had a durable effect for most patients in the study.

• The recent goal of TMS research has been to improve the efficacy and decrease the length of treatment from 4-6 weeks of daily treatments to 1-2 weeks.

• In 2018, deep TMS (dTMS) was cleared by the Food and Drug Administration for the treatment of obsessive-compulsive disorder after first- and second-line pharmacologic and psychotherapeutic treatments. In dTMS, the medial prefrontal cortex and the anterior cingulate cortex are targeted.

• Several studies suggest the pro-cognitive effects of TMS, and Dr. Janicak hopes that TMS might be on the radar as treatment for mild cognitive impairment.

• TMS also is being used in combination with psychotherapy, such as cognitive-behavioral therapy, under the theory that TMS enhances the activity of the neurocircuitry and potentiates the effect of the psychotherapy.

References

Janicak PG. What's new in transcranial magnetic stimulation. Current Psychiatry. 2019 Mar;18(3):10-6.

Dunner DL et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: Durability of benefit over a 1-year follow-up period. J Clin Psychiatry. 2014;75(12):1394-1401.

Janicak PG and Dokucu ME. Transcranial magnetic stimulation for the treatment of major depression. Neuropsychiatr Dis Treat. 2015;11:1549-60.

Vidrine R. Integrating deep transcranial stimulation into the OCD treatment algorithm. Psychiatric Times. 2020 Apr 7.

Marra HLD et al. TMS in mild cognitive impairment. Behav Neurol. 2015;2015:287843. doi: 10.1155/2015/287843.

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]

Dmitry M. Arbuck, MD, joins host Lorenzo Norris, MD, to discuss ways psychiatrists can help patients with treatment-resistant chronic pain.

Dr. Arbuck is clinical assistant professor of psychiatry and medicine at Indiana University, Indianapolis. Dr. Arbuck also serves as president and medical director of Indiana Polyclinic, a multispecialty pain management facility, and is an associate editor of Current Psychiatry.

Both Dr. Arbuck and Dr. Norris disclosed having no conflicts of interest.

And do not miss the "Dr. RK" segment, where Renee Kohanski, MD, discusses part 2 of her examination of the constructs of medicine.

Take-home points

• Acute and chronic pain are mediated by different mechanisms and therefore must be treated differently. Acute pain is caused by tissue damage leading to nociception, and it should heal. Chronic pain is the chronification of acute pain and more of an emotional state with sensations of pain without clear tissue damage.
• Many neurotransmitters are involved in pain, including dopamine, serotonin, norepinephrine, and the opioid system.
  • The levels of neurotransmitters will change as the pain (emotional and physical) thresholds change.
  • When patients with borderline personality disorder cut themselves, dopamine increases, and the patients, in turn, feel better. Likewise, when patients with PTSD reexperience negative events, this causes an increase in dopamine to protect against stress.
• Psychiatrists are particularly well positioned to help those with chronic pain because trauma and emotions are central to the perception of emotional and physical pain. Emotional trauma also influences the severity and chronicity of pain.
• Currently, pharmacogenetics are more of a general guide for clinicians than specific practice guidelines. But they can inform patients and physicians about drug metabolism and expression of receptors in difficult-to-treat patients.

Summary

• Chronic pain can be understood as emotions colored by nociception, while acute pain is the tissue damage and subsequent nociception causing pain. Opioids suppress the nociception of pain and are appropriate in acute pain. However, opioids should be used only in the normal time of healing in acute pain. If their use is extended, opioids can cause hyperalgesia, thus worsening chronic pain.
• Many forms of chronic pain, such as fibromyalgia and chronic back pain, do not have tissue damage. The sensations of physical pain and the compounding emotional pain are mediated by central pain sensitization. The theory behind central pain sensitization helps explain why medications such as SSRIs, serotonin-norepinephrine reuptake inhibitors, and antipsychotics can come into play in chronic pain treatment.
• In some patients, there can be dopaminergic hyperactivity in chronic pain. Dr. Arbuck conceptualizes dopamine as a defensive neurotransmitter. Dopamine is secreted in response to fear and can result in a physical response, such as weakness in the legs, but it also leads to emotional consequences, such as dissociation. Dopamine is also secreted with emotionally painful stimuli, such as trauma, so an event such as a sexual assault that results in a physical and emotional injury may produce substantial dopamine secretion. When the defense becomes chronic, excessive dopamine secretion can be pathological.
• Pharmacogenetics inform clinicians about a patient's ability to benefit from medications by looking at the presence of specific alleles for enzymes that metabolize medications and for receptors upon which medications act. Currently, Dr. Arbuck uses pharmacogenetics in specific indications, such as for patients with a seemingly treatment-resistant condition or with excessive adverse effects from medications.
• The pharmacogenetics results are meant to help physicians and patients understand the body's role in medications.
• Psychiatry needs to look more into the medical aspects of mental health, and training in psychiatry needs to be more biological in nature.

References

Arbuck DM. Current Psychiatry. 2020 Jan;19(1):25-9;31.

Clauw DJ. JAMA. 2014;311(15):1547-55.

Nijs J et al. Expert Opin Pharmacother. 2014 Aug;15(12):1671-83.

Dale R and Stacey B. Med Clin North Am. 2016 Jan;100(1):55-64.

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]

Roger S. McIntyre, MD, returns the Psychcast, this time to talk with host Lorenzo Norris, MD, about the mental health hazards of COVID-19 and what clinicians can do to help protect patients.

Dr. McIntyre is professor of psychiatry and pharmacology, and head of the mood disorders psychopharmacology unit at the University Health Network at the University of Toronto.

He disclosed receiving research or grants from the Stanley Medical Research Institute and the CIHR/GACD/National Natural Science Foundation of China. Dr. McIntyre also disclosed receiving consultation/speaker fees from several pharmaceutical companies. Dr. Norris has no disclosures.

Take-home points

• Uncertainty tied to the COVID-19 pandemic threatens to undermine mental health and exacerbate problems for those with mental illness.
• U.S. suicide rates, which were already rising after the Great Recession of 2007-2009, are likely to climb further because of the impact of COVID-19.
• Clinicians can take steps to prevent some of the negative mental health outcomes tied to the pandemic.

Summary

• COVID-19 presents a triple threat to patients' mental health.
  • The fear of viral infection is a mental health hazard.
  • The financial shock that COVID-19 has had on the economy has not been seen since the Great Depression. Links between suicide and unemployment are powerful. In a study published in World Psychiatry, McIntyre and colleagues found associations between COVID-19 and major depression, PTSD, binge alcohol use, and substance use disorders.
    • French social scientist Emile Durheim, PhD described the link between suicide and unemployment.
  • Quarantining affects mental health, and there is nothing like COVID-19 in the history books.
    • The Toronto experience with severe acute respiratory syndrome in 2003 offers lessons about the devastating impact of quarantining on mental health.
• "Deaths of despair" in the form of suicides have been on the increase in the United States. From the Great Recession, researchers found that for every 1% increase in unemployment, there is a commensurate 1% increase in suicide.
  • U.S. unemployment stood at 8%-9% during the Great Recession, and now those percentages are much higher. Dr. McIntyre and his team projected that an unemployment rate of 14%-20% would lead to an additional 8,000-10,000 suicides could occur each year for the next 2 years. That's in addition to the current number of approximately 50,000 suicides annually.
  • Express Scripts, a pharmacy benefits manager, recently reported a 40% increase in prescriptions for anxiety-related medications. This suggests that people are distressed.
• Clinicians should take an aspirational approach to addressing these issues by pivoting to virtual platforms to increase patients' access to care.
  • Create medical homes that are HIPAA compliant.
  • Look toward evidence-based models such as those found in Japan. That country found that, for every 0.2% increase in GDP spending on mental health care right after the Great Recession, the suicide rate fell by 1%.
  • Encourage patients to structure the day and avoid consuming too much news or participating on social media.
    • Two studies conducted in China found that people who spent more than 2-3 hours a day on news consumption were more likely to report clinical levels of depression, anxiety, and insomnia.
    • Social media consumption has been associated with many adverse mental health outcomes, including loneliness. People who spent more than 3 hours a day were more likely to experience depression.
  • Support programs for small-business people; jobs enhance resilience.
  • Target the "basics" of self-care, such as getting enough sleep and engaging with others.

References

McIntyre RS, Lee Y. Psychiatry Res. 2020 May 19. doi: 10.1016/j.psychres.2020.113104.

McIntyre RS, Lee Y. World Psychiatry. 2020 Jun;19(2):250-1.

Shanahan L et al. Am J Public Health. 2012 Jun;109(6):854-8.

Kang S, Chua HC. CMAJ. 2004 Mar 2;170(5):811-2.

Express Scripts. America's State of Mind Report. 2020 Apr 16.

Lee Y et al. Psychiatry Clin Neurosci. 2020 Jul 1. doi: 10.1111/pch.13101.

Hao F et al. Brain Behav Immun. 2020 Jul;87:100-6.

Tan W et al. Brain Behav Immun. 2020 Jul;87:84-92.

Wang C et al. Brain Behav Immun. 2020 Jul;87:40-8.

Harvey SB et al. Am J Psychiatry. 2018 Jan 1;175(1):28-36.

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Jack Rozel, MD, MSL, returns to the Psychcast, this time to discuss with host Lorenzo Norris, MD, how to think about guns, gun violence, and the intersection with mental health.

Dr. Rozel is medical director of resolve crisis services at the University of Pittsburgh Medical Center/Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis – rather than sell a gun. Dr. Norris has no disclosures.

Take-home points

• In the United States, more guns were sold in the month leading up to the COVID-19 pandemic than were ever sold in 1 month since gun sales were recorded.
• Suicide risk with a new gun in the home peaks in the first days to weeks of ownership and then trails off, but there is a measurable difference in risk of suicide in the 5 years after the purchase.
• Any surge in gun sales leads to greater accidental deaths and homicides from firearms.
• Rozel reminds clinicians to ask their patients (again) about guns. A good question to start is: "Are there guns in the home or new guns in the home?" He also asks about gun storage and the number of guns. Dr. Rozel goes through the basics of gun safety, such as handling a gun only while sober; securing the gun in a locked box unless the owner/responsible adult is holding it; using a responsible means to carry the gun, such as a holster; and not handling the gun like a toy.
  • If a patient is under financial pressure, the clinician might gently suggest that a way to remove some of that pressure might be to sell a weapon to a licensed gun dealer.

Summary

• It is likely that fear and uncertainty of the future with broad social disorder are influencing gun sales. Most of the gun sales during the pandemic are to new gun owners.
• Unfortunately, the increase in gun sales tracks with other major risks for suicide, such as unemployment and unstable housing, which might get worse during the COVID-19 pandemic.
• During this period of unstable employment and house, people might be moving to different houses, or relatives and friends might be moving in. With this fluidity, it is essential to inquire about guns in the home where they are staying or whether new people brought in guns. Dr. Rozel also explores who is in the house with the patient and checks in about the home environment regarding arguments and abuse, especially as tensions run high during pandemic shutdowns.
  • Make gentle assumptions by asking questions such as: "How do you store your guns?"
  • Get a sense of how safe the patient's environment is while conducting telehealth, and be aware of patients' social determinants of health issues.
• As psychiatrists, it is our role to talk to patients about how their mental health influences their safety. If a patient is experiencing acute symptoms of their illness or perhaps has relapsed on substances, then it is imperative to ask about gun safety and whether the gun should be temporarily moved from the house.

References

Rozel J. Clinical Psychiatry News. 2020 Apr 2.

Harvard School of Public Health. Means Matter: Firearm Access is a Risk Factor for Suicide

Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.10.1001/jamapsychiatry.2020.1060.

Rand Corporation. Gun Policy in America.

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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