Psychcast

This week, we decided to revisit three of the Psychcast episodes that examined various aspects of COVID-19. First, you will hear excerpts from the interview that host Lorenzo Norris, MD, did with Sheldon H. Preskorn, MD, on educating patients about SARS-CoV-2 and the disease. Next, Jay H. Shore, MD, MPH, conducts a Masterclass lecture on factors to consider while using telepsychiatry during the pandemic.

And later, guest host Jacqueline Posada, MD, talks with Lynne S. Gots, PhD, about using cognitive-behavior therapy to treat patients with anxiety.

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Thomas Abt, JD, spoke with Nick Andrews about his talk at the TEDMED 2020 conference in Boston.

Mr. Abt (@Abt_Thomas), senior fellow at the Council on Criminal Justice, discussed his evidence-based and community-informed strategies for reducing urban violence. Mr. Abt earned an undergraduate degree in economics from the University of Michigan in Ann Arbor, and a law degree from Georgetown University in Washington. Mr. Abt also worked as a prosecutor in the Manhattan District Attorney's office in New York, and as a teacher in Washington. He has no conflicts of interest.

Summary

Mr. Abt said the three fundamental principles of focus, balance, and fairness are central to interventions for reducing urban violence. This means focusing on people and places in which urban violence is concentrated, balancing between positive and negative incentives to reduce violence, and facilitating trust between the state and its citizens to foster a sense of fairness.

Mr. Abt's book, "Bleeding Out: The Devastating Consequences of Urban Violence - And a Bold New Plan for Peace in the Streets" is a compilation of 10- 12 strategies using evidence-based interventions. Mr. Abt promotes strategies informed by data and vetted by communities.

• Success stories can be found with deterrence in Boston; and Oakland, Calif; and Cincinnati; and Indianapolis; and with cognitive-behavioral therapy (CBT) in Chicago. Those strategies have not been brought to scale or sustained over time.
• The "Becoming a Man" program in Chicago is one the most promising examples of the power of CBT. The program focuses on at-risk youth in high school and teaches strategies for conflict resolution, interpersonal problem-solving skills, anger management, and future orientation.
• The program has three components: vigorous youth engagement; an intensive "man's work" educational program delving into positive masculine identity; and a CBT component.
  • CBT is only part of the success, and Mr. Abt argues that a clinical component is necessary when working with groups with traumatic backgrounds. A psychotherapy modality is required to meaningfully alter the impulsive, automatic responses that can lead to violence.
  • Street outreach workers, public health officials, and police officials have responded positively to the book. Criticism has come from political extremes.

• Conventional narratives about urban violence suggest that it is rooted in poverty or culture, or social and economic injustice. Yet research about urban violence suggests reducing violence must focus on urban violence itself and not on ancillary topics. Structural and historical factors, such as racism and de jure and de facto segregation, have produced high rates of urban violence, but we can't start over in a span of a few years to address those generational problems. Mr. Abt focuses on identifying interventions that target reducing violence, which has its own ripple effects on structural injustice.

• Abt emphasizes that urban violence is a concentrated problem with larger effects. The solutions need to be direct and focused so that the effect of the interventions is not diluted and able to be applied in multiple communities. The solutions direct and focused approaches so that the effect of the interventions is not diluted and able to be applied in multiple communities.

References

Abt T. Bleeding Out: The Devastating Consequences of Urban Violence – And a Bold New Plan for Peace in the Streets. (Basic Books, 2019).

Obbie M. This man says his anti-violence plan would save 12,000 lives. The Atlantic.

University of Chicago. Urban Labs. Becoming a Man program.

Heller SB et al. Thinking, Fast and Slow? Some Field Experiments to Reduce Crime and Dropout in Chicago. National Bureau of Economic Research. Working Paper 21178. May 2015. Revised August 2016.

Medscape Psychcast bonus episode transcript: Click Here.

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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.

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

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Igor Galynker, MD, returns to the Psychcast, this time to discuss his most recent work on suicidal crisis syndrome with host Lorenzo Norris, MD.

Dr. Galynker is professor of psychiatry and director of the Galynker Research and Prevention Laboratory at the Icahn School of Medicine at Mount Sinai, New York. He reported receiving funding from the National Institute of Mental Health and the American Foundation for Suicide Prevention. Dr. Norris has no disclosures.

Take-home points

• Suicide crisis syndrome (SCS) is a state or syndrome that develops shortly before a suicide attempt. Since the last Psychcast with Dr. Galynker, SCS has been replicated in several cohorts and countries.
• SCS has been refined to three primary factors instead of five. The factors of SCS include a state of entrapment which includes cognitive rigidity and flooding, insomnia/agitation, and social withdrawal.
• New data are emerging about how to treat the acute syndrome with medications, because patients are not susceptible to psychotherapy or even safety planning in this state of mind.
• Galynker and colleagues have validated the suicide crisis narrative model and have found that the clinician's response to the narrative is predictive of risk of suicide.

Summary

• In SCS, the two primary factors are a sense of entrapment and cognitive rigidity followed by insomnia or agitation and social withdrawal.
• The state of entrapment is characterized by frantic hopelessness with a sense of being trapped in a life situation that is painful, intolerable, and feeling that all escapes are blocked. Cognitive rigidity and dyscontrol can include ruminative flooding associated with headache or head pressure, and inability to suppress the ruminative thoughts. Cognitive rigidity, like psychosis, can make it difficult to engage in psychotherapy.
• SCS needs to be treated with medications such as an antipsychotic for cognitive rigidity, a benzodiazepine for the frantic hopelessness and sense of agitation, and something that targets the emotional pain.
  • Antidepressants might make SCS worse because they can increase anxiety.
• The accompanying narrative crisis model of suicide behavior includes five components: High-risk traits, stressful life events, a narrative of hopelessness and failure, the suicide crisis syndrome, and then suicide attempt. Clinicians can think of the long-term risk factors for suicide as vulnerable traits such as fearlessness, perfectionism, insecure attachment, and childhood abuse. When these vulnerable individuals have stressful life events, they enter a subacute phase in which they create a life narrative that tells a story of falling short of their goals, feeling humiliation, being a burden to others, and being unable to achieve future goals, all of which lead to social withdrawal.
• SCS is treated with medications and means restriction, and the narrative is treated with cognitive restructuring through specific forms of psychotherapy.
• Three clinician emotions triggered by a suicidal patient's narrative are predictive of risk of suicide death. The first emotion is clinician distress and dread. The second is anxious overinvolvement, which is similar to a rescue fantasy with false hope. The third is a sense of distancing and resignation that the patient is going to kill themselves. Clinicians must be trained to listen to their own emotional reactions to a patient's suicidal narrative of how they arrived at this state to detect this risk.
• Using emotions and something like the SCS is important for suicide prevention, because only one-third of people report suicidal ideation. Sometimes the burden of EMR documentation or checkboxes can get in the way of accurately assessing a patient's risk. This type of work requires awareness of emotions and managing them to make sure they are attuned to the patient. Other emotions, such as fatigue and burnout, can interfere with the risk assessment.

References

Cohen LJ et al. Suicide Life Threat Behav. 2019 Apr;49(2):413-22.

Hawes M et al. Compr Psychiatry. 2017 Jan;72:88-96.

Galynker I et al. Depress Anxiety. 2017 Feb;34(2):147-58.

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]

Lorenzo Norris, MD, spoke with Sheldon H. Preskorn, MD, about how to best educate patients about coronavirus.

Dr. Preskorn is a professor in the department of psychiatry at the University of Kansas School of Medicine–Wichita. Neither Dr. Norris nor Dr. Preskorn have any relevant financial relationships to disclose.

Take-home points

• Coronavirus 2019 (COVID-19) is the disease process caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
• SARS-CoV-2 is different from the previous SARS-type coronaviruses and is having a greater impact on society as a pandemic for three reasons: It's highly transmissible person to person, it can be spread by infected individuals who are asymptomatic or presymptomatic, and it has a high level of morbidity but a lower level of mortality.
• Psychiatrists work with vulnerable populations, including older adults and individuals with medical comorbidities that put them at risk for COVID-19.
• Psychiatrists must understand the pertinent facts about COVID-19 to help their patients who are suffering the consequences of social distancing, a shuttered economy, and changes in their daily lives from COVID-19.

Summary

• While coronaviruses are known to cause the common cold, some are more medically serious – and even lethal – based on their ability to cause a severe acute respiratory syndrome (SARS). SARS-CoV-2 is one in a line of several coronaviruses to make the leap from animals to humans and cause a severe acute respiratory syndrome with devastating effects.
• Previous coronaviruses include SARS-CoV-1, which caused an illness referred to as "SARS" that had a mortality rate close to a 10%, and MERS-CoV, which caused Middle East respiratory syndrome (MERS) and had an even higher mortality rate. The high mortality rate of these SARS-type coronaviruses is thought to be why they did not transition from epidemic to pandemic.
• SARS-CoV-2 is different from the previous SARS-type coronaviruses and is having a greater impact on society as a pandemic for three reasons: It's highly transmissible from person to person, it can be spread by infected individuals who are asymptomatic or presymptomatic, and it has a high level of morbidity but a lower level of mortality.
• In terms of transmissibility, each person infected can infect up to six additional people and individuals can spread the virus even while asymptomatic or presymptomatic. This is why wearing a mask and engaging in social distancing are essential to slowing the spread of COVID-19.
• SARS-CoV-2 is more lethal than influenza and is especially dangerous for certain populations, such as older adults and those with multiple medical comorbidities, including chronic pulmonary obstructive disease, hypertension, diabetes, obesity, and being immunocompromised. In the United States, 80% of COVID-19 deaths are in people older than age 65 years.
• Psychiatrists must understand these pertinent facts about COVID-19 to help their patients who are suffering the consequences of social distancing, a shuttered economy, and changes in their daily lives from COVID-19.
• Psychotropic medications that can lead to metabolic syndrome, such as second-generation antipsychotics, may put patients with serious mental illness at risk of worse outcomes if infected with COVID-19.
• Ultimately, psychiatrists are medical doctors who are helping treat the secondary mental health effects of the COVID-19 pandemic, so we have a responsibility to have a working knowledge of the epidemiology and basic science of the virus to help our patients.

References

Preskorn SH. Coronavirus Disease 2019: The first wave and beyond. Psychiatr Times. 2020 Apr 28.

Preskorn SH. COVID-19: Protecting the vulnerable and opening the economy. Psychiatr Times. 2020 May 6.

Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Older adults.

National Institute of Allergy and Infectious Diseases. Coronaviruses.

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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]

SPECIAL: Lorenzo Norris, MD, welcomes fourth-year psychiatry resident Brandon C. Newsome, MD, for a discussion on race relations as a physician in the wake of the death of George Floyd, who was killed when a white police officer kneeled on his neck during an arrest.

Dr. Newsome was raised in Alabama and currently lives in Boston. He shares his experiences with Dr. Norris in an important conversation.

The pair discuss what their patients are experiencing and what they're experiencing as black physicians.

Dr. Norris is a consultation-liaison psychiatrist and medical school dean affiliated with George Washington University, Washington (@GWSMHS). Dr. Newsome will begin a fellowship in July at Children's National Hospital (@ChildrensNatl).

References

American Medical Association (@AmerMedicalAssn) 2020 statement on police brutality (2020)

American Psychiatric Association (@APAPsychiatric) statement

National Medical Association (@NationalMedAssn) statement

Candrice R. Heath, MD, and Nicole B. Washington, DO, MPH, spoke with Psychcast host Lorenzo Norris, MD, about physician mental health.

Dr. Heath is affiliated with Temple University Hospital, Philadelphia. She has no disclosures.

Dr. Washington disclosed serving as chief medical officer and founder of Elocin Psychiatric Services, a telemedicine company that provides care to physicians. Dr. Norris is a consultation-liaison psychiatrist and medical school dean affiliated with George Washington University, Washington. He has no disclosures.

And stick around for Renee Kohanski, MD, who talks about expectations.

Take-home points

• Physicians often delay seeking mental health treatment. Compared with the general population, the risk of suicide is 2.27 times higher in female physicians and 1.4 times higher in male physicians.
• The COVID-19 pandemic has created additional risk factors for all physicians, including those on the front lines and others whose clinical practices and home lives have changed because of the pandemic.
• Prevention and mitigation of mental illness start with understanding your own risk factors and stressors and trying to address them before they become overwhelming.

Summary

• During the best of times, physicians are at risk for anxiety, depression, and substance use disorders. The syndromes of demoralization and burnout should be seen as prodromes to clinical diagnoses, such as major depressive disorder. An estimated 300-400 physicians die from suicide each year.
• Prevention of mental illness starts with identifying one's stressors, such as balancing personal and professional demands on time; knowing one's risk factors, such as a history of substance use and previous episodes of distress or psychiatric diagnoses; and thinking about the phases of disaster response. When it comes to the COVID-19 pandemic, are you surging with adrenaline, hitting a plateau, or experiencing a decline?
• Dr. Washington suggests that her patients focus on what they can control in their lives, because uncertainty and loss of control of our usual routines contribute to stress, anxiety, and fatigue. It is also helpful to reflect on past periods of hardship and resilience to identify strengths and previous strategies used to overcome challenges.
• Physicians who are not on the front lines are experiencing different forms of hardship, such as financial stress from furloughs and loss of patient volume. There may also be guilt about not addressing the pandemic in the same way as frontline physicians. Even without direct patient care of COVID-19, it must be acknowledged that the impact of the pandemic is everywhere.
• Most physicians delay seeking mental health treatment. This may particularly occur for physicians with better "lifestyles," such as dermatologists, who some may view as suffering less. This pandemic is a reminder that all physicians need to take care of themselves, regardless of specialty.
• We are all adjusting to the "new normal," so in times like this, it is helpful to seek practices such as mindfulness and "radical acceptance," the latter of which is part of dialectical behavior therapy.
  • Accepting reality with judging and setting expectations at a realistic level can help prevent suffering.

References

• Phases of disaster timeline: https://www.samhsa.gov/dtac/recovering-disasters/phases-disaster
• American Psychiatric Association Well-being Toolkit: https://www.psychiatry.org/psychiatrists/practice/well-being-and-burnout/well-being-resources
• Radical acceptance by Tara Brach, PhD: https://www.youtube.com/watch?v=_K35O3G82L4
• Facts about physician suicide: https://www.acgme.org/Portals/0/PDFs/ten%20facts%20about%20physician%20suicide.pdf

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Bill Scheidler, MD, is assistant clinical professor of psychiatry at the University of North Carolina, Chapel Hill. He also is associate training director for the consultation-liaison fellowship at UNC and is a lead consultant at UNC Hospitals Hillsborough.

Dr. Scheidler spoke with host Lorenzo Norris, MD, about how to think through patients' decision-making capacity in medical (rather than psychiatric) hospitals. Neither Dr. Scheidler nor Dr. Norris have disclosures.

Take-home points

• Decision-making capacity (DMC) is essential to informed consent, which is providing patients with the information necessary to make an informed decision about medical or surgical care.
  • Standards differ, depending on the U.S. state.
• DMC has four components, as defined by Paul Appelbaum, MD, and colleagues:
  • The ability to make and communicate a consistent choice
  • The ability to understand the information provided about medical conditions and decisions
  • The ability to appreciate the consequences of a choice
  • The ability to reason through the decision
• In the sliding-scale model of DMC, not all decisions carry the same weight. The assessment evaluates the risk-benefit ratio of a particular decision, and the bar for capacity depends on the ratio.
• When a patient lacks capacity and treatment over objection is pursued, the outcome is highly dependent on the hospital and state laws. Clinicians should confer with their risk management and legal team.

Summary

• A capacity assessment usually is implicit in the process of informed consent because clinicians usually are assessing whether the patient truly understands what they are consenting to.
• In the legal literature, "capacity" and "competency" are used interchangeably, but in the medical field they are different. It is easier to refer to adjudicated competency in which a judge legally determines a person's ability to make decisions. Usually, a person lacking adjudicated competency has a guardian to guide their decisions.
• In contrast, DMC is time and decision specific. A DMC assessment includes evaluation of the four components of capacity, including making a consistent choice, understanding the medical condition and decision, appreciating the risks, and using intact reasoning.
• It is a low bar of DMC for a decision that has a high benefit and low risk (e.g., a blood draw or an x-ray). An intervention that is high risk and low benefit, such as an experimental treatment, would require the highest bar of capacity for consent. The lowest bar for DMC is when the patient decides who should make medical decisions for them.
• In capacity assessments, clinicians must remember that a patient's desire for a certain outcome does not translate into DMC. In these impassioned cases, clinicians need to stick to the four components of capacity in their assessment. The presence of mental illness does not preclude DMC. It is helpful to consider whether the person's psychosis or symptoms of their disorder are influencing the decision.
• If a patient lacks capacity, a surrogate decision maker should be identified. With a surrogate decision maker, it's more likely the patient's wishes will be honored. The surrogate decision maker hierarchy differs state by state.
• Implicit in most DMC assessments are several questions, including: What do we do next if the person lacks capacity? Treatment over objection and the outcome are highly dependent on the hospital and state laws, so clinicians need to confer with their risk management and legal team. Usually, there are specific legal statutes to guide how to proceed if a patient's incapacity puts them at danger of harm.
• When treatment over objection is the only option, teams must consider whether treatment can be delayed, and what the alternative treatments should be. The mechanisms for keeping people in the hospital are usually are coercive.

References

Appelbaum PS. N Engl J Med. 2007;357(18):1834-40.

Appelbaum PS, Grisso T. N Engl J Med. 1988;319(25):1635‐8.

Wynn S. Decisions by surrogates: An overview of surrogate consent laws in the United States. American Bar Association. 2014 Oct 1.

Centers for Disease Control and Prevention. Legal authorities for quarantine and isolation.

National Conference on State Legislatures. State quarantine and isolation statutes.

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]

Renae Beaumont, PhD, assistant professor of clinical psychology at New York–Presbyterian/Weill Cornell Medical Center, spoke with host Lorenzo Norris, MD, about the Secret Agent Society.

The Secret Agent Society is a video gaming–based therapy program aimed at helping children with a range of social and emotional challenges learn the social skills required to make and keep friends. The program also helps children feel happier, calmer, and braver. Dr. Beaumont disclosed her role as creator of the Secret Agent Society program. Dr. Norris has no disclosures.

Take-home points

• The Secret Agent Society is a video gaming–based program that helps children detect how another person is feeling through the interpretation of facial expressions, body language, and vocal tone; use skills to socially engage; and to internally detect their own emotions.
• Secret Agent Society is meant to engage children. It can be used during clinical/therapy sessions to stimulate discussion as well as at home with parents. The indicated age range is 8-12 years, and it is useful for children with autism and with average intellectual functioning.

Summary

• The Secret Agent Society video game has four levels. Level one is about detecting emotions from facial expressions, vocal recognition, and body language. Level two is about detecting personal emotions and using scales to identify the components and range of emotions. Levels three and four are about navigating common social challenges in real time, from losing in a game to collaborating in a group project and learning calming techniques for themselves. To encourage practical application, there is a secret agent journal section where participants can chronicle how they used their skills.
• Beaumont initially developed the game to help children who are on the autism spectrum. For many children on the spectrum, social skills are not innate, but can be taught and developed into life skills to help children meet their potential.
• Parents might be conflicted about encouraging their children to play video games. It's important to consider the evidence behind the game and the age and skills of the research participants. In general, parents should favor video games that teach skills, have educational context, and allow parental involvement. Now that much of social interaction is over the virtual sphere and social media, games and exercises that teach social skills over these mediums help build skills early.
• The Secret Agent Society is meant to engage children. It can be used during a clinical/therapy to stimulate discussion and at home with parents. The game is also a helpful adjunct for psychological services offered online. The indicated age range is 8-12 years, as well as for children with autism and within average age intellectual functioning. New research is showing that the game may also be effective for children with social anxiety and ADHD.
• Gameplay can be integrated into what a clinician is already doing, or the Social Skills Training Institute offers online training for clinicians that would be helpful when using the game to treat patients with multiple comorbidities.
• Therapeutic gaming is useful during social distancing because it builds coping skills and helps children feel more in control of their emotions and actions.

References

Einfeld SL et al. J Intel Dev Disabil. 2018;43(1):29-39.

Sofronoff K et al. Develop Disabil. 2015 Apr 28. doi: 10.1177/1088357615583467.

Beaumont R, Sofronoff K. J Child Psychol Psychiatry. 2008 Jul;49(7):743-53.

Dr. Renae Beaumont's TEDx Talk: https://www.youtube.com/watch?v=KQVv2hKipYQ

Secret Agent Society/Social Skills Training Institute: https://www.sst-institute.net/

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]

Frederick S. Barrett, PhD, is affiliated with the Center for Psychedelic & Consciousness Research (@JHPsychedelics) at Johns Hopkins University, Baltimore (@Hopkins Medicine).

Dr. Barrett spoke with Nick Andrews (@Nick_Andrews_) at @TEDMED 2020, about the research that has been conducted by the Center for Psychedelic & Consciousness Research on the impact of psychedelics, or hallucinogens, on psychiatric disorders. He has no disclosures.

Take-home points

• Dr. Barrett transitioned into neuroscience research through his interest in the effect of music on human emotions and the brain.
• Until 1970, psychedelics such as psilocybin were widely used in clinical research, with more than 1,000 academic papers published about their use. For example, psychedelics were used as a model for schizophrenia and helped identify the role of serotonin in psychosis. They were also studied to treat addiction and as a treatment for existential anxiety in cancer. In 1970, psychedelics were deemed illegal by the Controlled Substances Act which brought the United States in compliance with the 1971 Convention on Psychotropic Substances.
  • Roland R. Griffiths, PhD, and a group at Johns Hopkins have led the way in reestablishing clinical research using psychedelics.
  • Enthusiasm at the lab is borne out by the potential that this research might help many people.
• Institutional concerns also are at work because of the "rich and sordid history" of these compounds.
• In the next 10 years, Dr. Barrett would like to have a clear understanding of the effect size of psychedelics on mood and substance use disorders.
• Psychedelic agents have a novel therapeutic quality: Studies support that a few or even one exposure to a psychedelic compound has a short-term biological effect and can lead to a long-lasting therapeutic effect, such as remission of mood disorder or change in personality characteristics. The clinical outcomes are mediated by the intensity of the psychedelic experience.

Summary

• The Center for Psychedelic & Consciousness Research is working to discern which medical indications have the most promise for being treated with psychedelics. Its goal is a balanced and rational approach to psychedelic research and subsequent treatment considering the societal and political contexts around these drugs.
• Dr. Barrett trained in music education and psychology and has been a musician all this life. He moved into neuroscience during graduate school and used music as a tool to study emotions and the brain.
• Music, meditation, and psychedelics have the similar flow component that inspires converging research questions and a desire to analyze the brain and understand this experience that is central to consciousness.
• Music is fundamental to the human experience, and it is exciting to try to describe the neural circuitry of how music affects the brain and emotions.
• Music is useful in therapy because it can regulate emotions. There has long been an overlap of the use of psychedelics and music in therapy. A prime example of this is guided imagery and music (GIM), which is a specialized form of therapy that arose out of work done by Helen Bonny, PhD, a nurse, music therapist, and concert violinist. Bonny developed a protocol for using music to regulate emotions during psychedelic experiences.
• In the next 10 years, Dr. Barrett would like to have a clear understanding of the effect size of psychedelics on mood and substance use disorders.
• It will be interesting to see whether and how psychedelics are efficacious in treating an array of substance use disorders. If effective, they would be a single-use treatment for addiction to substances that interact with diverse neural circuits.

References

Barrett FS et al. Sci Rep. 2020 Feb 10. doi: 10.1038/S41598-020-59282-y.

Barrett FS, Griffiths RR. Curr Top Behav Neurosci. 2018;36:393-430.

Barrett FS et al. Int Rev Psychiatry. 2018;30(4):350‐62.

Griffiths RR et al. J Psychopharmacol. 2018 Jan;32(1):49-69.

Barrett FS, Janata P. Neuropsychologia. 2016 Oct;91;234-46.

Johnson MW et al. Am J Drug Alcohol Abuse. 2017 Jan;43(1):55-60.

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]

Anne Marie Albano, PhD, professor of medical psychology and psychiatry at Columbia University, New York, and director of the Youth Anxiety Center at New York–Presbyterian Hospital, discusses strategies for treating childhood, youth, and young adult anxiety with Nick Andrews.

Dr. Albano (@AnneMarieAlbano), who also is director of Modern Minds, an anxiety and depression program in Charleston, S.C., spoke with Nick (@Nick_Andrews_) at @TEDMed 2020.

Dr. Albano has no conflicts of interest.

Take-home points

• Early identification of activity avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance.
• Parents should validate that facing anxiety is difficult and that the child might be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears rather than to accommodating and enabling.
• In 2008, Dr. Albano and colleagues published a randomized, controlled trial in the New England Journal of Medicine showing that sertraline, cognitive-behavioral therapy, or a combination of both are all more effective treatments for anxiety than placebo. The treatment effect degrades over time as the developmental challenges change, so children will need booster sessions or must return to treatment.
• Young adults sometimes misinterpret "normal" emotions of apprehension with overwhelming anxiety that disincentivizes them to engage in activities. Therapy teaches children to "ride the wave" of anxiety and continue to move toward new experiences.
• Dr. Albano is currently developing a program that uses virtual reality to role-play difficult developmental experiences that cause anxiety and help young adults learn how to advocate for themselves and problem-solve through anxiety.

Summary

• Dr. Albano noticed that, when parents do not push children to participate or let them get out of activities, this can exacerbate the child's anxiety. Early identification of avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance.
• As a strategy, parents can offer children a choice of activities and push for the child to choose one of them. Parents should validate that facing anxiety is difficult and the child may be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears instead of accommodating and enabling.
• The psychotherapy treatments focus on "riding the wave" of emotions that come with new or intimidating experiences and pushing toward exposures. Young adults sometimes misinterpret "normal" emotions of apprehension with overwhelming anxiety, and this confusion disincentivizes engaging in activities.
• Dr. Albano has always integrated parents into treatment. Working with parents means finding the balance between the parents swooping in to help or rescue the child with coaching, setting limits, and pushing children toward experiences that will be exposures to anxiety.
• The biggest challenge is the extent to which technology tethers parents to children and builds dependency.
• More research needs to be done on what types of children progress with specific types of treatment, how long to stay in treatment, how to transition out of treatment, and when to offer booster sessions. Dr. Albano wants to expand treatment out of clinics and to the places in the community where anxiety happens and is at risk of hindering child development.

References

Walkup JT et al. N Engl J Med. 2008 Dec 25;359(26):2753-66.

Kagan ER et al. Child Psychiatry Hum Dev. 2020 Apr 6. doi: 10.1007/s10578-020-009883-w.

Hoffman LJet al. Current Psychiatry Rep. 2018 Mar 27. doi: 10.1007/s11920-018-0888-R.

Chen A. For kids with anxiety, parents learn to let them face their fears. NPR. Morning Edition. 2019 Apr 15.

McGuire JF et al. Depress Anxiety. 2019 Aug;36(8):744-52.

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]