Psychcast

Cheryl A. King, PhD, clinical psychologist and professor in the department of psychiatry at Michigan Medicine, the academic health system at the University of Michigan, Ann Arbor, joined Nick Andrews at TEDMED2020.

Dr. King spoke with Nick (@Nick_Andrews_) at @TEDMed about a suicide risk screen for teens that is based on computerized algorithm.

Take-home points

• Dr. King is a longtime researcher in teen suicide, and her current project is creating a personalized adaptive suicide risk screen for teens called CASSY (Computerized Adaptive Screen for Suicidal Youth).
• In an adaptive algorithm, subsequent questions will change based on the previous answer. The aim is to create a profile of risk factors and warning signs to generate a risk level that will guide the type of mental health interventions required in the ED and beyond.
• CASSY also is being developed as a universal screen for those who might come to the ED without a mental health history. Many teens who die by suicide do not have previous contact with mental health professionals.
• More research is being done to create and validate treatment interventions for at-risk teens so the risk levels generated in the ED can be met with evidence-based interventions for preventing suicide.
• With the scarce mental health resources in some areas, Dr. King and associates have created an intervention that trains youth-nominated adults from within families to intervene in times of crisis.

Summary

• The CASSY is based on computerized algorithms from data collected by the Pediatric Emergency Care Applied Research Network (PECARN). Within this network, thousands of teens in mental health crisis, after suicide attempt or not, have completed a suicide risk survey aimed at modeling specific warning signs and risk factors for predicting suicide attempts in the next 3 months. In an adaptive algorithm, subsequent questions will change based on the previous answer.
• The risk factors for teen suicide are well established, but teens who attempt are a heterogeneous group. The key to predicting an imminent risk of suicide depends on developing profiles of risk based on how the risk factors and warning signs group together. The result of the CASSY is a level of risk. Individual institutions can set their risk levels.
• CASSY is being developed as a universal screen for those who might come to the ED without a mental health history. Many teens who die by suicide do not have previous contact with mental health professionals. The goal is for CASSY to be integrated into a medical system's EHR in order to make it easier to use on a broad population.
• The most common intervention in an ED for suicide risk is creating a safety plan that involves identifying warnings signs for decompensated mood, brainstorming coping skills, and delineating emergency contacts and a plan of action for suicidal emergency.
• Dr. King and associates developed the Youth-Nominated Support Team intervention, which harnesses the strength of the adults in the family to bolster treatment as usual. The teens nominate "caring adults" who they want to support them after hospitalization, and the adults are provided psychoeducation and training to more effectively support the teens.
• Dr. King is also working on a National Institute of Mental Health–supported study to identify the 24-hour warning signs for suicide attempts. Dr. King thinks there is more work to be done combining the screening tools with interventions in the ED and beyond.

References

King CA. J Am Acad Child Adolesc Psychiatry. 2019 Oct;58(10):S305.

King CA et al. J Clin Psychol Med Settings. 2017 Mar;24(1):8-20.

King CA et al. JAMA Psychiatry. 2019 Feb 6;76(5):492-8.

King CA et al. J Am Acad Child Adolesc Psychiatry. 2019 Dec 9. doi: 10.1016/j.jaac.2019.10.015.

ASQ toolkit for suicide screening: https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml

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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Lorenzo Norris, MD, touches base with Nick Andrews to discuss COVID-19 and to welcome Jacqueline Posada, MD, as an occasional cohost of the MDedge Psychcast.

Dr. Posada, associate producer, interviews Lynne S. Gots, PhD, about treating anxiety, obsessive-compulsive disorder, and other disorders in the midst of the COVID-19 pandemic.

Dr. Gots is an assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington. She has a private psychotherapy practice and has no financial relationships to disclosure.

Take-home points

• Anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities.
• Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. Anxiety is an adaptive response to a threat, and COVID-19 and its repercussions makes this a threatening time.
• In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety.
• Consider the following suggestions for working with anxious patients and clinicians:
  • Acknowledge that social media has the potential for shaming and worsening social anxiety.
  • Limit exposure to news and social media as much as possible.
  • Monitor patients for excessive reassurance-seeking behaviors, and enact ERP plans.
  • Establish a regular but flexible routine with boundaries between work, home, and rest.
  • Practice self-compassion by lowering expectations and even using formal self-compassion practices.

Summary

• Cognitive-behavioral therapy is an evidence-based therapy for obsessive-compulsive disorder (OCD) and many forms of anxiety and depression. Acceptance and commitment therapy (ACT) is considered a third-wave modality of CBT. The acceptance component is based on mindfulness and acceptance of "what is." The commitment component involves identifying core values and actions so that a person can use his/her values as a guide to behaviors. The goal is not to eliminate anxious or obsessional thoughts but to accept they are there and work alongside them.
• Clinicians should be aware that anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. For example, a person's OCD rituals may not be worsened, but an underlying tendency for perfectionism could be triggered as he/she tries to practice "the perfect quarantine."
• Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now.
• In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety.
• Clinicians can look for reassurance-seeking behaviors that have cropped up with increased anxiety. For example, for a person with contamination anxiety, it might be tempting to wash for longer than 20 seconds or to wipe things down compulsively. Advise patients to pick a routine, such as washing for 20 seconds and no more.
• Individuals can choose a reputable source and follow its guidelines. The key is to avoid falling into the trap that more reassurance-seeking behaviors will alleviate anxiety. Using excessive reassurance-seeking behaviors can lead to increased anxiety through the conditional learning mechanism of negative reinforcement.

Other helpful suggestions

• Social media contains a potential for shaming based on comparing oneself and behaviors to others, so individuals should limit exposure to it.
• News intake should be limited to 1 hour a day, and only reputable sources should be used.
• Video calls also can trigger social anxiety because individuals literally have to see themselves more often than usual. Ways to minimize this anxiety include minimizing your personal image or covering the image with a Post-it note.
• For people who are at home all day, establish a routine with a regular wake and sleep time and scheduled breaks. Some type of boundary between home and work life should be created.
• Self-compassion should be practiced. The first step is to lower expectations and live according to your values and what is realistically possible given the extensive changes in the past month.
• Professionals need to seek support from other professionals going through the same thing, so connect with a colleague who can relate to your situation.
  • Remember that, as mental health professionals, we are a repository for everyone else's anxiety and suffering, so we need to be kind to ourselves.
• Consider using a self-compassion practice.
  • Recognize that you are suffering.
  • Connect with the community: Everyone is suffering.
  • Hold that suffering and offer yourself words of compassion and loving kindness.

References and resources

Dr. Gots's website: https://cognitivebehavioralstrategies.com/

Blog post by Dr. Gots that summarizes her clinical advice: https://www.nami.org/Blogs/NAMI-Blog/March-2020/How-to-Protect-Your-Mental-Health-during-the-Coronavirus-Outbreak

Suggestions for when and how to decontaminate groceries: https://www.seriouseats.com/2020/03/food-safety-and-coronavirus-a-comprehensive-guide.html

Self-compassion practice suggestion: https://self-compassion.org/exercise-2-self-compassion-break/

Supportive touch practice for times of stress and vulnerability: https://self-compassion.org/exercise-4-supportive-touch/

Self-compassion evidence-based resources: https://self-compassion.org/the-research/

International OCD Foundation: https://iocdf.org/

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Show notes by Dr. Posada, 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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Lorenzo Norris, MD, interviews Mary D. Moller, DNP, MSN, about taking advantage of the polyvagal theory of anxiety and social engagement during psychotherapy.

Dr. Moller is associate professor of nursing at Pacific Lutheran University in Tacoma, Wash., where she coordinates the psychiatric mental health nurse practitioner doctorate nursing practice program. She also is in practice at Northwest Integrated Health. Dr. Moller has no conflicts of interest.

Later, Renee Kohanski, MD, discusses the sacred relationship that exists between doctors and patients.

Take-home points

• The polyvagal (PV) theory relates autonomic nervous system functions to human behavior and response to trauma.
• The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which together regulate the autonomic state in response to the environment and influence behavior.
• The unmyelinated dorsal vagus nerve controls the "freeze response," while the myelinated ventral vagus nerve modulates social communication and can inhibit the arousal state.
• This theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagus nerve.
• It's easier to apply the insights of polyvagal theory in person, but Dr. Moller suggests specific techniques during teletherapy. She prioritizes eye contact, which has to be done by looking at the camera; modulating your tone of voice to be more soothing; and having the patient use biofeedback techniques, such as taking their pulse during a session to make note of their physical response to anxiety.

Summary

• The association between the sympathetic nervous system and "fight or flight" is well known. The polyvagal theory relates autonomic nervous system functions to behavior and response to trauma. The PV theory presents the autonomic nervous system as a combination of the dorsal and ventral vagus nerve, which regulate the autonomic state in response to the environment and influence behavior.
• The unmyelinated dorsal vagus nerve innervates from the diaphragm down, controlling the "freeze" response. When the dorsal vagus nerve is activated, physical signs can include bradycardia or tachycardia, shallow breathing, and a "pit in the stomach" feeling from slowing down the GI tract.
• The myelinated ventral vagus nerve innervates from the diaphragm up, and modulates social communication and engagement, which can inhibit the arousal state. Social engagement is attunement to the subtle cues occurring during engagement with another person.
• The PV theory is used in psychotherapy to help patients understand the value of using techniques to accentuate the activity of the dorsal vagal nerve.
• In the PV theory, the concept of "neuroception" is likened to an unconscious threat detector sensed by the vagus nerve before the threat is registered by the brain.
• Coregulation is using the environment, most commonly the physical and emotional response of another person, for emotional regulation. This occurs in the therapeutic dyad when the therapist is attuned by and not enmeshed with the patient. Think of coregulation as akin to attachment theory; when the parent is attuned and present, the child feels safer and is able to relax.
• Dissociation is the "freeze" mechanism of reacting to traumatic events in the moment, and again when the memories are triggered by stimulus in the environment. One way to treat dissociation is through engaging the ventral vagus nerve using social connection, such as gentle voice, gentle touch, and deep breathing or other grounding exercises. The PV theory connects the physical and emotional responses to trauma.
• It is impossible to physically connect through telehealth, so Dr. Moller prioritizes eye contact by looking at the camera, though this means taking one's eyes off the patient, as well as having the patient take their own pulse to reinforce the use of biofeedback, and "breathing together" over the video treatment.

References

Dana DA, Porges SW. The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation (New York: W.W. Norton & Co., 2018).

Porges SW. The polyvagal perspective. Biol Psychol. 2007;74(2):116-43.

Beauchaine TP et al. Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biol Psychol. 2007 Feb;74(2):174-84.

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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Email the show: [email protected]

Jay H. Shore, MD, MPH, returns to the Psychcast, this time to conduct a Masterclass lecture on using telepsychiatry in a regulatory environment that is quickly changing because of the physical distancing forced by the COVID-19 pandemic.

Dr. Shore is director of telemedicine at the Helen and Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also directs telemedicine programming at the medical center's department of psychiatry.

He disclosed serving as chief medical officer of AccessCare Services and receiving royalties from American Psychiatric Association Publishing and Springer.

Take-home points

Practicing telepsychiatry has administrative, technological, and clinical considerations.

• Administrative concerns include licensure, prescribing, billing, and establishing a procedure and protocol, especially about emergencies.
• Technological considerations include choosing software, understanding HIPAA compliance during the current COVID-19 crisis (and afterward), and incorporating a virtual clinic workflow, such as scheduling and billing.
• Clinical considerations include understanding how to manage a hybrid relationship with patients and tailoring your clinical style to teleconferencing, such as reading body language through video and directing the environment as the clinician.
• Basic dos and don'ts: The clinical space for teleconferencing of both clinician and patient must be private and secure. Every person in each room must be introduced. The webcam should be placed on top of the computer screen that so eye contact is maintained, and the clinician's head should take up two-thirds of the screen.

Administrative considerations

• To practice telepsychiatry, typically psychiatrists must be licensed in the state in which the patient is located, with some exemptions within federal systems. During the COVID-19 pandemic, however, many states have waived this requirement. Inform your malpractice company that you are now participating in telepsychiatry to ensure that you are covered. During the COVID-19 crisis, the federal government has waived the Ryan Haight Act to allow the prescription of controlled substances without an initial in-person visit.
• Tips for dealing with an emergency: The psychiatrist should establish the physical location of the patient at the start of every appointment and document how to get a hold of them if the connection is lost. It's helpful to know how and when to contact local emergency services; 911 is often a local call based on the GPS of the cell phone. American Telemedicine Association and American Psychiatric Association guidelines suggest using a patient support person. That person would either be a family member or close friend who is onsite during the event with whom you have preconsent to contact the clinicians if an emergency occurs.

Technological considerations

• Telepsychiatry services should have a procedures and protocol document to outline scheduling, billing, documentation, and how to address psychiatric emergencies. For telemedicine, the videoconferencing software must be HIPAA compliant. During the COVID-19 emergency declaration, the Department of Health & Human Services' Office for Civil Rights will exercise "enforcement discretion" and, in most cases, waive penalties of HIPAA enforcement for clinicians who are serving their patients in good faith.
  • Use only technologies such as FaceTime or Skype if you are unable to make adequate connection with HIPAA-compliant technology.
  • Take your in-person operational workflow and try to replicate it virtually. Make sure that people's responsibilities are clearly delineated.

Clinical considerations

• "Hybrid relationships" are increasingly more common with in-person and virtual interactions from videoconferencing, patient portals, email, etc. In hybrid relationships, there are both physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. The virtual space often is convenient and provides a sense of physical and emotional space between clinician and patient, with advantages and disadvantages. The virtual space means rendering care to the patient in their home and gives insight into their environment. The virtual space can also decrease stigma because the patient does not have to seek care in a physical clinic. Sometimes, more small talk than usual about the environment is helpful to bridge that virtual gap. Use more active inquiry into emotions or body language if these are not clearly communicated over videoconference.
• Dos and don'ts: Make sure that the lighting is good. Use the picture setting, so you can monitor your body language during the session.
  • Make sure you are not too passive during the session. Be proactive. Animate yourself a little more than you would in person.
  • Ask patients questions about their environment.
  • Have a lower threshold for asking how patients are doing. More active inquiry can prove helpful.

References

American Psychiatric Association Telepsychiatry Toolkit: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit

American Telemedicine Association: https://www.americantelemed.org/

Joint guideline on telepsychiatry from APA and ATA: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-and-ata-release-new-telemental-health-guide

State licensure exemptions: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

HHS HIPAA information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

Ryan Haight Act information: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/ryan-haight-act

Yellowlees P and Shore JH. Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals. Arlington, Va.: American Psychiatric Association Publishing, 2018.

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

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As the nation's health care system braces for COVID-19 cases, physicians who've faced the pandemic first have critical lessons for everyone.

In this bonus episode, two Seattle-area critical care leaders explain how their medical centers are preparing for and responding to their region's early outbreaks. And they share some creative approaches that are uniting Seattle's critical care departments.

MDedge Psychcast host Lorenzo Norris, MD, interviews Steven Wengel, MD, about the challenges of loneliness in geriatric populations in nursing homes, especially during the current COVID-19 pandemic.

Dr. Norris also discusses potential interventions with Dr. Wengel, who is a geriatric psychiatrist at the University of Nebraska Medical Center in Omaha.

And later, in the "Dr. RK" segment, Renee Kohanski, MD, talks about how, in the midst of the pandemic, we are slowing down while we're speeding up … and are learning how to use – and not abuse – technology.

Take-home points

• Loneliness has been defined as a form of social pain; it is more than sadness or a "state of mind."
• Loneliness and being alone are separate issues suggesting that loneliness is more of an emotional state and being alone is often a choice. Loneliness can be characterized as deficits in authentic interactions and connection because you can be surrounded by people and still feel lonely.
• Loneliness has been studied as a predictor of health problems and is identified as a risk factor for early mortality and dementia and as a predictor of chronic illnesses such as depression.
• When it comes to treating loneliness in the geriatric population, favor any type of intervention over none and avoid chalking up symptoms as "just loneliness." Basic interventions include providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive type symptoms with an SSRI.

Summary

• In a study of nursing-home patients, 9% report loneliness often or always and 25% report loneliness sometimes; older adults are more susceptible to loneliness secondary to frailty and limited transport options.
• Loneliness is an independent risk factor for early mortality and a predictor for other chronic diseases including dementia, hypertension, depression, and overall poor health.
• During the COVID-19 pandemic, most nursing homes are under lockdown, and all visitors are barred to minimize the introduction of COVID-19 to the facilities. This means residents are unable to see family and loved ones. This necessary intervention brings up the question of quality of life over quantity of life for older individuals. Isolation and social distancing have also taken away group activities like communal meals and games with socializing. Children of institutionalized patients might also feel a sense of loss and guilt as they are not allowed to see their loved ones. Particular to geriatrics, physical touch is essential to healing emotional pain, for example, a gentle touch or massage to relieve anxiety or physical redirection to ease agitation secondary to dementia.
• Two primary means of addressing loneliness for the geriatric population include providing structure and finding opportunities for volunteerism such as helping other residents or completing simple tasks within the institution.
• Loneliness and major depressive disorder are difficult to differentiate in the older population. Dr. Wengel recommends favoring intervention over none. This means using basic interventions like providing structure and routine, pushing someone to engage with others through volunteerism, or having a low index of suspicion to treat depressive symptoms with an SSRI.

References

Jansson AH et al. Loneliness in nursing homes and assisted living facilities: Prevalence, associated factors and prognosis. Jour Nursing Home Res. 2017;3:43-9.

Social isolation, loneliness in older people pose health risks. National Institute on Aging. https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks.

Cacioppo JT. Loneliness: Human Nature and the Need for Social Connection. New York: W.W. Norton and Company, 2008.

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

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MDedge Psychcast host Lorenzo Norris, MD, interviews Sy Atezaz Saeed, MD, MS, about his annual analysis of the key studies that could change day-to-day psychiatric practice.

Dr. Norris's conversation with Dr. Saeed is based on a two-part evidence-based review that identified the top 12 research findings for clinical practice from July 2018 to June 2019. Part 1, which Dr. Saeed wrote with Jennifer B. Stanley, MD, and Part 2 were published in Current Psychiatry.

Take-home points

• Each year, Dr. Saeed identifies 10-20 high-quality journal articles with direct impact on clinical practice that, if used appropriately, can generate better outcomes for psychiatric patients. The goal of the list is to close the gap between cutting-edge science and clinical practice.
• Secondary literature (for example, Cochrane Reviews, NEJM Journal Watch, and so on) is used to differentiate the clinically relevant "signal" from the noise of all the research produced.
• Knowledge changes over time, so it's important to be up to date but flexible in how the knowledge is applied.

Summary

• The methodology used to generate the list is aimed at identifying 10-20 useful articles. Dr. Saeed took a three-pronged approach that reviewed research findings suggesting readiness for clinical utilization published between July 1, 2018, and June 30, 2019; asked several professional organizations and colleagues: "Among the papers published from July 1, 2018, to June 30, 2019, which ones in your opinion have (or are likely to have or should have) impacted/changed the clinical practice of psychiatry?"; and looked for appraisals in postpublication reviews such as NEJM Journal Watch, F1000 Prime, Evidence-Based Mental Health; commentaries in peer-reviewed journals; and other sources that suggest an article is of high quality and clinically useful.
• This approach generated a solid list of articles to consider presenting at journal clubs or a topic to present at grand rounds.
  • Studies on this list also might overlap with research covered in popular media, so the list is a tool that clinicians can use to answer questions patients raise.
• The secondary literature is used to differentiate the clinically relevant "signal" from the noise of all the research produced. Those secondary sources include Cochrane Reviews, BMJ Best Practice, NEJM Journal Watch, Evidence-Based Mental Health, and commentaries in peer-reviewed journals to help distill the clinically useful articles for a busy clinician.
• Four of the 12 articles that affected Dr. Saeed's practice covered the risk of death associated with antipsychotic medication usage in children, the role of antipsychotic polypharmacy in schizophrenia to decrease inpatient hospitalizations, the outcomes associated with prescribing different adjunctive medications in combination with antipsychotics, and the use of prazosin for nightmares in PTSD.

References

Saeed SA et al. Top research findings of 2018-2019 for clinical practice. Part 1. Current Psychiatry. 2020 January;19(1):12-8.

Saeed SA. Top research findings of 2018-2019 for clinical practice. Part 2. Current Psychiatry. 2020 February;19(2):22-8.

Ray WA et al. Association of antipsychotic treatment with risk of unexpected death among children and youths. JAMA Psychiatry. 2019;76(2):162-71.

Tijhonen J et al. Association of antipsychotic polypharmacy vs. monotherapy with psychiatric rehospitalization among adults with schizophrenia. JAMA Psychiatry. 2019;76(5):499-507.

Stroup TS et al. Comparative effectiveness of adjunctive psychotropic medications in patients with schizophrenia. JAMA Psychiatry. 2019;76(5):508-15.

Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507-17.

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

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Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, conducts a Masterclass on what psychiatrists and other mental health clinicians can do to mitigate the impact of COVID-19.

Dr. Ritchie is writing additional commentaries on this topic for MDedge Psychiatry.

And later, in the "Dr. RK" segment, Renee Kohanski, MD, says that, with simple tools or guidelines, humans have the ability to withstand adversity that is stronger than we will ever know.

Take-home points

• Epidemics and pandemics are characterized by fear and anxiety.
• Quarantine will be a challenge for patients with addictions and vulnerable populations such as individuals who are homeless.
• Psychiatrists can aid with social distancing by providing patients refills for psychotropic medications without requiring an in-person visit and switching to telepsychiatry where possible. The Coronavirus Preparedness and Response Supplemental Appropriations Act waives Medicare telehealth reimbursement restrictions for mental health services during certain emergency periods.
• Inpatient psychiatric units must take special precautions to prevent spread of COVID-19, such as improving procedures for sanitizing communal areas and items, limiting visitation, screening patients for symptoms, and arranging transfer when appropriate. COVID-19 infection can spread on units to patients and staff and may compromise clinicians' ability to provide care safely.
• Psychiatrists also play a role in helping address the shortage of personal protective equipment (PPE) by talking to patients about the appropriate use of PPE and sanitizer.

Summary

• Emotional response to pandemics: Epidemics and pandemics are characterized by fear and anxiety as people worry about their risk of exposure, infection, and spreading the pathogen. Clinics can alleviate the anxiety by transitioning to telehealth when possible, discouraging handshakes, keeping a distance from patients, and rearranging waiting rooms and other spaces to provide more room between chairs and tables. Psychiatrists can encourage patients and fellow clinicians to engage in activities that normally reduce anxiety, such as exercising, setting aside time for relaxation at home, and taking regularly prescribed or over-the-counter medications.
• Quarantine considerations: Quarantine and isolation will be difficult for most people, and especially so for patients with psychiatric disorders, including substance use disorders. Psychiatrists can prepare themselves and patients for quarantine by refilling medications for more than 30 days. The Centers for Disease Control and Prevention recommends clinicians refill nonurgent medications without an in-person visit. Patients who are addicted to alcohol or other substances may be tempted to leave the house to acquire those substances. It may be a physician's responsibility to either suggest to patients that they have enough of their substance at home or give them something to treat withdrawal or cravings.
• Considerations for inpatient psychiatric units: Psychiatric units are built for socialization and communal treatment; thus, psychiatric units will have to change policies, including limiting visitors; decreasing occupancy on the units; and ensuring that communal items such as phones, chairs, and books are properly sanitized.
• Long-term psychological impact of a pandemic: The negative economic impact of the pandemic, such as unemployment in the tourism and service industries, may have consequences including rising rates of depression and anxiety, suicides, and increases in domestic violence and substance abuse. Psychiatrists can help address the shortage of PPE by talking to patients about the appropriate use of PPE and sanitizer. It is wise to have a stock of food, medications, and supplies for 14-21 days of quarantine, but in a public health emergency we can urge patients and ourselves to be mindful of the needs of others and avoid hoarding. We need to remind ourselves, our patients, and our colleagues to stay healthy by getting enough sleep, taking on the appropriate level of readiness, and remaining flexible as our daily lives are changed by the pandemic.

References

Centers for Disease Control and Prevention. Interim guidelines for healthcare facilities: Preparing for community transmission of COVID-19 in the United States.

H.R. 6074: Coronavirus Preparedness and Response Supplemental Appropriations Act. Passed Congress 2020 Mar 6.

Brooks SK et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet. 2020 Mar 14;395(10227):912-20.

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Lorenzo Norris, MD, interviews Nina J. Gutin, PhD, a psychologist with a private practice in Pasadena, Calif., about losing patients and loved ones to suicide.

Dr. Gutin wrote two evidence-based reviews on the topic late last year. The reviews were published in Current Psychiatry.

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Take-home points

• When mental health clinicians lose a patient to suicide, the sequelae can include stigma, potential legal consequences, impact on future clinical work, and restraints on processing the loss because of confidentiality concerns.
• The American Association of Suicidology founded the Clinician Survivor Task Force (CSTF), which provides consultation, support, and education to mental health professionals to help them respond to the personal/professional loss from the suicide of a patient or loved one.
• Mental health institutions can benefit from protocols on how to respond to a potential completed suicide, so clinicians and families are not left in a vacuum of uncertainty and blame.
• After a patient suicide, clinicians need an anonymous or safe space to talk about the patient and the suicide without breaking confidentiality. This can be an online forum, such as the one sponsored by the CSTF, or an institution can identify a supportive colleague who has suffered a similar loss.
  • The CSTF forum allows clinicians to remain anonymous.

Summary

Several domains require attention after the loss of a patient from suicide:

• Confidentiality restrains the ability to talk about the details of the loss, which stymies grief and learning from the event. Restraints of confidentiality pertain to individual clinicians and clinical teams. On a team, it might feel as if the clinicians are unable to process the loss as a group and talk about important details.
• Legally, clinicians worry about potential lawsuits, and "psychological autopsies" can lead to retraumatization. Clinicians might struggle with how – or whether – to talk to a patient's family after suicide. Some lawyers advise compassion over caution. In collaboration with lawyers who advise what can be disclosed, a clinician can speak with a family, and this compassion toward families might decrease the risk of a lawsuit.
• Clinicians should be prepared for a patient suicide to affect their clinical work. A clinician might become hypervigilant about suicide risk and overreact, or they might experience denial about the risk and avoid asking questions about suicide.
• Ethically, suicide is an "occupational hazard" of working in the mental health field. Blaming clinicians for patient suicide hampers the depth of working with people with mental illness by causing some clinicians to avoid "high-risk" patients.
• The stigma around death by suicide extends to the survivors of the loss. When clinicians express vulnerability about loss, it can be interpreted as guilt. Clinicians are expected to keep going no matter what, which is unrealistic. Grief over a patient's death should be neither pathologized nor shamed.
• Guilt and blame are the flip sides of each other; both express the complexity and ambiguity of these kinds of losses.
• Institutions should have "postvention" protocols in place to respond to the likely event of a completed suicide. Guidelines can address what needs to be covered in a review of the case while also supporting clinicians, so they don't feel like it's a tribunal. Clinicians should be warned of the normal sequelae of a client suicide, and institutions can make accommodations based on the expected impact of suicide on a clinician's work. Institutions can provide support by connecting clinicians who have also lost clients to suicide to dispel the belief that they are alone in their loss and to mitigate self-blame.
• The CSTF provides support through in-person and online support groups, and postvention protocols for institutions. It also and maintains a bibliography of research on clinician survivorship.

References

Gutin NJ. "Losing a patient to suicide: What we know." Current Psychiatry. 2019 Oct 18(10):14-6,19-22,30-2.

Gutin NJ. Losing a patient to suicide: Navigating the aftermath. Current Psychiatry. 2019 Nov 18(11):17-18,20,22-4.

American Association of Suicidiology. Clinicians as Survivors: After a Suicide Loss.

Owen JR et al. Suicide symposium: A multidisciplinary approach to risk assessment and the emotional aftermath of patient suicide. MedEdPORTAL. 2018 Nov 28;14:10776.

Myers MF and Fine C. Touched by suicide: Bridging the perspectives of survivors and clinicians. Suicide Life Threat Behav. 2007 Apr;37(2):119-26.

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

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

Email the show: [email protected]

Jonathan Meyer, MD, returns to the Psychcast, this time to conduct a Masterclass lecture on treating patients with lumateperone.

Dr. Meyer, of the University of California, San Diego, disclosed receiving either speaking honoraria or advising fees from several companies, including Intra-Cellular Therapies, which developed lumateperone (Caplyta).

Later, Renee Kohanski, MD, discusses tailored interventions psychiatrists can incorporate into their practices to address overweight and obesity resulting from medications tied to weight gain.

Take-home points

• Lumateperone, an atypical antipsychotic, was approved by the Food and Drug Administration for the treatment of adults with schizophrenia on Dec. 20, 2019. It has only one approved effective dose of 42 mg given with food.
  • Further studies might define doses higher or lower, but those data are not available yet.
  • The only adverse effect found with lumateperone was somnolence or sedation. Lumateperone was 24%; placebo was 10%.
• The medication has a low affinity and occupancy of the dopamine D2 receptors. This pharmacodynamic trait is reflected by the relatively low rates of extrapyramidal side effects in the clinical trial data.
  • For now, the short-term studies of lumateperone suggest limited metabolic and endocrine effects, compared with other atypical antipsychotics.
• The primary indication for using lumateperone may be its tolerability profile, because nonadherence contributes to the morbidity of schizophrenia.
• Lumateperone is not a drug that should be used for treatment-resistant schizophrenia. The only drug that should be used for refractory patients with schizophrenia is clozapine (Clozaril).

Summary

• Lumateperone has a unique pharmacologic profile. It has a low affinity for muscarinic, histaminergic, and alpha-adrenergic receptors. In the clinical trials, the primary side effect reported was somnolence and/or sedation.
• The medication also has a lower affinity for dopamine D2 receptors and occupies less than 40% of these receptors even at peak-dose timing. Conventional treatment of psychosis suggests that antipsychotic properties of D2 antagonist medications occur when 60%-80% of D2 receptors are occupied. Yet, there may be other properties of atypical antipsychotics that can increase the efficacy with lower levels of D2 blockade.
• Knowledge of alternative mechanisms comes from studying other antipsychotics. For example, pimavanserin (Nuplazid), an antipsychotic medication for treatment of psychosis in Parkinson's disease, has no affinity for any dopamine receptors. Instead, it has a high affinity for serotonin 5-HT2A receptors as an inverse agonist and antagonist likely in cortical circuits with downstream glutamate signaling to dopamine circuits in the ventral tegmental area, which then decreases the amount of dopamine released in the mesolimbic pathway.
  • Pimavanserin does not have any activity on the presynaptic D2 autoreceptors. Though counterintuitive, other atypical antipsychotics block the D2 presynaptic autoreceptor, which increases dopamine release. This mechanism is possibly why other antipsychotics require a 60%-80% D2 blockade to be effective in treating psychosis. In vitro studies suggest that lumateperone does not have presynaptic autoreceptor antagonism, which could be another reason why it doesn't need as much D2 antagonism to be an effective antipsychotic agent.
• Lumateperone also is a weak inhibitor of serotonin reuptake occupying 30% of the serotonin receptors. Given its diverse pharmacologic mechanisms, lumateperone may confer antidepressant properties, and clinical trials are in the process to evaluate the use of lumateperone in bipolar depression.
• The drug is expected to be available at the end of March 2020.

References

Meltzer HY et al. Pimavanserin, a selective serotonin (5-HT)2A-inverse agonist, enhances the efficacy and safety of risperidone, 2 mg/day, but does not enhance efficacy of haloperidol, 2 mg/day: comparison with reference dose risperidone, 6 mg/day. Schizophr Res. 2012;141(2-3):144-52.

Correll CU et al. Efficacy and safety of lumateperone for treatment of schizophrenia: A randomized clinical trial. JAMA Psychiatry. 2020 Jan 8. doi: 10.1001/jamapsychiatry.2019.4379.

Corponi F et al. Novel antipsychotics specificity profile: A clinically oriented review of lurasidone, brexpiprazole, cariprazine, and lumateperone. Eur Neuropsychopharmacol. 2019;29(9):971-85.

U.S. National Library of Medicine. Lumateperone drug label

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

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

Email the show: [email protected]