Psychcast

Patricia Westmoreland, MD, returns to the Psychcast to conduct a Masterclass on treating bulimia.

Dr. Westmoreland, an attending psychiatrist at the Eating Recovery Center in Denver, previously discussed eating disorders. She is an adjunct assistant professor in the department of psychiatry at the University of Colorado at Denver, Aurora, and has a private forensic psychiatry practice in Denver.

Takeaway points

• Anorexia nervosa and bulimia nervosa can have life-threatening medical complications.
• All medical complications can resolve with consistent nutrition and full weight restoration.
• Eating disorders must be treated and associated behaviors stopped to prevent complications from returning.
• Anorexia-related medical complications usually are attributable to weight loss and malnutrition.
• Bulimia-related medical complications can occur at any weight, and are related to the mode and frequency of purging. Complications include metabolic abnormalities, such as electrolyte and acid-base disturbances, volume depletion, and damage to the colon.
• Patients with bulimia have a lower mortality rate than do those with anorexia. However, the mortality of patients with bulimia is two times higher than that of age-matched healthy controls because of acid-base disturbances and severe electrolyte abnormalities.
  • The weight of the patients with bulimia does not matter. Acid-based disturbances and severe electrolyte abnormalities can kill patients at any time without warning and at any weight.

Summary

• About 90% of purging behaviors consists of self-induced vomiting and/or laxative abuse.
• Self-induced vomiting can cause local complications such as gastric reflux, which can lead to dysphagia and dyspepsia; hematemesis from Mallory-Weiss tears in the esophagus; nosebleeds and subconjunctival hemorrhages; and parotid gland enlargement, known as sialadenosis, which is a chronic, noninflammatory cause of swelling of the major salivary glands.
• Systemic complications of self-induced vomiting include metabolic derangements, such as hypokalemia, metabolic alkalosis, and volume depletion, which can lead to pseudo-Bartter syndrome from chronic aldosterone secretion as the body attempts to maintain blood pressure; the syndrome is characterized by hyperaldosteronism, metabolic alkalosis, hypokalemia, and normal blood pressure.
• Treatment of local complications: Gastric reflux can be treated with proton pump inhibitors, and the patient should be screened for Barrett's esophagus with esophagogastroduodenoscopy. Dental complications such as erosion of the enamel should be addressed with fluoride-based mouthwashes and toothpastes, and gentle toothbrushing. Parotid gland enlargement is treated by sucking on sour candies, applying hot packs, and using anti-inflammatory medications.
• Treatment of systemic complications: Hypokalemia, which is diagnosed on a basic metabolic panel, needs immediate repletion orally or intravenously. Depending on the severity of the hypokalemia, the patient may need cardiac monitoring in the hospital or ICU to prevent mortality from a lethal arrhythmia. In pseudo-Bartter syndrome, the elevated aldosterone does not normalize until a few weeks after purging stops, so individuals can develop edema and the other electrolyte abnormalities. Treatment is spironolactone, 25-200 mg/day.
• Complications from laxative abuse occur primarily from stimulant laxatives, which stimulate the myenteric plexus, the nerves of the intestines, and increase intestinal secretions and motility. Cathartic colon syndrome occurs from continued use of stimulant laxatives, which damage the nerves of the colon by rendering it incapable of peristalsis without continued use of laxatives. Individuals who abuse laxatives more than three times per week for at least 1 year are at risk of cathartic colon syndrome and need to stop laxatives immediately.

References

Westmoreland P et al. Medical complications of anorexia nervosa and bulimia. Am J Med. 2016;129(1):30-7.

Mehler PS, Walsh K. Electrolyte and acid-base abnormalities associated with purging behaviors. Int J Eat Disord. 2016 Mar;49(3):311-8.

Gibson D et al. Medical complications of anorexia nervosa and bulimia nervosa. Psychiatr Clin North Am. 2019 Jun;42:263-74.

Sato Y, Fukado S. Gastrointestinal symptoms and disorders in patients with eating disorders. Clin J Gastroenterol. 2015 Oct;8(5):255-63.

* * *

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

Email the show: [email protected]

Charles L. Raison, MD, returns to the Psychcast to conduct a Masterclass on psychedelics for patients with major depressive disorder.

Dr. Raison, professor of psychiatry at the University of Wisconsin–Madison, previously conducted a Masterclass on the risks and benefits of antidepressants. He disclosed that he is director of translational research at the Usona Institute, also in Madison.

Later, Renee Kohanski, MD, raises questions about the felony child abuse case of pediatric emergency department doctor John Cox.

Takeaway points

• Psychedelics are a range of compounds that share a common mechanism as agonists at the postsynaptic 5-HT2A serotonin receptor.
• Psychedelic agents have a novel therapeutic quality. Studies suggest that a few or even one exposure to a psychedelic compound, which has a short-term biological effect, leads to 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.
• A psychedelic experience is characterized by profound, rapid alterations in what is seen, sensed, felt, and thought. It often leads to personal growth with experiences of transcendence. Subjects in trials often report a "mystical experience" they describe as a sense of unity with the universe and understanding of one's deeper purpose. Psychedelic experiences also are characterized by a difficulty in describing them with words.
• Because psychedelics are illegal substances, the traditional route of pharmaceutical companies' funding the research for clinical trials is not available. Organizations such as Usona Institute and MAPS (Multidisciplinary Association for Psychedelic Studies) are leading the way.
• The Food and Drug Administration has granted psilocybin a "breakthrough therapy designation" for the treatment of major depressive disorder.

Summary

• Psilocybin, lysergic acid diethylamide (LSD), mescaline, ayahuasca (active ingredient: N,N-dimethyltryptamine [DMT]), and 3,4-methylendioxy-methamphetamine (MDMA) are all classified as psychedelics. Psychedelics have been used for thousands of years for spiritual ceremonies.
• Psychedelics came to the attention of medicine and science after 1943 when Albert Hofmann, PhD, a chemist at a Sandoz Lab in Basel, Switzerland, synthesized LSD and accidentally ingested it, serendipitously identifying its mind-altering properties.
• Until 1970, psychedelics were widely used in clinical research, and more than 1,000 academic papers about their use were published. For example, psychedelics were used as a model for schizophrenia and helped identify the role of serotonin in psychosis. They also were studied to treat addiction and as a treatment for existential anxiety in cancer. In 1971, psychedelics were declared illegal under the U.N. Convention on Psychotropic Substances.
• Researchers returned to psychedelics in the 2000s, examining a variety of uses, including the capability to reliably induce psychedelic experience in healthy normal volunteers (no previous psychiatric diagnosis) and promote emotional well-being in healthy normal volunteers. The role of psychedelics as medicine are once again being studied in a variety of contexts, such as mood disorders, PTSD, addiction, and phase-of-life problems.
• Most notable from the research is the capability of psychedelic compounds to induce long-lasting effects on personality, mood disorders, and PTSD after one or a few ingestions. What is remarkable is how the therapeutic effect remains long after the biological presence of the compound is gone from the body. The clinical outcomes are mediated by the intensity of the psychedelic experience.
• The Usona Institute, a medical research organization, started as a nonprofit to advance the research into psychedelics needed for the FDA to approve psychedelics as a treatment. Because psychedelics are still illegal, the traditional route of pharmaceutical companies funding this type of research is not available.
• The FDA has granted psilocybin a "breakthrough therapy designation" for the treatment of major depressive disorder. The breakthrough therapy designation "indicates that the drug may demonstrate substantial improvement on a clinically significant endpoint(s) over available therapies."
• The breakthrough therapy designation is for major depressive disorder, not for treatment-resistant depression, suggesting that the FDA recognizes the shortcomings of current treatments for depression.

References

Johnson MW, Griffiths RR. Potential therapeutic effects of psilocybin. Neurotherapeutics. 2017 Jul;14(3):734-40.

Griffiths RR et al. Psilocybin-occasioned mystical-type experience in combination with meditation and other spiritual practices produces enduring positive changes in psychological functioning in trait measures of prosocial attitudes and behaviors. J Psychopharmacol. 2018 Jan;32(1):49-69.

Johnson MW et al. Long-term follow-up of psilocybin-facilitated smoking cessation. Am J Drug Alcohol Abuse. 2017 Jan;43(1):55-60.

Griffiths RR et al. Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. J Psychopharmacol. 2016 Dec;30(12):1181-97.

Rozzo M. Book review: "'How to Change Your Mind." Columbia Magazine. 2018 Fall.

* * *

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

Email the show: [email protected]

William Lynes, MD, joins guest host Michael F. Myers, MD, to discuss his struggles with medical and psychiatric hardships, his suicidality, and the eventual suicide attempt that changed his life. Dr. Myers is professor of clinical psychiatry, State University of New York, Brooklyn.

Dr. Lynes, a retired urologist, author, and speaker/advocate on physician burnout and suicide, divides his professional life into two distinct eras: 1987-1998, during which he had a successful practice and happy life, and after 1998, when he spiraled downward medically and psychiatrically.

After meeting another physician with a similar experience who had published her story of burnout and mental health struggles in 2015, Dr. Lynes decided to speak out. Eventually, he published an essay about his experience in the Annals of Internal Medicine.

Take-home points

• Being open with close colleagues or supervisors about mental health struggles and/or burnout can provide a much-needed lifeline to struggling physicians.
• Addressing burnout and mental health diagnoses of physicians requires medical groups and institutions to provide access to psychiatric treatment from clinicians outside of the professional network in which the physician practices.
• Practicing medicine can be a 24/7 profession, and being "on" all the time can contribute to burnout. Lifestyle choices such as exercise, hobbies, family, and spirituality are all helpful outlets to address the constancy of practicing medicine.
• Giving in to the notion that you can treat yourself is not a good idea.
• Decreasing the stigma tied to mental illness can be helped by people with lived experience, such as Dr. Lynes.

* * *

References

Lynes W. The last day. Ann Intern Med. 2016 May 3;164(9):631.

Myers MF and Freeland A. The mentally ill physician: Issues in assessment, treatment and advocacy. Can J Psychiatry. 2019 Dec 6;64(12):823-37.

Forbes MP et al. Optimizing the treatment of doctors with mental illness. Aust NZ Psychiatry. 2019 Feb;53(2):106-9.

Myers MF. "Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared." 2017 Feb 14. (Self-published).

Bird JL. "Using Narrative Writing to Enhance Healing." Medical Information Science Reference, 2019.

* * *

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

Email the show: [email protected]

George T. Grossberg, MD, conducts a Masterclass on treating mood disorders in geriatric patients from the CP/AACP Psychiatry Update 2019 meeting in Las Vegas. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Grossberg is the Samuel W. Fordyce professor and director of geriatric psychiatry at St. Louis University School of Medicine in St. Louis.

Later, Renee Kohanski, MD, discusses the first thing psychiatrists can do for patients.

Take-home points from Dr. Grossberg:

• The prevalence of major depressive disorder among older adults who reside in the community is similar to that of the general population (6%). In nursing homes, the prevalence of significant clinical depression is close to 25%.
• Depression in older adults in long-term care facilities is underrecognized and undertreated. Risk factors for depression include advanced age (80-90 years), loneliness and lack of social support, painful conditions, frailty, and medical comorbidities. Medications that are central nervous system depressants, such as opiates and benzodiazepines, also can contribute to depression. Alcohol can also be a depressant. Depression in the face of cognitive impairment is extremely common and can even speed cognitive decline.
• Apathy, defined as lack of motivation, can look like depression. However, depression will have amotivation coupled with vegetative symptoms, such as disrupted sleep and loss of appetite, and mood changes, such as sadness and tearfulness. Low-dose stimulants are effective for apathy, but antidepressants are not; so, it's important to differentiate the two.
• Undiagnosed and untreated depression contributes to a significant degree of morbidity because it can slow recovery in rehabilitative settings and impair adherence to essential medications. Treating depression also can improve pain control by making it more tolerable as a somatic symptom.
• Individuals older than 65 years account for more than 20% of all completed suicides in the United States. Psychological autopsy studies suggest that many of these individuals had undiagnosed depression.
• Clinicians should not shy away from treating geriatric patients for depression with medication and interventions such as cognitive-behavioral therapy. With pharmacotherapy, start low, go slow, and titrate up to a therapeutic dose. Older adults may take longer, up to 8-12 weeks, to respond to SSRIs, so it's imperative not to give up on medications too soon.
• Electroconvulsive therapy is the most effective treatment for severe depression in geriatric patients. Some consider advanced age an indication for ECT; medical comorbidities are not a contraindication for ECT.
• It is unclear how effective ketamine is in older patients, but it deserves consideration.
• Prompt diagnosis and treatment of mood disorders is paramount in patients of advanced age and those living in long-term care facilities. Treating depression in the older patient also improves the quality of life for caregivers and professional staff.

References

Birer RB et al. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician. 2004 May 15;69(10):2375-82.

Sjoberg L et al. Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults. J Affect Disord. 2017 Oct 15;221:123-31.

Grossberg GT et al. Rapid depression assessment in geriatric patients. Clin Geriatr Med. 2017 Aug;33(3):383-91.

***

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

In this, the 100th episode of Psychcast, Nick Andrews talks with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about the January front-page article in Clinical Psychiatry News that featured Matthew E. Seaman, MD, an emergency physician with depression who took his own life. The article describes the Dr. Seaman faced.

Later, Christine B.L. Adams, MD, a psychiatrist who practices in Louisville, Ky., discusses her book, "Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships" (Santa Barbara: Praeger, 2018), with Dr. Norris.

Take-home points from Dr. Adams

• Children learn emotional patterns in families. These behaviors get reinforced. As children form dating relationships, for example, those patterns continue to be reinforced.
• People may go on autopilot and have knee-jerk reactions in response to people, which allows them to react emotionally without thinking about what's necessary for each person.
• Long-term dynamic psychotherapy can help patients observe what they are doing in relationships and what others are doing.
• Ultimately, patients can be taught to look at and uncover their automatic responses.
• Once these patterns are uncovered and moved from the emotional realm to the intellectual realm, they can be interrupted.

Genesis and development of the book's principles

• Homer B. Martin, MD, a Louisville, Ky.–based adult psychiatrist who worked with Dr. Adams for 30 years, developed the original premise of the book. When he died, his wife asked Dr. Adams, who was his protégé, to finish it.
• The book is based on the observations made by Dr. Martin during his 40 years of conducting psychotherapy with patients. It is designed to be accessible both to psychiatric trainees as well as to general readers.
  • Dr. Adams started teaching the concepts in the book during a 6-week university class to determine whether the ideas were digestible and useful.
  • Mainstream movies were used to help people learn to observe and identify roles that were emotionally conditioned and to determine how a character's change in behavior would change the other person.
    • Movies that can be used to help people identify problematic patterns include "Ordinary People," "Gran Torino," "The Remains of the Day," "The Door in the Floor," and "When Harry Met Sally."

References

Yazici E et al. Use of movies for group therapy of psychiatric inpatients: Theory and practice. Int J Group Psychother. 2014 Apr;64(2):254-70.

Ross J. You and me: Investigating the role of self-evaluative emotion in preschool prosociality. J Exp Child Psychol. 2017 Mar;155:67-83.

Werner AM et al. The clinical trait self-criticism and its relation to psychopathology: A systematic review – Update. J Affect Disord. 2019 Mar;246:530-47.

* * *

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

In episode 99 of the Psychcast, Frank Yeomans, MD, PhD, clinical associate professor of psychiatry at the Weill Medical College of Cornell University, Ithaca, N.Y., spoke with Dr. Norris at the Group for the Advancement of Psychiatry (GAP) fall 2019 meeting about treating patients with personality disorders.

Characteristics of personality disorders

• A personality disorder affects the quality of a person's experience and his or her ability to deal with challenges in life, including comorbid psychiatric disorders. A personality disorder is not based on symptoms alone and determines how people engage with their environment; it is a part of the biological side of psychiatry.
• The DSM traditionally relied on a traits-based definition of personality disorders. Yet, in the "emerging measures and models" section, the DSM-5 describes a dimensional/categorical model of personality disorders, which looks at personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. This harkens back to the concept of borderline personality organization as outlined by Otto F. Kernberg, MD.
• The dimensional model suggests that individuals with personality disorders benefit from behavioral therapies, such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT), to treat problematic traits. Exploratory and insight-focused psychotherapies can help individuals understand their personality organization. Ideally, the treatments for personality disorders would be sequenced, starting with CBT or DBT and transitioning into exploratory therapy.
  • Much like borderline personality disorder, at the core of narcissistic personality disorder is a fragmented sense of self, but in the latter disorder, a self-centered narrative exists that is coherent to the person but does not support reality. If mental health is defined as the ability to adapt to the different circumstances of life, people with narcissism cannot adapt and instead, develop a grandiose narrative to soothe the fragmented self.
    • Therapeutic interventions for narcissism focus on disrupting the narrative in a gentle way that allows patients to understand the model in which they currently experience the world and then reconstitute an adaptive narrative.
  • An effective treatment approach is psychodynamic therapy, with a focus on a treatment contract and specific, explicitly agreed-upon goals. Try to focus more on the interaction with the patient than on the narrative content of the session. The therapy must focused on how the patient acts in therapy, and their adaptations and reactions, because these are the actions that negatively affect their relationships and daily lives.
  • The biological part of a person is processed at the psychological level, so psychiatrists must be interested in psychological aspects of treatment.

References

Sharp C et al. The structure of personality pathology: Both general ('G') and specific ('S') factors? Abnorm Psychol. 2015 May;124(2):387-98.

Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry. 2009 May 1;166(5):530-9.

Caligor E et al. Narcissistic personality disorder: Diagnostic and clinical challenges. Am J Psychiatry. 2015 May;172(5):415-22.

Morey LC et al. Personality disorders in DSM-5: Emerging research on the alternative model. Curr Psychiatry Rep. 2015 Apr;17(4):558.

* * *

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Alberto J. Espay, MD, MSc, conducts a Masterclass lecture on treating patients with Parkinson's-related psychosis from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry.

Dr. Espay is professor of neurology at the University of Cincinnati. He also serves as director of the James J. and Joan A. Gardner Family Center Research Chair for Parkinson's Disease and Movement Disorders.

And later, in the "Dr. RK" segment, Renee Kohanski, MD, asks you to think about some of the complex issues tied to getting treatment for people who are both homeless and have serious mental illness.

* * *

Treatment of Parkinson's-related psychosis

• Psychosis related to Parkinson's disease (PD) is a common reason for hospitalization, institutionalization, and decline of patients with PD. The diagnosis of PD is required before the development of psychosis to diagnose patients with Parkinson's-related psychosis. Parkinsonism that appears after development of psychosis is Lewy body dementia.
• Many factors influence the development of psychosis in PD. Extrinsic factors include medical illnesses or metabolic derangement causing delirium with psychosis; nonessential dopaminergic medications such as ropinirole and selegiline; anticholinergic medications such as benztropine, amantadine, and bladder antispasmodics; and insomnia. The last resort for treatment of psychosis is levodopa because patients will experience motoric decline and loss of functioning.
• There are several mechanisms for psychosis to occur via the dopaminergic, serotonergic, and glutamatergic pathways; thus, three neurotransmitters – serotonin, dopamine, and glutamate – can be manipulated to treat psychosis. Quetiapine, clozapine, and pimavanserin are the three antipsychotics safe for use in Parkinson's disease.
• Clozapine is infrequently used, because of the risk of neutropenia and required blood work monitoring, but evidence shows that the benefits usually outweigh the risks of motor decline.
• Quetiapine is commonly used, because it has a favorable effect on sleep and psychosis, but it negatively affects the movement disorder of Parkinson's disease.
• Pimavanserin (Nuplazid), the only medication FDA approved for hallucinations and delusions associated with psychosis in Parkinson's disease, is highly selective for the 5-HT2A receptor as both an inverse agonist and antagonist.
• Primary adverse effects are peripheral edema and confusion, but overall the adverse effects profile is similar to that of placebo. In the pimavanserin clinical trials, a subset of patients worsened and experienced more visual hallucinations. In addition, pimavanserin can prolong the QT interval, so patients taking other QT-prolonging medications or who have cardiac comorbidities should be monitored with an EKG.
• Post hoc data analysis from as pivotal phase 3 study suggests that patients with cognitive impairment and dementia may receive more benefit from pimavanserin.

* * *

References

Cruz MP. Pimavanserin (Nuplazid): A treatment for hallucinations and delusions associated with Parkinson's disease. P T. 2017 Jun;42(6):368-71.

Cummings J et al. Pimavanserin: Potential treatment for dementia-related psychosis. J Prev Alzheimers Dis. 2018;5(4):253-8.

Huot P. 5HT2A receptors and Parkinson's disease psychosis: A pharmacological discussion. Neurodegenerative Disease Management. 2018 Nov 19. doi: 10.2217/nmt-2018-0039.

* * *

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

Michael A. Norko, MD, professor of psychiatry at Yale University in New Haven, Conn., spoke with Lorenzo Norris, MD, MDedge Psychiatry editor in chief, about incorporating patients' spiritual and religious histories into psychiatric evaluations.

Dr. Norko, lead author of a paper exploring whether religion is protective against suicide, sat down with Dr. Norris at the 2019 fall meeting of the Group for the Advancement of Psychiatry, or GAP.

Evidence, questions to consider about religion and spirituality

• Various spiritual and religious factors are linked to decreased rates of suicide behaviors and attempts, including weekly attendance to worship services, personal beliefs about the preciousness of life, and commitment to a faith practice. Which specific parts of religious and spirituality are protective? Are the protective factors the social connection or the spiritual connection alone?
• Those who attend worship services weekly are at lower risk of suicide. It's unclear whether weekly attendance is a proxy for the social connectedness or for the level of internalization of the religious beliefs.
• Commitment to a faith is measured by a consistent and strong belief in the faith tradition. Just because someone says they belong to a faith tradition does not automatically mean a person is at lower risk of suicide.
• Strong alignment with the faith also is protective. Alignment is different from commitment, because if patients are doubting or their personal beliefs conflict with long-held religious traditions, this can increase patients' suicide risk.

Questions to ask about spirituality and religion in clinical practice

• A spiritual and religious history is essential to a psychiatric evaluation, because asking about religion lets the patient know that this is a welcome topic. Examples of questions a clinician can ask include: "Is there any faith tradition that you belong to? How important is your faith or beliefs? Is there anything about your religious beliefs you think are important to your mental health treatment?"

Difficult areas to navigate with religion and spirituality

• Lack of expertise or personal experience with religion can be a barrier. It is important to remember that patients usually welcome curiosity about their religious beliefs and emotional lives. Clinicians need not be experts in religion, but they can be alert to the salient values and notice whether the person is struggling with certain beliefs. Clinicians also can encourage patients to talk to their clergy.
• When someone asks a clinician, "What is your faith practice?" this can be approached as an informed consent question. The clinician can ask how talking about their own beliefs or faith practices will deepen and help the therapeutic work of the patient.
• If a person is feeling let down by a certain failing of their religious community, therapy is a good place to explore what strengths and succor they had received from their religion. Therapy also can be used to guide patients toward additional places, or even substitutes, to meet their needs.
• Understanding patients' faith background and beliefs can help clinicians reframe certain crises, especially if the psychiatrist and therapist have talked discussed those crises with patients over time. It's more useful to understand patients' faith before the crisis, because grasping for a spiritual or religious answer at the last moment can feel inauthentic.

References

Norko et al. Can religion protect against suicide? J Nerv Ment Dis. 2017. Jan;205(1):9-14.

Kruizinga R et al. Toward a fully-fledged integration of spiritual care and medical care. J Pain Symptom Manage. 2018 Mar;55(3):1035-40.

Thomas LP et al. Meaning-centered psychotherapy: A form of psychotherapy for patients with cancer. Curr Psychiatry Rep. 2014 Oct;16(10):488.

Lawrence RE et al. Religion and suicide risk: A systematic review. Arch Suicide Res. 2016;20(1):1-21.

D'Souza R, George K. Spirituality, religion and psychiatry: its application to clinical practice. Australas Psychiatry. 2006 Dec;14(4):408-12.

FICA Spiritual History Tool: https://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool, which is based on Puchalski C and Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000 Spring;3(1):129-37.

George Washington University Institute for Spirituality and Health (GWISH): https://smhs.gwu.edu/gwish/

Lorenzo Norris, MD, and Roger McIntyre, MD, talk about obesity, inflammation, and mental illness. The conversation, which originally dropped a few months ago, took place at the Focus on Neuropsychiatry 2019 meeting. The meeting was sponsored by Current Psychiatry and Global Academy for Medical Education.

The original podcast included robust Show Notes by Jacqueline Posada, MD. Also, you can watch the conversation between Dr. Norris and Dr. McIntyre on video or on YouTube.

Later, Renee Kohanski, MD, talks about different ways to think about resolutions and behavioral change.

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych

In this episode of the MDedge Psychcast, we revisit an interview that Lorenzo Norris, MD, MDedge Psychiatry editor in chief, conducted earlier this year by phone with two psychiatrists working in New Mexico.

Dr. Norris spoke with Caroline Bonham, MD, and Avi Kriechman, MD, about enhancing resilience in rural communities. Dr. Bonham is vice chair in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is assistant professor in that department, and a pediatrician who works on youth suicide prevention and school mental health.

Understanding risks of suicide in rural communities

• Nationally, suicide rates have been going up across the United States, including in rural communities.
• Paucity of mental health clinicians supporting youth and their families has implications for youth suicide.
• Impact of structural poverty and the opioid epidemic also have implications for these rising rates.

Identifying resources within small, rural communities

• Communities have resources that are not tapped into enough by clinicians, such as churches, teachers, and community health workers. Recent studies show that most communities have members who know people at risk and want to help.
• It is important for clinicians to think outside of the box so that they help facilitate the use of natural resources/strengths that exist within small communities, such as food pantries that operate out of mental health centers, spiritual organizations, and aftercare programs in schools.

Building resilience among individuals

• The literature shows that engaging people in a collaborative, transparent process of care is effective.
• If community members who do not have problems, such as suicidality, physical ailments, or a severe mental illness, are taught to reach out, destigmatize, and facilitate treatment, the mental health outcomes of patients are better.
• Concrete, feasible intervention would be to work with gun store owners about the risk factors for suicide, how to encourage people to seek help.
• Some police departments provide education about the safe storage of firearms.

References

Curtin SC and Heron M. Death rates due to suicide and homicide among persons aged 10-24: United States, 2000-2017. NCHS Data Brief. 2019 Oct;(352):1-8.

Altschul DB et al. State legislative approach to enumerating behavioral health workforce shortages: Lessons learned in New Mexico. Am J Prev Med. 2018 Jun;54(6 suppl 3):S220-9.

Bonham C et al. Training psychiatrists for rural practice: A 20-year follow-up. Acad Psychiatry. 2014 Oct;38(5):623-6.

Kriechman A et al. Expanding the vision: The strength-based, community-oriented child and adolescent psychiatrist working in schools. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):149-62.

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgePsych