106 épisodes

MDedge Psychcast is a weekly podcast from MDedge Psychiatry, online home of Clinical Psychiatry News and Current Psychiatry. Hosted by Editor in Chief Lorenzo Norris, MD, Psychcast features psychiatric clinicians discussing the issues and concerns that most affect their specialty. The information in this podcast is provided for informational and educational purposes only.

MDedge Psychcast MDedge Psychiatry

    • Médecine

MDedge Psychcast is a weekly podcast from MDedge Psychiatry, online home of Clinical Psychiatry News and Current Psychiatry. Hosted by Editor in Chief Lorenzo Norris, MD, Psychcast features psychiatric clinicians discussing the issues and concerns that most affect their specialty. The information in this podcast is provided for informational and educational purposes only.

    Clinically relevant research with Dr. Sy Saeed

    Clinically relevant research with Dr. Sy Saeed

    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

    • 38 min
    Mitigating the impact of COVID-19 with Dr. Cam Ritchie

    Mitigating the impact of COVID-19 with Dr. Cam Ritchie

    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

    • 20 min
    Losing a patient to suicide with Dr. Nina Gutin

    Losing a patient to suicide with Dr. Nina Gutin

    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.
    *  *  *  
    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

    • 39 min
    Lumateperone for treating schizophrenia by Dr. Jonathan Meyer

    Lumateperone for treating schizophrenia by Dr. Jonathan Meyer

    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 risperi

    • 23 min
    Treating bulimia with Dr. Patricia Westmoreland

    Treating bulimia with Dr. Patricia Westmoreland

    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
    W

    • 13 min
    Psychedelics for MDD with Dr. Charles Raison

    Psychedelics for MDD with Dr. Charles Raison

    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

    • 33 min

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