126 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.

Psychcast MDedge Psychiatry

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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.

    TMS, ECT, and other device-based therapies for treating refractory major depression and bipolar depression with Dr. Philip Janicak   

    TMS, ECT, and other device-based therapies for treating refractory major depression and bipolar depression with Dr. Philip Janicak   

    Episode 128 interview:
    Philip G. Janicak, MD, joins MDedge Psychiatry Editor in Chief Lorenzo Norris, MD, to discuss device-based therapies for psychiatric patients.
    Dr. Janicak is adjunct professor of psychiatry and behavioral sciences at Northwestern University in Chicago. He serves as an unpaid consultant to Neuronetics and has a financial relationship with Otsuka. Dr. Norris, medical director of psychiatric and behavioral services at George Washington University Hospital in Washington, has no disclosures.
    Take-home points 
    Therapeutic neuromodulation, including electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS), refers to the use of device-based therapies that alter neurocircuitry implicated in the pathophysiology of psychiatric disorders. Most available evidence is from studies in major depressive disorder, though more research is emerging for bipolar disorder and other diagnoses The advantage of TMS is minimal cognitive adverse effects, compared with ECT.  Dr. Janicak recommends ECT over TMS when a patient requires inpatient psychiatric treatment, is acutely suicidal, has psychotic features, or is not taking care of basic needs.  Summary 
    TMS originated in England when Anthony T. Barker, PhD, began using TMS as a probe for the peripheral and central nervous systems.  Imaging studies showed that, in the context of depression, the left dorsolateral prefrontal cortex had less metabolism and blood flow, and when TMS was applied, those phenomena were reversed. One large randomized, controlled trial showed that TMS treatment could lead to remission of depression and had a durable effect for most patients in the study.   
    The recent goal of TMS research has been to improve the efficacy and decrease the length of treatment from 4-6 weeks of daily treatments to 1-2 weeks.   
    In 2018, deep TMS (dTMS) was cleared by the Food and Drug Administration for the treatment of obsessive-compulsive disorder after first- and second-line pharmacologic and psychotherapeutic treatments. In dTMS, the medial prefrontal cortex and the anterior cingulate cortex are targeted.  
    Several studies suggest the pro-cognitive effects of TMS, and Dr. Janicak hopes that TMS might be on the radar as treatment for mild cognitive impairment.   
    TMS also is being used in combination with psychotherapy, such as cognitive-behavioral therapy, under the theory that TMS enhances the activity of the neurocircuitry and potentiates the effect of the psychotherapy.  References
    Janicak PG. What’s new in transcranial magnetic stimulation. Current Psychiatry. 2019 Mar;18(3):10-6. 
    Dunner DL et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: Durability of benefit over a 1-year follow-up period. J Clin Psychiatry. 2014;75(12):1394-1401. 
    Janicak PG and Dokucu ME. Transcranial magnetic stimulation for the treatment of major depression. Neuropsychiatr Dis Treat. 2015;11:1549-60.
    Vidrine R. Integrating deep transcranial stimulation into the OCD treatment algorithm. Psychiatric Times. 2020 Apr 7. 
    Marra HLD et al. TMS in mild cognitive impairment. Behav Neurol. 2015;2015:287843. doi: 10.1155/2015/287843.
    Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.  Dr. Posada has no conflicts of interest.
    For more MDedge Podcasts, go to mdedge.com/podcasts
    Email the show: podcasts@mdedge.com

    • 35 min
    Using the biological aspects of mental health to provide psychiatric treatment of patients with refractory chronic pain with Dr. Dmitry Arbuck

    Using the biological aspects of mental health to provide psychiatric treatment of patients with refractory chronic pain with Dr. Dmitry Arbuck

    Dmitry M. Arbuck, MD, joins host Lorenzo Norris, MD, to discuss ways psychiatrists can help patients with treatment-resistant chronic pain.
    Dr. Arbuck is clinical assistant professor of psychiatry and medicine at Indiana University, Indianapolis. Dr. Arbuck also serves as president and medical director of Indiana Polyclinic, a multispecialty pain management facility, and is an associate editor of Current Psychiatry.
    Both Dr. Arbuck and Dr. Norris disclosed having no conflicts of interest.
    And do not miss the “Dr. RK” segment, where Renee Kohanski, MD, discusses part 2 of her examination of the constructs of medicine.
    Take-home points
    Acute and chronic pain are mediated by different mechanisms and therefore must be treated differently. Acute pain is caused by tissue damage leading to nociception, and it should heal. Chronic pain is the chronification of acute pain and more of an emotional state with sensations of pain without clear tissue damage. Many neurotransmitters are involved in pain, including dopamine, serotonin, norepinephrine, and the opioid system. The levels of neurotransmitters will change as the pain (emotional and physical) thresholds change. When patients with borderline personality disorder cut themselves, dopamine increases, and the patients, in turn, feel better. Likewise, when patients with PTSD reexperience negative events, this causes an increase in dopamine to protect against stress. Psychiatrists are particularly well positioned to help those with chronic pain because trauma and emotions are central to the perception of emotional and physical pain. Emotional trauma also influences the severity and chronicity of pain. Currently, pharmacogenetics are more of a general guide for clinicians than specific practice guidelines. But they can inform patients and physicians about drug metabolism and expression of receptors in difficult-to-treat patients. Summary
    Chronic pain can be understood as emotions colored by nociception, while acute pain is the tissue damage and subsequent nociception causing pain. Opioids suppress the nociception of pain and are appropriate in acute pain. However, opioids should be used only in the normal time of healing in acute pain. If their use is extended, opioids can cause hyperalgesia, thus worsening chronic pain. Many forms of chronic pain, such as fibromyalgia and chronic back pain, do not have tissue damage. The sensations of physical pain and the compounding emotional pain are mediated by central pain sensitization. The theory behind central pain sensitization helps explain why medications such as SSRIs, serotonin-norepinephrine reuptake inhibitors, and antipsychotics can come into play in chronic pain treatment. In some patients, there can be dopaminergic hyperactivity in chronic pain. Dr. Arbuck conceptualizes dopamine as a defensive neurotransmitter. Dopamine is secreted in response to fear and can result in a physical response, such as weakness in the legs, but it also leads to emotional consequences, such as dissociation. Dopamine is also secreted with emotionally painful stimuli, such as trauma, so an event such as a sexual assault that results in a physical and emotional injury may produce substantial dopamine secretion. When the defense becomes chronic, excessive dopamine secretion can be pathological. Pharmacogenetics inform clinicians about a patient’s ability to benefit from medications by looking at the presence of specific alleles for enzymes that metabolize medications and for receptors upon which medications act. Currently, Dr. Arbuck uses pharmacogenetics in specific indications, such as for patients with a seemingly treatment-resistant condition or with excessive adverse effects from medications. The pharmacogenetics results are meant to help physicians and patients understand the body’s role in medications. Psychiatry needs to look more int

    • 47 min
    COVID-19, the ‘echo pandemic’ of suicide and mental illness, and the need to virtualize health care to mitigate risks with Dr. Roger McIntyre

    COVID-19, the ‘echo pandemic’ of suicide and mental illness, and the need to virtualize health care to mitigate risks with Dr. Roger McIntyre

    Roger S. McIntyre, MD, returns the Psychcast, this time to talk with host Lorenzo Norris, MD, about the mental health hazards of COVID-19 and what clinicians can do to help protect patients.
    Dr. McIntyre is professor of psychiatry and pharmacology, and head of the mood disorders psychopharmacology unit at the University Health Network at the University of Toronto.
    He disclosed receiving research or grants from the Stanley Medical Research Institute and the CIHR/GACD/National Natural Science Foundation of China. Dr. McIntyre also disclosed receiving consultation/speaker fees from several pharmaceutical companies. Dr. Norris has no disclosures. 
    Take-home points
    Uncertainty tied to the COVID-19 pandemic threatens to undermine mental health and exacerbate problems for those with mental illness. U.S. suicide rates, which were already rising after the Great Recession of 2007-2009, are likely to climb further because of the impact of COVID-19. Clinicians can take steps to prevent some of the negative mental health outcomes tied to the pandemic. Summary
    COVID-19 presents a triple threat to patients' mental health. The fear of viral infection is a mental health hazard. The financial shock that COVID-19 has had on the economy has not been seen since the Great Depression. Links between suicide and unemployment are powerful. In a study published in World Psychiatry, McIntyre and colleagues found associations between COVID-19 and major depression, PTSD, binge alcohol use, and substance use disorders. French social scientist Emile Durheim, PhD described the link between suicide and unemployment. Quarantining affects mental health, and there is nothing like COVID-19 in the history books. The Toronto experience with severe acute respiratory syndrome in 2003 offers lessons about the devastating impact of quarantining on mental health. “Deaths of despair” in the form of suicides have been on the increase in the United States. From the Great Recession, researchers found that for every 1% increase in unemployment, there is a commensurate 1% increase in suicide. U.S. unemployment stood at 8%-9% during the Great Recession, and now those percentages are much higher. Dr. McIntyre and his team projected that an unemployment rate of 14%-20% would lead to an additional 8,000-10,000 suicides could occur each year for the next 2 years. That’s in addition to the current number of approximately 50,000 suicides annually. Express Scripts, a pharmacy benefits manager, recently reported a 40% increase in prescriptions for anxiety-related medications. This suggests that people are distressed. Clinicians should take an aspirational approach to addressing these issues by pivoting to virtual platforms to increase patients’ access to care. Create medical homes that are HIPAA compliant. Look toward evidence-based models such as those found in Japan. That country found that, for every 0.2% increase in GDP spending on mental health care right after the Great Recession, the suicide rate fell by 1%. Encourage patients to structure the day and avoid consuming too much news or participating on social media. Two studies conducted in China found that people who spent more than 2-3 hours a day on news consumption were more likely to report clinical levels of depression, anxiety, and insomnia. Social media consumption has been associated with many adverse mental health outcomes, including loneliness. People who spent more than 3 hours a day were more likely to experience depression. Support programs for small-business people; jobs enhance resilience. Target the “basics” of self-care, such as getting enough sleep and engaging with others. References
    McIntyre RS, Lee Y. Psychiatry Res. 2020 May 19. doi: 10.1016/j.psychres.2020.113104.
    McIntyre RS, Lee Y. World Psychiatry. 2020 Jun;19(2):250-1.
    Shanahan L et al. Am J Public Health. 20

    • 42 min
    Fear, impulsivity, and surges in gun sales amid the COVID-19 pandemic: How clinicians can redirect patients’ stress and anxiety with Dr. Jack Rozel

    Fear, impulsivity, and surges in gun sales amid the COVID-19 pandemic: How clinicians can redirect patients’ stress and anxiety with Dr. Jack Rozel

    Jack Rozel, MD, MSL, returns to the Psychcast, this time to discuss with host Lorenzo Norris, MD, how to think about guns, gun violence, and the intersection with mental health.
    Dr. Rozel is medical director of resolve crisis services at the University of Pittsburgh Medical Center/Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis – rather than sell a gun. Dr. Norris has no disclosures.  
    Take-home points
    In the United States, more guns were sold in the month leading up to the COVID-19 pandemic than were ever sold in 1 month since gun sales were recorded. Suicide risk with a new gun in the home peaks in the first days to weeks of ownership and then trails off, but there is a measurable difference in risk of suicide in the 5 years after the purchase. Any surge in gun sales leads to greater accidental deaths and homicides from firearms. Rozel reminds clinicians to ask their patients (again) about guns. A good question to start is: “Are there guns in the home or new guns in the home?” He also asks about gun storage and the number of guns. Dr. Rozel goes through the basics of gun safety, such as handling a gun only while sober; securing the gun in a locked box unless the owner/responsible adult is holding it; using a responsible means to carry the gun, such as a holster; and not handling the gun like a toy. If a patient is under financial pressure, the clinician might gently suggest that a way to remove some of that pressure might be to sell a weapon to a licensed gun dealer. Summary
    It is likely that fear and uncertainty of the future with broad social disorder are influencing gun sales. Most of the gun sales during the pandemic are to new gun owners. Unfortunately, the increase in gun sales tracks with other major risks for suicide, such as unemployment and unstable housing, which might get worse during the COVID-19 pandemic. During this period of unstable employment and house, people might be moving to different houses, or relatives and friends might be moving in. With this fluidity, it is essential to inquire about guns in the home where they are staying or whether new people brought in guns. Dr. Rozel also explores who is in the house with the patient and checks in about the home environment regarding arguments and abuse, especially as tensions run high during pandemic shutdowns. Make gentle assumptions by asking questions such as: “How do you store your guns?” Get a sense of how safe the patient’s environment is while conducting telehealth, and be aware of patients’ social determinants of health issues. As psychiatrists, it is our role to talk to patients about how their mental health influences their safety. If a patient is experiencing acute symptoms of their illness or perhaps has relapsed on substances, then it is imperative to ask about gun safety and whether the gun should be temporarily moved from the house. References
    Rozel J. Clinical Psychiatry News. 2020 Apr 2.
    Harvard School of Public Health. Means Matter: Firearm Access is a Risk Factor for Suicide
    Reger M et al. JAMA Psychiatry. 2020 Apr 10. doi: 10.10.1001/jamapsychiatry.2020.1060.
    Rand Corporation. Gun Policy in America.
    Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest.
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    For more MDedge Podcasts, go to mdedge.com/podcasts
    Email the show: podcasts@mdedge.com

    • 43 min
    The ‘best of’ COVID-19: Dr. Sheldon Preskorn on educating patients about coronavirus, Dr. Jay Shore on using telepsychiatry, and Dr. Lynne Gots on using CBT to help patients with anxiety

    The ‘best of’ COVID-19: Dr. Sheldon Preskorn on educating patients about coronavirus, Dr. Jay Shore on using telepsychiatry, and Dr. Lynne Gots on using CBT to help patients with anxiety

    This week, we decided to revisit three of the Psychcast episodes that examined various aspects of COVID-19. First, you will hear excerpts from the interview that host Lorenzo Norris, MD, did with Sheldon H. Preskorn, MD, on educating patients about SARS-CoV-2 and the disease. Next, Jay H. Shore, MD, MPH, conducts a Masterclass lecture on factors to consider while using telepsychiatry during the pandemic.
    And later, guest host Jacqueline Posada, MD, talks with Lynne S. Gots, PhD, about using cognitive-behavior therapy to treat patients with anxiety.
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    For more MDedge Podcasts, go to mdedge.com/podcasts
    Email the show: podcasts@mdedge.com

    • 32 min
    From TEDMED 2020: Reducing urban violence in the United States, and partnering with police and communities with Thomas Abt

    From TEDMED 2020: Reducing urban violence in the United States, and partnering with police and communities with Thomas Abt

    Thomas Abt, JD, spoke with Nick Andrews about his talk at the TEDMED 2020 conference in Boston.
    Mr. Abt (@Abt_Thomas), senior fellow at the Council on Criminal Justice, discussed his evidence-based and community-informed strategies for reducing urban violence. Mr. Abt earned an undergraduate degree in economics from the University of Michigan in Ann Arbor, and a law degree from Georgetown University in Washington. Mr. Abt also worked as a prosecutor in the Manhattan District Attorney’s office in New York, and as a teacher in Washington. He has no conflicts of interest.
     Summary
     Mr. Abt said the three fundamental principles of focus, balance, and fairness are central to interventions for reducing urban violence.  This means focusing on people and places in which urban violence is concentrated, balancing between positive and negative incentives to reduce violence, and facilitating trust between the state and its citizens to foster a sense of fairness.
     Mr. Abt’s book, “Bleeding Out: The Devastating Consequences of Urban Violence - And a Bold New Plan for Peace in the Streets” is a compilation of 10- 12 strategies using evidence-based interventions. Mr. Abt promotes strategies informed by data and vetted by communities.
    Success stories can be found with deterrence in Boston; and Oakland, Calif; and Cincinnati; and Indianapolis; and with cognitive-behavioral therapy (CBT) in Chicago. Those strategies have not been brought to scale or sustained over time. The “Becoming a Man” program in Chicago is one the most promising examples of the power of CBT. The program focuses on at-risk youth in high school and teaches strategies for conflict resolution, interpersonal problem-solving skills, anger management, and future orientation. The program has three components: vigorous youth engagement; an intensive “man’s work” educational program delving into positive masculine identity; and a CBT component. CBT is only part of the success, and Mr. Abt argues that a clinical component is necessary when working with groups with traumatic backgrounds. A psychotherapy modality is required to meaningfully alter the impulsive, automatic responses that can lead to violence. Street outreach workers, public health officials, and police officials have responded positively to the book. Criticism has come from political extremes. Conventional narratives about urban violence suggest that it is rooted in poverty or culture, or social and economic injustice. Yet research about urban violence suggests reducing violence must focus on urban violence itself and not on ancillary topics. Structural and historical factors, such as racism and de jure and de facto segregation, have produced high rates of urban violence, but we can’t start over in a span of a few years to address those generational problems. Mr. Abt focuses on identifying interventions that target reducing violence, which has its own ripple effects on structural injustice. Abt emphasizes that urban violence is a concentrated problem with larger effects. The solutions need to be direct and focused so that the effect of the interventions is not diluted and able to be applied in multiple communities. The solutions direct and focused approaches so that the effect of the interventions is not diluted and able to be applied in multiple communities. References
    Abt T. Bleeding Out: The Devastating Consequences of Urban Violence – And a Bold New Plan for Peace in the Streets. (Basic Books, 2019).
    Obbie M. This man says his anti-violence plan would save 12,000 lives. The Atlantic.
    University of Chicago. Urban Labs. Becoming a Man program.
    Heller SB et al. Thinking, Fast and Slow? Some Field Experiments to Reduce Crime and Dropout in Chicago. National Bureau of Economic Research. Working Paper 21178. May 2015. Revised August 2016.
    Medscape Psychcast bonus episode tran

    • 39 min

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