128 episodes

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

    • Medicine

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.

    Understanding the neurobiology of addiction and the brain, and determining treatment options for patients with substance use disorders with Dr. Abigail Kay

    Understanding the neurobiology of addiction and the brain, and determining treatment options for patients with substance use disorders with Dr. Abigail Kay

    Abigail Kay, MD, MS, joins host Lorenzo Norris, MD, to discuss the treatment of patients with substance use disorders.
    Dr. Kay is an addiction psychiatrist at Thomas Jefferson University Hospital in Philadelphia and is associate dean of academic affairs and medical student education at Sidney Kimmel Medical College. Dr. Norris is assistant dean of student affairs, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington.
    Dr. Kay disclosed no conflicts of interest for the past year. Before that, she reported receiving payment from the American Society of Addiction Medicine, through a grant from the Substance Abuse and Mental Health Services Administration, to teach a free training to clinicians to be certified to prescribe buprenorphine. Dr. Norris, who also serves as medical director of psychiatric and behavioral sciences at George Washington University Hospital, disclosed no conflicts.
    Take-home points
    Substance use disorders have genetic and environmental factors. The genetic component is sometimes overlooked because the environmental factor – the exposure to using a substance – is heavily focused as the only trigger for addiction. Methadone is a pure agonist at the mu-opioid receptor so the higher dose the greater the effect. The average dose of methadone to achieve blocking of cravings, withdrawal, and opiate intoxication is 80-120 mg. Buprenorphine is a partial agonist: At low doses, it acts as an agonist, and at high doses it acts as an antagonist with quite high affinity for the receptor. As a partial agonist, it has a ceiling effect with more than 90% of opiate receptors occupied at 24 mg. Dr. Kay suggests a helpful rule of thumb is to assume that, if patients have an addiction, there’s a 50/50 chance that they have another psychiatric disorder and vice versa. With this in mind, all patients with substance use disorder should be evaluated for comorbid psychiatric disorders and underlying medical conditions. Summary
    Dr. Kay breaks down human cognition into the primitive brain and thoughtful brain. The primitive brain keeps us alive by preferentially focusing on sleeping, drinking, and eating. Addiction to a drug hijacks the primitive brain, making it prioritize the substance of choice above all else. Methadone is the “gold-standard” treatment for opioid use disorder in the sense that all treatments are compared with its efficacy and mechanism of action. Methadone is a pure agonist at the mu-opioid receptor, meaning the higher dose the greater the effect; the average dose of methadone is 80-120 mg. The goal of treatment is to achieve a blocking dose, meaning a dose that blocks the craving, the withdrawal, and the high if people were to use illicit opiates on top of their methadone. Methadone is administered only at federally approved sites, and one advantage is that additional services, such as counseling, can be offered on site after daily administration. Buprenorphine as a partial agonist can play both “roles” on the mu-opioid receptor. At low doses, it acts as an agonist, and at high doses, it acts as an antagonist with quite high affinity for the receptor. In addition, as a partial agonist buprenorphine has a ceiling effect: At 24 mg of buprenorphine occupies 92% of opiate receptors and at 32 mg only an additional 1% of receptors are occupied. Buprenorphine must be administered when the person is already in withdrawal, because its affinity to the receptor dislodges other opiates from the mu receptor thus precipitating withdrawal. Buprenorphine works well for individuals who would require an average 40-60 mg of methadone to achieve their blocking dose. Because of the ceiling effect, some individuals continue to crave opiates while on buprenorphine. This means that, despite the greater convenience offered by buprenorphine, it is not the treatment

    • 36 min
    John Lewis, Herman Cain, COVID-19, and men’s health: Processing the complexity of this moment with Dr. Derek Griffith

    John Lewis, Herman Cain, COVID-19, and men’s health: Processing the complexity of this moment with Dr. Derek Griffith

    Derek M. Griffith, PhD, joints host Lorenzo Norris, MD, to discuss different ways to look at men’s health within the context of COVID-19.
    Dr. Griffith is founder and director of the Center for Research on Men’s Health at Vanderbilt University, Nashville, Tenn. He also serves as professor of medicine, health, and society at the university. Neither Dr. Griffith nor Dr. Norris have disclosures.
    And do not miss Renee Kohanski, MD, who offers a message of hope in the “Dr. RK” segment.
    Take-home points
    The confluence of the COVID-19 pandemic, the death of civil rights leader Rep. John Lewis, and the death of Herman Cain from COVID-19 requires us to reflect on race, gender, personal identity, and our own vulnerability. Sometimes denial in the form of thinking “that won’t happen to me” is a trope within masculinity, especially black masculinity, and can lead to men delaying preventive treatments and interventions, which makes them more vulnerable to excess morbidity and mortality from preventable diseases. Some research suggests that men are more likely to suffer severe effects of COVID-19 than women. Personal preference and agency are hallmarks of the American ethos, and those attitudes made it difficult to accept new and challenging information during the beginning of the COVID-19 pandemic. Ironically, this fierce autonomy is celebrated and demonized in the male identity and will have an effect on their behavior in the environment. In terms of mental health, we must consider how schemas influence behavior, and one’s ability to take in and act on relevant information. Any singular lens is limited when discussing an issue as complex as the current pandemic. Many perspectives must be examined if we are to work toward an effective solution. While society is examining COVID-19 morbidity and mortality through the lens of race, we may miss other essential perspectives, such as place, gender, age, etc. In a situation such as the COVID-19 pandemic, we must manage complexity by asking the hard questions. Dr. Norris asked Dr. Griffith to identify what factor in the pandemic we are missing from our current perspectives. Dr. Griffith suggested that our society continues to assume that we know more about COVID-19 than we actually know. Several times throughout the pandemic, we have assumed that we have it “figured out,” only to be shown that the SARS-CoV-2 virus is more unpredictable than we realize. Race, gender, age, and health disparities also will be at play when it comes time to test and administer a COVID-19 vaccine. References
    Griffith DM et al. Prev Chronic Dis. 2020;17:E63.
    Griffith DM et al. The COVID-19 elephant and the blind men of race, place, and gender. Gender & COVID-19.org. 2020 Jul 26.
    Elder K and Griffith DM. Am J Public Health. 2016 Jul;106(7):1157. doi: 10.2105/AJPH.2016.303237.
    Peters JW. Will Herman Cain’s death change Republican views on the virus and masks? New York Times. 2020 Jul 30.
    Cain H. This is Herman Cain!: My Journey to the White House. New York: Threshold Editions, 2011.
    Sharma G et al. JACC Case Rep. 2020 Jul 15;2(9):1407-10.
    Baker P et al. Lancet. 2020 Jun;395(10241):1886-8.
    Indini A et al. Crit Rev Oncol Hematol. 2020 Sep;153:103059.
    Chowkwanyun M and Reed AL. Racial disparities and COVID-19 – Caution and context. N Engl J Med. 2020 Jul 16;383:201-3.
    Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. Updated 2020 Jul 24.
    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

    • 38 min
    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

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