101 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.

MDedge 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.

    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
    ‘Lived experience’ with suicidality with Dr. Lynes and Dr. Myers

    ‘Lived experience’ with suicidality with Dr. Lynes and Dr. Myers

    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.
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    • 34 min
    Late-life mood disorders with Dr. George T. Grossberg

    Late-life mood disorders with Dr. George T. Grossberg

    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.
    ***
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    • 21 min
    Dysfunctional patterns in relationships with Dr. Christine B.L. Adams

    Dysfunctional patterns in relationships with Dr. Christine B.L. Adams

    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.
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    • 55 min
    Personality disorders with Dr. Frank Yeomans

    Personality disorders with Dr. Frank Yeomans

    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.
    *  *  * 
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    Email the show: podcasts@mdedge.com
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    • 34 min
    Parkinson’s-related psychosis with Dr. Alberto J. Espay

    Parkinson’s-related psychosis with Dr. Alberto J. Espay

    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.
     *  *  * 
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    • 21 min

Customer Reviews

Sunfun315 ,

Relatable Topics

I really enjoy listening to the Psychcast podcast. They cover topics that are relatable yet educational. I would be interested in hearing more podcasts about mental health, gut health and mental health and perhaps mental disorders and women who seek help but may be dismissed by physicians who think that they are over exaggerating their symptoms. Love this!

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Dr. Norris is Great - Masterclass CE

I feel like I'm participating in the conversation. The Masterclasses are great, wish I could take a quiz or something and get CE for listening.

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Great podcast

Wonderful reviews and great speakers. Very interesting and relevant topics. I highly recommend it.

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