» John J. Miller, MD
Editor in Chief, Psychiatric TimesTM
Psychiatric Times™, along with our colleagues at Physicians’ Education Resource, would like to thank everyone who participated in the 2020 Annual Psychiatric Times® World CME Conference™, which was held virtually October 15 – 17.
During this year’s conference, our esteemed faculty of 30 presenters covered a diverse range of clinically relevant topics applicable to the daily clinical practice of psychiatry. Presentations, including several Medical Crossfire® discussions on hot and controversial topics, ranged from 15 to 45 minutes, allowing for an adequate review and update of many topics. Question-and-answer roundtables were interspersed so faculty could engage virtually via audience-submitted questions, bringing the conference to life. Here you will find reviews of a sampling of the sessions.
Feedback has been excellent, and we look forward to next year’s conference, which will be held September 30th through October 2nd, 2021, in San Diego, CA. ❒
A Glimpse Into the Future of Psychiatry: Educator of the Year Award
» Heidi Anne Duerr, MPH
The best indicator of the future is looking at the past,” Sidney Zisook, MD, told attendees. Zisook, director of the University of California, San Diego Residency Training Program and a distinguished professor of psychiatry at UCSD, spoke to the future of psychiatry in the Educator of the Year Lecture.
Zisook grounded attendees by sharing a brief history of psychiatry, beginning around 2000 BC. The prevailing psychiatric theory was “eat this root.” Over time, humans and psychiatric treatment theory evolved. Around 1000 BC, eating roots was considered heathen and prayer was the answer to psychiatric ills. Fast forwarding through time, mental health care professionals moved to potions circa 1850 AD, pills in the 1950s, and then the Prozac revolution and more effective pills in 1985. As we hit the 2000s, we heard, “That pill is artificial. Here, take this root.” So, he posed, perhaps the future is really just a reflection and refinement of the past.
To further explore the future of psychiatry, Zisook turned to colleagues across the country and asked them about their hopes, fears, and predictions. Among the common themes were the prediction that the field will grow as a specialty, as noted by Joan Anzia, MD, vice chair for education in the department of Psychiatry and Behavioral Sciences at Northwestern Medicine. Indeed, Zisook noted that there are more residents choosing psychiatry as a specialty, leaving less room for international graduates.
Sheldon Benjamin, MD, interim chair of the department of psychiatry at the University of Massachusetts Medical School, said he hopes the field will increasingly work with case managers and primary care physicians to provide new opportunities for prevention, screening, and decreasing stigma. Again, Zisook felt psychiatry was moving in the right direction with collaborative and integrative models of care.
In his exploration, Zisook also looked to The WPA-Lancet Psychiatry Commission on the Future of Psychiatry for guidance in imaging the future of psychiatry. Although the commission examined 6 areas, Zisook focused on 2 of them that he felt spoke to the heart of psychiatry: the patient and treatment and training the psychiatrist of the future. He imagined psychiatrists will become team leaders, as care extenders help address the need for care and make up for shortages in psychiatry manpower. Technology would continue to play an important role in care. From smart phones and apps that allow patients to monitor and record their symptoms in between visits to telepsychiatry, he noted the digital world can help improve delivery of care and outcomes. And while Zisook said personalized medicine will remain an aspiration, the human elements (eg, cultural sensitivity and strong therapeutic alliances) will remain central to the field’s successes.
In psychiatric training, Zisook said it is imperative that the field embarks on cutting edge research and pursues innovative treatment while prioritizing patient narratives and the doctor-patient relationship to continue to attract and retain top notch talent. Similarly, he said burnout must be addressed, with an emphasis on wellness. There are too many clinicians who suffer from depression and addiction.
After considering the fears and hopes for psychiatry, Zisook said the field needs to learn from its failures, learn to persist, and learn humility. He quoted Michael Jordan:
I’ve missed more than 9000 shots in my career. I’ve lost almost 300 games. Twenty-six times I’ve been trusted to take the game-winning shot and missed. I’ve failed over and over and over again in my life. And that is why I succeed.
Ultimately, he reminded attendees, the past is not so much different from the future, and 2030 is likely to be similar to (as opposed to different from) 2020. Still, he said he believes there will be at least 1 major breakthrough treatment that nobody has yet to imagine. And, he concluded, “Psychiatry will continue to be a rewarding and essential calling.” ❒
Cannabis in Psychiatry: Prominent Issues and Developments
» Leah Kuntz
Just because it’s natural, doesn’t mean there aren’t side effects,” said David A. Gorelick, MD, PhD, DLFAPA, in his presentation on the clinical, legal, and ethical issues surrounding cannabis.
Cannabis, the third most widely used psychoactive drug, is a hot button issue in the United States. As Gorelick noted, the country is divided on state and federal levels about the legality of cannabis and all cannabis-related products. Federally, cannabis is illegal, classified as a Schedule I drug by the Controlled Substances Act (CSA). Several states, however, have expanded and adopted laws for the legalization of cannabis, with 33 approved for legal medical cannabis use. The 2018 Farm Act legally approved hemp, or the Cannabis sativa where the delta-9 tetrahydrocannabinol concentration (or THCs) is below 0.3%.
Very few other cannabis-derived products have been approved, he explained. Those that have are used to treat childhood seizures, nausea in cancer or chemotherapy patients, and spasticity in multiple sclerosis.
There are few controlled clinical trials on cannabis and cannabis-derived compounds, which are the gold standard for regulatory approval, Gorelick reported. The scattered case studies do not establish efficacy, and therefore cannot prove the safety and effectiveness of these substances for treatment of any disease or condition. Until more observance is done clinically, the likelihood of federal approval of cannabis is low.
Gorelick also spoke on cannabis use disorder. To treat patients with cannabis use disorder, he suggested the use of psychosocial modalities, which have proven efficacy in controlled clinical trials, such as cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET). He stated that while contingency management was effective when combined with either CBT or MET, it was minimally effective when used as the singular method of treatment.
As to the suggestion of whether or not oral CBD can effectively treat social anxiety disorder, Gorelick warned against listening to rumors. There are no clinical trials or evidence to suggest its effectiveness, but if the patient truly believes it is helpful, he recommended monitoring side effects and efficacy. ❒
The Debate Goes On: Are Antidepressants for Bipolar Moot?
» Laurie Martin
Should bipolar disorder be treated with antidepressants? There is no short answer, but that was the topic of a Medical Crossfire® at the conference. A lively discussion was had by all in this session moderated by Roger McIntyre, MD, and joined by Chris Aiken, MD; S. Nassir Ghaemi, MD; and Joseph F. Goldberg, MD.
Chris Aiken, MD, shared his experience working with patients with bipolar disorder who are prescribed antidepressants. “In bipolar depression, about 90% of the responses you see with antidepressants are due to the placebo,” said Aiken, director of the Mood Treatment Center; instructor in clinical psychiatry at Wake Forest University School of Medicine in Winston-Salem, NC; editor in chief of Carlat Psychiatry; and mood disorders section editor at Psychiatric Times. “Bipolar depressions last 2 to 3 months on average, so if you start an antidepressant in the middle of an episode, you’re likely to think that it worked when it was just the natural ebb and flow of the illness. If it were a sugar pill, this wouldn’t be a problem, but over time, these antidepressants can cause rapid cycling, mixed states, and mania.”
Rapid cycling is the most difficult risk to detect because it has a slow build. “In the Step-BD trial, antidepressants sped up the frequency of episodes three-fold in patients who were prone to rapid cycling.” Aiken recommended using mood charts to detect changes in episode frequency.
SYSTEMIC ISSUES. S. Nassir Ghaemi, MD, professor of psychiatry at Tufts University School of Medicine, and lecturer on psychiatry, Harvard Medical School, Boston, MA, addressed the complexities in resolving bipolar depression with antidepressants. “The majority of patients with bipolar illness are getting an antidepressant. They have been since I entered the field in 1995. Over 25 years of my talking about this and writing about this, it hasn’t changed; it has gotten worse,” he told the audience.
The larger problem is in the profession of psychiatry, said Ghaemi. Historically, psychiatry’s orientation was psychoanalytic, but in the 1980s the field shifted toward psychopharmacology. “It seems as if we say that a particular subclass of our drugs are not effective, or are not as effective as we thought, we are somehow harming the profession of psychiatry itself.”
“This psychopharmacological efficacy is seen as equivalent to professional competence, which of course is false,” said Ghaemi. In any other area of medicine, some drugs work for some things and they do not work for others, he explained. It is nothing bad to say that a certain class of drug does not work for a certain disorder. And herein lies the controversy: “Psychiatrists are almost unwilling to say that about anything. And if there’s one place where it’s clear, it is that antidepressants are not effective in bipolar depression.”
PERSONALIZED TREATMENT. Joseph F. Goldberg, MD, took a different view, stating that antidepressants may work in a subset of patients with bipolar depression like “someone who has never had rapid cycling, substance abuse, recent manic symptoms . . . But you don’t see that too often.” Dr Goldberg, clinical professor of psychiatry at Icahn School of Medicine at Mount Sinai, New York, NY, added that we have few studies of antidepressants in bipolar depression.
Rather than trying to figure out whether antidepressants work in bipolar depression, Goldberg called for research to better characterize who responds to antidepressants and who gets worse on them. As an example, he cited a meta-analysis by Ghaemi that found patients who were homozygous for the short arm of the serotonin transporter gene (S/S at 5-HTTLPR) were 135% more likely to have antidepressant-induced mania.1
He warned against lumping all antidepressants into one category given their varied mechanisms of action. “None of the newer agents have been studied in bipolar depression—including vortioxetine and vilazodone—so we can’t say what they would do.”
AN AREA OF AGREEMENT. Roger McIntyre, MD, the moderator of the Plenary Session: Special Report on Bipolar Disorder and program co-chair of the conference weighed in. “My own view is that antidepressants have been, frankly, largely useless to most people that I have seen—and useless would be considered a good outcome.”
Some consensus emerged around 2 opposing facts. While antidepressants carry a significant risk of mood destabilization, they are effective in a small minority of bipolar patients, which Ghaemi estimated at fewer than 20%. “The problem is that 60% of patients with bipolar disorder are taking them, and most of those antidepressants are prescribed without a mood stabilizer,” said Ghaemi.2
All agreed that antidepressants have meager benefits and clear risks in bipolar disorder. What is less clear is when to use them and when to come off them, and therein lies the controversy.
1. Daray FM, Thommi SB, Ghaemi SN. The pharmacogenetics of antidepressant-induced mania: a systematic review and meta-analysis. Bipolar Disord. 2010;12(7):702-706.
2. Rhee TG, Olfson M, Nierenberg AA, Wilkinson ST. 20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings. Am J Psychiatry. 2020 Aug 1;177(8):706-715. ❒
Algorithms for Improved Practice
» Leah Kuntz
David N. Osser, MD, shared 10 examples of evidence from the Psychopharmacology Algorithm Project at the Harvard South Shore Psychiatry Residency Training Program that might change how you practice. “We’re offering you realistic, evidence-based medicine,” Osser explained.
The published and peer-reviewed algorithms, available online at psychopharm.mobi/algo_live, help practitioners determine treatments with the best efficacy, tolerability, and cost. They intend to lighten the load for clinicians who cannot keep up with the volume of new research by providing decision-making tools that are practical for everyday usage.
1. Selection of first antidepressant for major depression. If the patient has not had an adequate trial of sertraline, escitalopram, or bupropion, the algorithm suggests 2 selective serotonin reuptake inhibitors as the first line of treatment for depression. Meta-analyses indicate that sertraline and escitalopram are among the most effective, best tolerated, and least costly. Bupropion should be considered if the patient wishes to avoid the risk of sexual side effects. Serotonin and norepinephrine reuptake inhibitors, mirtazapine, vortioxetine, and tricyclic antidepressants are not recommended as first line treatment due to various side effects, health risks, or cost.
2. Selection of a second treatment for major depression.If there is no response after an adequate trial with the agents previously suggested, try to switch or augment. No evidence suggests preferring either switching or augmenting; it is mostly the patient’s choice.
3. Duloxetine as an alternative to an SSRI and a first line treatment for general anxiety disorder (GAD). Duloxetine may be a good first choice when treating GAD because its efficacy is similar to that of an SSRI, it has lower rates of sexual side effects, and it is US Food and Drug Administration-approved. Concerns include infrequent urinary retention, perspiration, and risk for those with liver abnormalities.
4. Hydroxyzine as an alternative to an SSRI and a first line treatment for GAD. Hydroxyzine, an antihistamine with 5-HT2 receptor blocking effects, has low abuse potential, sedating properties, and a lack of sexual side effects. However, clinicians are skeptical of it because it has no benefit for comorbid disorders like depression or other anxiety disorders.
5. Pregabalin as an alternative to an SSRI and a first line treatment for GAD.Approved for GAD in Europe, pregabalin was found to be comparably effective to other medications for both somatic and psychic symptoms of GAD. It was not approved by the FDA for an undisclosed reason. It has a rapid onset, helps with sleep, but may have dangerous side effects for the elderly, such as somnolence, dizziness, and increased risk for fractures via fall.
6. Bupropion as an alternative to an SSRI and a first line treatment for GAD.While bupropion is not usually considered for treating anxiety, a double-blind controlled trial with 24 outpatients aged 18-64 years with DSM-IV GAD found endpoint scores favored bupropion over escitalopram.
7. Benzodiazepine should not be a first line option. Despite the advantages of benzodiazepine, the side effects (eg, sedation, memory impairment, and psychomotor dysfunction like falls and car accidents) are dissuading. Additionally, up to 40% of patients develop tolerance or dependence. It could be fatal when combined with opiates and should not be used in patients with substance use disorders.
8. For nightmares or disturbed awakenings in patients with posttraumatic stress disorder try prazosin. Prazosin, a non-sedating alpha-1 antagonist, crosses the blood-brain barrier. It has 5 out of 8 positive placebo-controlled studies, whereas sertraline has 4 randomized controlled negative placebo-controlled trials in Veterans and no positive trials.
9. Dose prazosin properly. The algorithm notes a regimen of dosage that best works for men, and a separate, lower dose regimen for women based on a 2013 study by Raskind and colleagues.
10. The pharmacotherapy of obsessive-compulsive disorder (OCD).Meta-analysis of the dose-response relationship shows only a 9% or 7% greater decline in OCD symptoms for those on a high dose SSRI compared to a low- or medium-dose SSRI. So, a good trial on a low dose should occur first.
This list is only a demonstration of how the algorithms might assist a clinician’s decision-making process. Osser hopes these algorithms can help avoid ineffective, inefficient, or harmful medical practices. ❒
Psychiatric Disorders and Migraine Comorbidity: Treatment Implications
» Laurie Martin
Alleviating migraines can attenuate psychiatric comorbidities, Heidi Moawad, MD, told attendees. Moawad, clinical assistant professor, Division of Medical Education, Case Western Reserve University School of Medicine, Cleveland, OH, spoke about therapeutic interventions and best practices for migraine treatment as it relates to psychiatric comorbid conditions.
Clinicians have a limited repertoire for approaching migraine and psychiatric treatment. “Off-label antidepressants can be used for migraine prophylaxis, and there has to be some consideration of the appropriate doses for migraine versus the dose for depression,” she said.
If patients come to a psychiatrist with a previously prescribed medication that is no longer appropriate, communication and patient education are key. “Speak to the patient about why that dose has been changed and what they can expect in anticipating the change.”
“Whether antidepressants are being used to prevent migraine or to treat depression, adverse effects can be very upsetting to patients and can affect their well-being,” Moawad told attendees. Patients can experience sleep disturbances, fatigue, and daytime drowsiness. She also noted weight gain or weight loss is one of most common adverse effects with which patients struggle. Some patients can also be at risk for suicidal ideation when taking antidepressants, and some patients may experience mania as well.
In thinking about the treatment implications of migraine and psychiatric comorbidities, prescription medications are important, as are therapeutic interventions and procedures. Patients with migraines are often compliant with lifestyle modification strategies.
According to Moawad, patients are often drawn to other interventions, such as migraine prevention devices, particularly because there may be fewer adverse effects and drug interactions. Lifestyle changes, such as dietary factors (eg, avoiding certain foods), and avoiding certain odors or bright lights can be effective. The use of questionnaires to monitor changes in symptoms can be useful for patients’ self-awareness and ability to assess progress. ❒