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MDedge Psychcast

MDedge

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MDedge Psychcast
MDedge Psychcast

MDedge Psychcast

MDedge

7
Followers
1.0K
Plays
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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.

Latest Episodes

Brain imaging of forensic patients with Dr. Kent Kiehl

Kent A. Kiehl, PhD, joins hostLorenzo Norris, MD on the MDedge Psychcast to discuss the use of MRI scans to provide information about the brains of people who exhibit antisocial behaviors. The goals are to use the information to treat patients and prevent violent crimes. Timestamps: This week in Psychiatry (00:33) Meet the guest (03:35) Interview (04:25) Credits (54:10) Dr. Kiehl is professor of psychology, neuroscience, and law at the University of New Mexico, Albuquerque. He also codirects a nonprofit mental health research institute called the Mind Research Network, also in Albuquerque. He also helps run a for-profit consulting firm that helps attorneys do better science, called MINDSET. This week in Psychiatry: Suicide attempts up in black U.S. teens by Randy Dotinga Overall rates of suicide dipped from 1991 to 2017, according to research published in Pediatrics. However, the rate of suicide attempts grew slightly in black adolescents during that time. SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI: 10.1542/peds.2019-1187. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Brain imaging can support diagnoses Dr. Kiehl works with cutting-edge technology using noninvasive structural and functional brain imaging; machine learning, such as artificial intelligence; and algorithms to evaluate forensic patients and understand psychopathology, predict outcomes, and measure the impact of interventions. Dr. Kiehl and his team travel to prisons across the country with two mobile MRI units imaging incarcerated individuals and forensic patients. More and more, brain imaging is considered in capital cases, because MRI provides valuable information for defense attorneys and prosecutors. For example, a man was charged with murder and his MRI supported a diagnosis of frontotemporal dementia with a behavioral variant, so he was able to plead not criminally responsible based on his illness – and was sent to a state mental hospital rather than to death row. The case of John W. Hinckley Jr., who shot former President Ronald Reagan and his press secretary, James Brady in 1981, was an initial case in which neuroscience and imaging influenced the verdict. The shooter’s brain imaging showed enlarged ventricles and cortical atrophy, which supported a diagnosis of schizophrenia – particularly when compared with the imaging of age-matched controls. Structural and functional MRI is an adjunct to neuropsychological tests. Neuroscientists are elucidating patterns through artificial intelligence and algorithms that can be useful to civil and criminal cases. For example, age is considered a strong predictor of antisocial behaviors. To enhance accuracy, Dr. Kiehl’s team has developed a neuroprediction model in which MRI quantifies brain age, which correlates closely with cognitive testing scores. So, brain age might be more useful for predicting behavior than chronological age. This study used more than 1,000 imaging studies of inmates. The data were analyzed using an algorithm called independent component analysis, which evaluates distinct neural circuits to identify components that predict age. In the next step of analysis, the algorithm identifies patterns associated with reoffending. Younger brain age in the anterior temporal lobe and orbitofrontal cortex – brain areas associated with decision making – accurately estimates the risk of reoffending better than just chronological age. Based on an understanding of brain plasticity, dogma suggesting that people who commit violent crimes cannot be changed should be challenged. A group at the University of Wisconsin, Madison, was asked to create an evidence-based, multimodal treatment program for the hardest-to-treat violent juvenile offenders. The program, which includes interventions such as multisystemic family therapy and positive reinforcement contingency treatme

54 MIN4 d ago
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Brain imaging of forensic patients with Dr. Kent Kiehl

Identifying and treating postpartum psychosis with Dr. Susan Hatters Friedman

Susan Hatters Friedman, MD, returns to the MDedge Psychcast to join host Lorenzo Norris, MD, to discuss postpartum psychosis. Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman and colleagues recently wrote an article published in Current Psychiatry examining this topic, Postpartum psychosis: Protecting mother and infant. Timestamps: This week in psychiatry (01:09) Interview (05:07) Dr. RK (22:07) Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Overview of postpartum psychosis Postpartum psychosis is a medical emergency with a fulminant development occurring within 1-4 weeks after delivery. Onset is usually 3-10 days postpartum, and women experience a spectrum of symptoms from psychosis to dysphoric mania and confusion. Many women who experience postpartum psychosis do not have a past psychiatric history, although they might go on to develop bipolar disorder. Symptoms change quickly, with risks of devastating consequences. A woman with postpartum psychosis might minimize or even conceal her symptoms to avoid being separated from her child or out of fear that her child will be taken away. Collateral information is extremely important. A woman is at the greatest risk of developing a mental illness in the period around childbirth. The rate of postpartum depression is 1 in 9, and the baseline rate of postpartum psychosis is 1/500. Women with bipolar disorder (which may be undiagnosed until the postpartum psychosis) or a previous episode of postpartum psychosis are at highest risk of postpartum psychosis. Prevention and intervention Clinicians must be proactive with their psychoeducation about pregnancy, contraception, and the natural course of mental disorders during pregnancy and postpartum. If a patient with bipolar disorder is of childbearing age, the clinician should consider having her on medications that are relatively safe during pregnancy. In 2011, 45% of pregnancies in the United States were unintended; thus, preconception counseling is necessary. Medications for bipolar disorder can help prevent postpartum psychosis. Other preventive measures include using sleep strategies after childbirth, such as arranging support to assist at night and weighing the risks of breastfeeding. Breastfeeding can lead to sleep deprivation, which in turn, increases the risk of decompensation. If a woman wants to breastfeed, the psychiatrist should be in touch with the pediatrician and plan for breastfeeding by having the mother on medications that are safe for breastfeeding. Involuntary hospitalization might be required if the postpartum psychosis puts the mother or child at imminent risk of harm. Family and nonpsychiatrists on the health care team might be resistant to psychiatric hospitalization because it would mean separating the mother from the child. Psychiatrists can broach resistance by explaining the details of a thorough risk assessment and emphasizing that, while bonding is important, the hospitalization is meant to prevent the worst outcomes of suicide or infanticide. Review of key points Postpartum psychosis can present with mood symptoms or delirium, so those signs should make a clinician vigilant for postpartum psychosis. The symptoms of postpartum psychosis change rapidly with escalating danger, such as infanticide and suicide, so collateral from family and speedy treatment are essential. Focused early collaboration and education with team member such as ob.gyns. and pediatricians help make future interventions go more smoothly. References Friedman SH et al. Postpartum psychosis: Protecting mother and infant. Curr Psychiatr. 2019 Apr 1;18(4):13-21. Sit D et al. A review of postpartum p

25 MIN1 w ago
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Identifying and treating postpartum psychosis with Dr. Susan Hatters Friedman

Preventing murder in the family with Dr. Susan Hatters Friedman

Susan Hatters Friedman, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about family murder. Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman is editor of Family Murder: Pathologies of Love and Hate, which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Overview of family murder Family murder is defined as situations in which any member of a family kills another family member. It encompasses a wide scope of violence that includes intimate partner homicide; infanticide, including purposeful feticide; neonaticide (murder in first day of life); siblicide; and parricide (a child killing a parent). The book, Family Murder: Pathologies of Love and Hate, discusses the epidemiology and public health implications of family murder, various motivations, and pertinent psychiatric assessments, including risk assessments and sanity evaluations. It was written to prompt better screening and risk assessments, with the goal of prevention. Motivating factors leading to murder Phillip J. Resnick, MD, who also works in forensic psychiatry at Case Western, identified five main motives of parent-child violence. Fatal maltreatment is the result of fatal neglect or abuse by a parent. This type of family murder is common and is most likely to be prevented, especially with intervention by Child Protective Services. Altruistic murder occurs in three categories in which a parent wants to spare a child from perceived suffering: Psychotic parents with delusions about their children being harmed. Murder-suicide, such as when a severely depressed and suicidal parent kills their child to avoid leaving them without a parent after their suicide. Parents who kill a child with serious, chronic physical illness as a means of “saving” the child from a “worse” fate. Acutely psychotic murder occurs in the context of serious mental illness such as schizophrenia, bipolar disorder, or postpartum psychosis. Preventing this type of murder means monitoring the content of delusions and hallucinations related to family members. The Andrea Yates murders are a prime example of this type of murder. Unwanted child motive is most common in neonaticide cases. The child is considered a hindrance to something the parent wants, such as a relationship. To screen for this risk, physicians can ask whether the pregnancy was planned and observe the interaction between child and parent, especially during the first hours to days of life. Partner revenge is rare but is most likely to occur in context of a custody battle, with one partner seeing murder as a means of revenge. Psychiatrists can observe interactions between partners and inquire about threats from partners. Screening and preventing violence Psychiatrists can screen for violence by asking: “How are disagreements handled in your family?” This broad, neutral question elucidates family dynamics about partner violence, anger, and negative parental practices. It can generate information aimed at preventing fatal outcomes. Strong human emotions, such as anger, jealousy, and pride, combined with risk factors such as a history of violence and access to weapons, drive family murder. Psychoeducation about childhood development can decrease the risk of violence, especially in the fatal maltreatment category. Addressing countertransference issues Family murder stimulates strong countertransference in response to the perpetrator. Working as a team can diffuse these emotions and allows a venue for processing. Building rapport with patients and recogni

31 MIN2 w ago
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Preventing murder in the family with Dr. Susan Hatters Friedman

ICYMI: Schizophrenia with Dr. Henry Nasrallah

Henry Nasrallah, MD, was the first-ever guest on the MDedgePsychcast. In a three-part series, he joined Lorenzo Norris, MD, host of the Psychcast and editor in chief of MDedge Psychiatry, to talk about schizophrenia. In this throwback episode, the three-part conversation has been edited together into one episode. Part I: Etiology, presentation, and recent advances Part II: Manifestations; treating early Part III: Treatment of first-episode schizophrenia In part I, Dr. Nasrallah and Dr. Norris talk about the etiology, presentation, and the recent advances in how schizophrenia is conceptualized. In part II, the two discuss the need for clinicians to treat the schizophrenia as early in the disease process as possible. In part III, the conversation continues, as they talk about treatment of a patient's first episode of schizophrenia. Henry Narallah, MD, is Sydney W. Souers Endowed Chair and professor and chairman of psychiatry and behavioral sciences at Saint Louis University. He alsois...

22 MIN2 w ago
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ICYMI: Schizophrenia with Dr. Henry Nasrallah

Evidence-based approaches to treating insomnia with Dr. Karl Doghramji

Karl Doghramji, MD, is professor of psychiatry with secondary appointments in neurology and medicine at Thomas Jefferson University in Philadelphia. He also directs the Sleep Disorders Center at Thomas Jefferson. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Classification and consequences Insomnia is defined by the DSM-5 as dissatisfaction with sleep quantity or quality, difficulty falling asleep or staying asleep, or both. The symptoms need to occur at least three times per week for more than 3 months and cause dysfunction or distress in the patient. 20%-30% of the population reports insomnia; within inpatient psychiatry populations, the rates rise to up to 80%. Insomnia is thought to be caused by central nervous system hyperarousal or hyperactivity of unclear etiology, and there is evidence of genetic vulnerability. Insomnia is associated with significant impair...

17 MIN3 w ago
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Evidence-based approaches to treating insomnia with Dr. Karl Doghramji

Mental health disaster response with Dr. Judith Milner

Judith R. Milner, MD, MEd, SpecEd, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about steps psychiatrists can take to address the mental health needs of people traumatized by a natural disaster, such as Hurricane Dorian survivors. In This Week in Psychiatry, Katherine Epstein, MD, and Helen M. Farrell, MD, write about miracle cures in psychiatry. You can read the article online by clicking here or you can access the downloadable PDF by clicking here. Time Stamps: This Week in Psychiatry (02:37) Interview with Dr. Milner (06:33) Dr. RK with Dr. Renee Kohanski (39:31) Dr. Milner is a general and child and adolescent psychiatrist in private practice in Everett, Wash. She has traveled across the globe with various groups in an effort to alleviate some of the suffering caused by war and natural disaster. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses the extent to which people choose what is important an...

44 MINSEP 18
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Mental health disaster response with Dr. Judith Milner

Dr. John Mann discusses suicide prevention

Show Notes J. John Mann, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about the need for medicine to shift its approaches to preventing suicide. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education. Dr. Mann is professor of translational neuroscience at Columbia University in New York. For a complete video of this interview, see this vodcast. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how a religious wedding she attended made her think about the distinction between cults and cultures. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Why are suicide rates on the rise? In the United States, between 2001-2017, the suicide rate increased by 33%, making suicide the second-leading cause of death for people aged 15-34 years. Why the suicide rate has increased is unclear. Factors influencing rising suicide rates include the 2008 recession and the opioid crisis; however, these events cannot fully explain the trend because they occurred in the middle of the rising rates. As suicide rates increase, the medical community missed opportunities for prevention at both primary care and psychiatry visits. A Centers for Disease Control and Prevention study that examined suicide rates and psychiatric illness found approximately half of suicide decedents did not have a known mental health condition. Connections to untreated psychiatric illness Only 22% of people with psychiatric illness who die by suicide had their mental illness treated. The age of onset for major depressive disorder has been occurring earlier and indicates a greater pool of individuals is at risk of suicide. For example, during 2005-2014, major depressive episodes in adolescents increased by nearly one-third. Individuals who attempt and die by suicide have a predisposition to respond to their mental illness with suicidal behaviors. This trait poses a challenge in the face of rising rates of mental illness in the United States. Role of treatment by primary care physicians 45% of individuals who die from suicide see their primary care clinician within a month of their death. If nonpsychiatrist doctors or primary care physicians are trained to recognize depression and suicide, the rates of death and disability from depression can be decreased. Most people who die by suicide are seeking help by going to a health care professional. How should the clinician respond? If a person presents with somatic complaints with no clear causes (for example, normal lab values), this is a time for the primary care physicians to ask about depression and suicide. What steps can be taken to prevent suicide? Medicine needs an updated approach in education about depression and suicide that is similar to the changes that have taken place during the opioid crisis. Now all clinicians must complete continuing medical education about pain management and opioid prescribing, which has led to a decrease in deaths from prescription pain medications. All clinicians must be able to recognize and treat depression, because it is becoming a leading cause of death and disability. Clinicians need to do a better job of making connections between somatic complaints and mood disorders. References U.S. Department of Health and Human Services, National Institutes of Health. Mental health information: Suicide. Updated August 2019. Stene-Larsen K and A Reneflot. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019 Feb;47(1):9-17. Reed J. Primary care: A crucial setting for suicide prevention. SAMHSA-HRSA Center for Inte

25 MINSEP 10
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Dr. John Mann discusses suicide prevention

Dr. Phillip Harvey on aging, cognitive function, and technology

In this masterclass, Philip D. Harvey, PhD, professor of psychiatry and behavioral sciences at the University of Miami, discusses the relationships between aging, neurocognition, and functional outcomes. And in a new segment from MDedge, called This Week in Psychiatry, we’d like to share a Current Psychiatry evidence-based review on using antidepressants for pediatric patients (PDF) by Jennifer B. Dwyer, MD, PhD, and Michael H. Bloch, MD, MS. Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Introduction to normal aging Changes in cognitive abilities are part of normal aging. Crystalized intelligence, the storage of information learned throughout life, does not change over time in normal, healthy aging. Fluid intelligence, the ability to learn new information, solve problems, concentrate, and rapidly process information, starts changing at age 65 or so. Episodic memor...

19 MINSEP 4
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Dr. Phillip Harvey on aging, cognitive function, and technology

Dr. Roger McIntyre discusses the role of inflammation in mental illness

Show Notes Roger McIntyre, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about obesity, inflammation, and treatment implications for mental health conditions. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education. Dr. McIntyre is a professor of psychiatry and pharmacology at the University of Toronto, and head of the mood disorders psychopharmacology unit at the University Health Network, also in Toronto. For a complete video of this interview, please visit the vodcast. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how to think through whether sharing personal information with patients helps move their therapy forward. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Reconceptualizing mental illness by looking at inflammation Mental illness should be viewed as a disease involving many organs – including the brain – and psychiatry should expand its understanding of the etiology of mental illness. Increasingly, research suggests that a subgroup of people with mental disorders, including those with a variety of diagnoses, have symptoms related to alterations in their immune system and inflammation. Inflammation plays a role in disparate psychiatric diagnoses, including childhood disorders such as obsessive-compulsive disorder, ADHD, and autism, and adult disorders such as schizophrenia, depression, and Alzheimer’s disease. Currently, psychiatry uses the monoamine paradigm to explain psychiatric diagnosis, and most medications were developed using that paradigm. A subgroup of people is not sufficiently helped by current medications, so looking at inflammation as a driver of mental illness provides another biological avenue to pursue drug development. Role of obesity and chronic health conditions in worsening inflammation Obesity, particularly abdominal obesity, is overrepresented in people with mental illness and is not fully explained by either social determinants of health or medication side effects. Obesity and mental illness have a bidirectional relationship; each affects the body as multiorgan system diseases. Mental illness can be conceptualized as a kind of “metastasis to the brain.” Adipose tissue releases a surfeit of neurochemicals hazardous to brain function and that disrupt neurocircuitry. For example, compared with an individual with major depressive disorder (MDD) only, an individual with MDD and obesity is more likely to have symptoms driven by inflammation, such as anhedonia, cognitive impairment, limited motivation, and a dysregulated reward system. Obesity should also be a target symptom worthy of a focused treatment plan. Heart disease is the leading cause of death in schizophrenia, and coronary artery disease is an inflammatory illness. Research is identifying connections between psychiatric illness such as schizophrenia and potentially inflammatory driven symptoms, often called “sickness behaviors,” such as low motivation, anhedonia, and cognitive impairment. Clinical implications of obesity and inflammation Alterations in inflammation and metabolism are not just a consequence of obesity. For example, patients will bipolar disorder who report sexual or physical trauma are more likely to be in a proinflammatory neurochemical state and benefit from anti-inflammatory interventions. Are patients with early trauma who do not respond fully to “traditional” monoamine medications part of the subpopulation who respond to anti-inflammatory interventions because trauma is driving inflammation? The genetics of mental illness already are complicated and will be influenced by the environment and a “proinflammatory

32 MINAUG 28
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Dr. Roger McIntyre discusses the role of inflammation in mental illness

Gun violence prevention: Dr. Jack Rozel returns

Show Notes Jack Rozel, MD, returns to the MDedge Psychcast to discuss gun violence and a new report from the National Council for Behavioral Health. In episodes 29 and 33, Dr. Rozel talked with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about this topic in the wake of the shooting last year at the Tree of Life synagogue in Pittsburgh. Dr. Rozel is medical director of resolve Crisis Services at the Western Psychiatric Institute and Clinic of the University of Pittsburgh. He also is president-elect of the American Association for Emergency Psychiatry and a member of the National Council. Dr. Rozel can be found on Twitter @ViolenceWonks. Later, Renee Kohanski, MD, discusses betrayal in the context of Erik Erikson’s conceptualization of trust vs. mistrust. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaiso...

51 MINAUG 21
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Gun violence prevention: Dr. Jack Rozel returns

Latest Episodes

Brain imaging of forensic patients with Dr. Kent Kiehl

Kent A. Kiehl, PhD, joins hostLorenzo Norris, MD on the MDedge Psychcast to discuss the use of MRI scans to provide information about the brains of people who exhibit antisocial behaviors. The goals are to use the information to treat patients and prevent violent crimes. Timestamps: This week in Psychiatry (00:33) Meet the guest (03:35) Interview (04:25) Credits (54:10) Dr. Kiehl is professor of psychology, neuroscience, and law at the University of New Mexico, Albuquerque. He also codirects a nonprofit mental health research institute called the Mind Research Network, also in Albuquerque. He also helps run a for-profit consulting firm that helps attorneys do better science, called MINDSET. This week in Psychiatry: Suicide attempts up in black U.S. teens by Randy Dotinga Overall rates of suicide dipped from 1991 to 2017, according to research published in Pediatrics. However, the rate of suicide attempts grew slightly in black adolescents during that time. SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI: 10.1542/peds.2019-1187. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Brain imaging can support diagnoses Dr. Kiehl works with cutting-edge technology using noninvasive structural and functional brain imaging; machine learning, such as artificial intelligence; and algorithms to evaluate forensic patients and understand psychopathology, predict outcomes, and measure the impact of interventions. Dr. Kiehl and his team travel to prisons across the country with two mobile MRI units imaging incarcerated individuals and forensic patients. More and more, brain imaging is considered in capital cases, because MRI provides valuable information for defense attorneys and prosecutors. For example, a man was charged with murder and his MRI supported a diagnosis of frontotemporal dementia with a behavioral variant, so he was able to plead not criminally responsible based on his illness – and was sent to a state mental hospital rather than to death row. The case of John W. Hinckley Jr., who shot former President Ronald Reagan and his press secretary, James Brady in 1981, was an initial case in which neuroscience and imaging influenced the verdict. The shooter’s brain imaging showed enlarged ventricles and cortical atrophy, which supported a diagnosis of schizophrenia – particularly when compared with the imaging of age-matched controls. Structural and functional MRI is an adjunct to neuropsychological tests. Neuroscientists are elucidating patterns through artificial intelligence and algorithms that can be useful to civil and criminal cases. For example, age is considered a strong predictor of antisocial behaviors. To enhance accuracy, Dr. Kiehl’s team has developed a neuroprediction model in which MRI quantifies brain age, which correlates closely with cognitive testing scores. So, brain age might be more useful for predicting behavior than chronological age. This study used more than 1,000 imaging studies of inmates. The data were analyzed using an algorithm called independent component analysis, which evaluates distinct neural circuits to identify components that predict age. In the next step of analysis, the algorithm identifies patterns associated with reoffending. Younger brain age in the anterior temporal lobe and orbitofrontal cortex – brain areas associated with decision making – accurately estimates the risk of reoffending better than just chronological age. Based on an understanding of brain plasticity, dogma suggesting that people who commit violent crimes cannot be changed should be challenged. A group at the University of Wisconsin, Madison, was asked to create an evidence-based, multimodal treatment program for the hardest-to-treat violent juvenile offenders. The program, which includes interventions such as multisystemic family therapy and positive reinforcement contingency treatme

54 MIN4 d ago
Comments
Brain imaging of forensic patients with Dr. Kent Kiehl

Identifying and treating postpartum psychosis with Dr. Susan Hatters Friedman

Susan Hatters Friedman, MD, returns to the MDedge Psychcast to join host Lorenzo Norris, MD, to discuss postpartum psychosis. Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman and colleagues recently wrote an article published in Current Psychiatry examining this topic, Postpartum psychosis: Protecting mother and infant. Timestamps: This week in psychiatry (01:09) Interview (05:07) Dr. RK (22:07) Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Overview of postpartum psychosis Postpartum psychosis is a medical emergency with a fulminant development occurring within 1-4 weeks after delivery. Onset is usually 3-10 days postpartum, and women experience a spectrum of symptoms from psychosis to dysphoric mania and confusion. Many women who experience postpartum psychosis do not have a past psychiatric history, although they might go on to develop bipolar disorder. Symptoms change quickly, with risks of devastating consequences. A woman with postpartum psychosis might minimize or even conceal her symptoms to avoid being separated from her child or out of fear that her child will be taken away. Collateral information is extremely important. A woman is at the greatest risk of developing a mental illness in the period around childbirth. The rate of postpartum depression is 1 in 9, and the baseline rate of postpartum psychosis is 1/500. Women with bipolar disorder (which may be undiagnosed until the postpartum psychosis) or a previous episode of postpartum psychosis are at highest risk of postpartum psychosis. Prevention and intervention Clinicians must be proactive with their psychoeducation about pregnancy, contraception, and the natural course of mental disorders during pregnancy and postpartum. If a patient with bipolar disorder is of childbearing age, the clinician should consider having her on medications that are relatively safe during pregnancy. In 2011, 45% of pregnancies in the United States were unintended; thus, preconception counseling is necessary. Medications for bipolar disorder can help prevent postpartum psychosis. Other preventive measures include using sleep strategies after childbirth, such as arranging support to assist at night and weighing the risks of breastfeeding. Breastfeeding can lead to sleep deprivation, which in turn, increases the risk of decompensation. If a woman wants to breastfeed, the psychiatrist should be in touch with the pediatrician and plan for breastfeeding by having the mother on medications that are safe for breastfeeding. Involuntary hospitalization might be required if the postpartum psychosis puts the mother or child at imminent risk of harm. Family and nonpsychiatrists on the health care team might be resistant to psychiatric hospitalization because it would mean separating the mother from the child. Psychiatrists can broach resistance by explaining the details of a thorough risk assessment and emphasizing that, while bonding is important, the hospitalization is meant to prevent the worst outcomes of suicide or infanticide. Review of key points Postpartum psychosis can present with mood symptoms or delirium, so those signs should make a clinician vigilant for postpartum psychosis. The symptoms of postpartum psychosis change rapidly with escalating danger, such as infanticide and suicide, so collateral from family and speedy treatment are essential. Focused early collaboration and education with team member such as ob.gyns. and pediatricians help make future interventions go more smoothly. References Friedman SH et al. Postpartum psychosis: Protecting mother and infant. Curr Psychiatr. 2019 Apr 1;18(4):13-21. Sit D et al. A review of postpartum p

25 MIN1 w ago
Comments
Identifying and treating postpartum psychosis with Dr. Susan Hatters Friedman

Preventing murder in the family with Dr. Susan Hatters Friedman

Susan Hatters Friedman, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about family murder. Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman is editor of Family Murder: Pathologies of Love and Hate, which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Overview of family murder Family murder is defined as situations in which any member of a family kills another family member. It encompasses a wide scope of violence that includes intimate partner homicide; infanticide, including purposeful feticide; neonaticide (murder in first day of life); siblicide; and parricide (a child killing a parent). The book, Family Murder: Pathologies of Love and Hate, discusses the epidemiology and public health implications of family murder, various motivations, and pertinent psychiatric assessments, including risk assessments and sanity evaluations. It was written to prompt better screening and risk assessments, with the goal of prevention. Motivating factors leading to murder Phillip J. Resnick, MD, who also works in forensic psychiatry at Case Western, identified five main motives of parent-child violence. Fatal maltreatment is the result of fatal neglect or abuse by a parent. This type of family murder is common and is most likely to be prevented, especially with intervention by Child Protective Services. Altruistic murder occurs in three categories in which a parent wants to spare a child from perceived suffering: Psychotic parents with delusions about their children being harmed. Murder-suicide, such as when a severely depressed and suicidal parent kills their child to avoid leaving them without a parent after their suicide. Parents who kill a child with serious, chronic physical illness as a means of “saving” the child from a “worse” fate. Acutely psychotic murder occurs in the context of serious mental illness such as schizophrenia, bipolar disorder, or postpartum psychosis. Preventing this type of murder means monitoring the content of delusions and hallucinations related to family members. The Andrea Yates murders are a prime example of this type of murder. Unwanted child motive is most common in neonaticide cases. The child is considered a hindrance to something the parent wants, such as a relationship. To screen for this risk, physicians can ask whether the pregnancy was planned and observe the interaction between child and parent, especially during the first hours to days of life. Partner revenge is rare but is most likely to occur in context of a custody battle, with one partner seeing murder as a means of revenge. Psychiatrists can observe interactions between partners and inquire about threats from partners. Screening and preventing violence Psychiatrists can screen for violence by asking: “How are disagreements handled in your family?” This broad, neutral question elucidates family dynamics about partner violence, anger, and negative parental practices. It can generate information aimed at preventing fatal outcomes. Strong human emotions, such as anger, jealousy, and pride, combined with risk factors such as a history of violence and access to weapons, drive family murder. Psychoeducation about childhood development can decrease the risk of violence, especially in the fatal maltreatment category. Addressing countertransference issues Family murder stimulates strong countertransference in response to the perpetrator. Working as a team can diffuse these emotions and allows a venue for processing. Building rapport with patients and recogni

31 MIN2 w ago
Comments
Preventing murder in the family with Dr. Susan Hatters Friedman

ICYMI: Schizophrenia with Dr. Henry Nasrallah

Henry Nasrallah, MD, was the first-ever guest on the MDedgePsychcast. In a three-part series, he joined Lorenzo Norris, MD, host of the Psychcast and editor in chief of MDedge Psychiatry, to talk about schizophrenia. In this throwback episode, the three-part conversation has been edited together into one episode. Part I: Etiology, presentation, and recent advances Part II: Manifestations; treating early Part III: Treatment of first-episode schizophrenia In part I, Dr. Nasrallah and Dr. Norris talk about the etiology, presentation, and the recent advances in how schizophrenia is conceptualized. In part II, the two discuss the need for clinicians to treat the schizophrenia as early in the disease process as possible. In part III, the conversation continues, as they talk about treatment of a patient's first episode of schizophrenia. Henry Narallah, MD, is Sydney W. Souers Endowed Chair and professor and chairman of psychiatry and behavioral sciences at Saint Louis University. He alsois...

22 MIN2 w ago
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ICYMI: Schizophrenia with Dr. Henry Nasrallah

Evidence-based approaches to treating insomnia with Dr. Karl Doghramji

Karl Doghramji, MD, is professor of psychiatry with secondary appointments in neurology and medicine at Thomas Jefferson University in Philadelphia. He also directs the Sleep Disorders Center at Thomas Jefferson. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Classification and consequences Insomnia is defined by the DSM-5 as dissatisfaction with sleep quantity or quality, difficulty falling asleep or staying asleep, or both. The symptoms need to occur at least three times per week for more than 3 months and cause dysfunction or distress in the patient. 20%-30% of the population reports insomnia; within inpatient psychiatry populations, the rates rise to up to 80%. Insomnia is thought to be caused by central nervous system hyperarousal or hyperactivity of unclear etiology, and there is evidence of genetic vulnerability. Insomnia is associated with significant impair...

17 MIN3 w ago
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Evidence-based approaches to treating insomnia with Dr. Karl Doghramji

Mental health disaster response with Dr. Judith Milner

Judith R. Milner, MD, MEd, SpecEd, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about steps psychiatrists can take to address the mental health needs of people traumatized by a natural disaster, such as Hurricane Dorian survivors. In This Week in Psychiatry, Katherine Epstein, MD, and Helen M. Farrell, MD, write about miracle cures in psychiatry. You can read the article online by clicking here or you can access the downloadable PDF by clicking here. Time Stamps: This Week in Psychiatry (02:37) Interview with Dr. Milner (06:33) Dr. RK with Dr. Renee Kohanski (39:31) Dr. Milner is a general and child and adolescent psychiatrist in private practice in Everett, Wash. She has traveled across the globe with various groups in an effort to alleviate some of the suffering caused by war and natural disaster. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses the extent to which people choose what is important an...

44 MINSEP 18
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Mental health disaster response with Dr. Judith Milner

Dr. John Mann discusses suicide prevention

Show Notes J. John Mann, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about the need for medicine to shift its approaches to preventing suicide. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education. Dr. Mann is professor of translational neuroscience at Columbia University in New York. For a complete video of this interview, see this vodcast. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how a religious wedding she attended made her think about the distinction between cults and cultures. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Why are suicide rates on the rise? In the United States, between 2001-2017, the suicide rate increased by 33%, making suicide the second-leading cause of death for people aged 15-34 years. Why the suicide rate has increased is unclear. Factors influencing rising suicide rates include the 2008 recession and the opioid crisis; however, these events cannot fully explain the trend because they occurred in the middle of the rising rates. As suicide rates increase, the medical community missed opportunities for prevention at both primary care and psychiatry visits. A Centers for Disease Control and Prevention study that examined suicide rates and psychiatric illness found approximately half of suicide decedents did not have a known mental health condition. Connections to untreated psychiatric illness Only 22% of people with psychiatric illness who die by suicide had their mental illness treated. The age of onset for major depressive disorder has been occurring earlier and indicates a greater pool of individuals is at risk of suicide. For example, during 2005-2014, major depressive episodes in adolescents increased by nearly one-third. Individuals who attempt and die by suicide have a predisposition to respond to their mental illness with suicidal behaviors. This trait poses a challenge in the face of rising rates of mental illness in the United States. Role of treatment by primary care physicians 45% of individuals who die from suicide see their primary care clinician within a month of their death. If nonpsychiatrist doctors or primary care physicians are trained to recognize depression and suicide, the rates of death and disability from depression can be decreased. Most people who die by suicide are seeking help by going to a health care professional. How should the clinician respond? If a person presents with somatic complaints with no clear causes (for example, normal lab values), this is a time for the primary care physicians to ask about depression and suicide. What steps can be taken to prevent suicide? Medicine needs an updated approach in education about depression and suicide that is similar to the changes that have taken place during the opioid crisis. Now all clinicians must complete continuing medical education about pain management and opioid prescribing, which has led to a decrease in deaths from prescription pain medications. All clinicians must be able to recognize and treat depression, because it is becoming a leading cause of death and disability. Clinicians need to do a better job of making connections between somatic complaints and mood disorders. References U.S. Department of Health and Human Services, National Institutes of Health. Mental health information: Suicide. Updated August 2019. Stene-Larsen K and A Reneflot. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019 Feb;47(1):9-17. Reed J. Primary care: A crucial setting for suicide prevention. SAMHSA-HRSA Center for Inte

25 MINSEP 10
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Dr. John Mann discusses suicide prevention

Dr. Phillip Harvey on aging, cognitive function, and technology

In this masterclass, Philip D. Harvey, PhD, professor of psychiatry and behavioral sciences at the University of Miami, discusses the relationships between aging, neurocognition, and functional outcomes. And in a new segment from MDedge, called This Week in Psychiatry, we’d like to share a Current Psychiatry evidence-based review on using antidepressants for pediatric patients (PDF) by Jennifer B. Dwyer, MD, PhD, and Michael H. Bloch, MD, MS. Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Introduction to normal aging Changes in cognitive abilities are part of normal aging. Crystalized intelligence, the storage of information learned throughout life, does not change over time in normal, healthy aging. Fluid intelligence, the ability to learn new information, solve problems, concentrate, and rapidly process information, starts changing at age 65 or so. Episodic memor...

19 MINSEP 4
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Dr. Phillip Harvey on aging, cognitive function, and technology

Dr. Roger McIntyre discusses the role of inflammation in mental illness

Show Notes Roger McIntyre, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about obesity, inflammation, and treatment implications for mental health conditions. They spoke at the Focus on Neuropsychiatry 2019 meeting, sponsored by Current Psychiatry and Global Academy for Medical Education. Dr. McIntyre is a professor of psychiatry and pharmacology at the University of Toronto, and head of the mood disorders psychopharmacology unit at the University Health Network, also in Toronto. For a complete video of this interview, please visit the vodcast. Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how to think through whether sharing personal information with patients helps move their therapy forward. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Reconceptualizing mental illness by looking at inflammation Mental illness should be viewed as a disease involving many organs – including the brain – and psychiatry should expand its understanding of the etiology of mental illness. Increasingly, research suggests that a subgroup of people with mental disorders, including those with a variety of diagnoses, have symptoms related to alterations in their immune system and inflammation. Inflammation plays a role in disparate psychiatric diagnoses, including childhood disorders such as obsessive-compulsive disorder, ADHD, and autism, and adult disorders such as schizophrenia, depression, and Alzheimer’s disease. Currently, psychiatry uses the monoamine paradigm to explain psychiatric diagnosis, and most medications were developed using that paradigm. A subgroup of people is not sufficiently helped by current medications, so looking at inflammation as a driver of mental illness provides another biological avenue to pursue drug development. Role of obesity and chronic health conditions in worsening inflammation Obesity, particularly abdominal obesity, is overrepresented in people with mental illness and is not fully explained by either social determinants of health or medication side effects. Obesity and mental illness have a bidirectional relationship; each affects the body as multiorgan system diseases. Mental illness can be conceptualized as a kind of “metastasis to the brain.” Adipose tissue releases a surfeit of neurochemicals hazardous to brain function and that disrupt neurocircuitry. For example, compared with an individual with major depressive disorder (MDD) only, an individual with MDD and obesity is more likely to have symptoms driven by inflammation, such as anhedonia, cognitive impairment, limited motivation, and a dysregulated reward system. Obesity should also be a target symptom worthy of a focused treatment plan. Heart disease is the leading cause of death in schizophrenia, and coronary artery disease is an inflammatory illness. Research is identifying connections between psychiatric illness such as schizophrenia and potentially inflammatory driven symptoms, often called “sickness behaviors,” such as low motivation, anhedonia, and cognitive impairment. Clinical implications of obesity and inflammation Alterations in inflammation and metabolism are not just a consequence of obesity. For example, patients will bipolar disorder who report sexual or physical trauma are more likely to be in a proinflammatory neurochemical state and benefit from anti-inflammatory interventions. Are patients with early trauma who do not respond fully to “traditional” monoamine medications part of the subpopulation who respond to anti-inflammatory interventions because trauma is driving inflammation? The genetics of mental illness already are complicated and will be influenced by the environment and a “proinflammatory

32 MINAUG 28
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Dr. Roger McIntyre discusses the role of inflammation in mental illness

Gun violence prevention: Dr. Jack Rozel returns

Show Notes Jack Rozel, MD, returns to the MDedge Psychcast to discuss gun violence and a new report from the National Council for Behavioral Health. In episodes 29 and 33, Dr. Rozel talked with Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, about this topic in the wake of the shooting last year at the Tree of Life synagogue in Pittsburgh. Dr. Rozel is medical director of resolve Crisis Services at the Western Psychiatric Institute and Clinic of the University of Pittsburgh. He also is president-elect of the American Association for Emergency Psychiatry and a member of the National Council. Dr. Rozel can be found on Twitter @ViolenceWonks. Later, Renee Kohanski, MD, discusses betrayal in the context of Erik Erikson’s conceptualization of trust vs. mistrust. Dr. Kohanski, a member of the MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in private practice in Mystic, Conn. Show notes by Jacqueline Posada, MD, consultation-liaiso...

51 MINAUG 21
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Gun violence prevention: Dr. Jack Rozel returns