"I'm anti-gunshot wound," Rozel says. "Not anti-second amendment." 

is the Medical Director at resolve Crisis Services and President of the American Association for Emergency Psychiatry. He is also an associate professor of psychiatry and adjunct professor of law at the University of Pittsrburgh. 

Videos

March 2020, as Dr Jack Rozel tells it, saw the most guns ever sold in 1 month. What is motivating this fear-driven purchasing? Better yet, what can you do to understand and prevent gun violence? 

Understanding What Drives Gun Violence

Spooky or cute? Scary or whimsical? What do you see in this image when you think about Halloween? 

Hermann Rorschach was a Swiss Freudian psychiatrist and psychoanalyst. Dr Rorschach is remembered for having developed the Rorschach inkblot test. The purpose was, in part, to analyze and interpret the nuances of each 

answer given by the patient in order to delve into the unconscious.

 cues also convey important information about the patient. Psychiatrists know this. Thousands of hours of training go into honing their skills to listen and observe how patients communicate with them and the world around them.

 report that well over half of communication is nonverbal. They also note that the clinical setting often places too much value on the spoken word: "Many nonverbal behaviors are unconscious and may represent a more accurate depiction of a patient's attitude and emotional state."

To gain insight into the patient's state of mind (or yours, if you're taking this test), observe her as she interprets a piece of art (in this case, a Rorschach-

 ink blot). Take in the information as you ask, “What do you see?”

Before the answer comes, ask her to think about Halloween. Gaze at the image and reminisce. Where is she looking? Down? Up? Around? At her hands? At the ceiling? Does she lick her lips as she recalls the sweet and salty flavors of treats from a decade ago? Does she crack a smile?

These cues may help us understand the true nature of the image--and perhaps one's state of mind.

1. Foley GN, Gentile JP. Nonverbal communication in psychotherapy. 

This article was originally posted on October 29, 2015, and has since been updated. -Ed

Articles

Scary or sweet? Read about the value of nonverbal communication and have some spooky fun.

Spooky Rorschach

Adial Pharmaceuticals recently announced that the US Food and Drug Administration (FDA) has lifted the clinical hold and reactivated the US Investigational New Drug (IND) application for AD04, Adial’s genetically targeted therapeutic agent for the treatment of alcohol use disorder (AUD).

According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA) and the 

Journal of the American Medical Association

), approximately 35 million people each year struggle with AUD in the United States. The severe health impacts of this data is reflected in the numbers: excessive alcohol use is the fourth leading cause of preventable death, with 31% of driving fatalities resulting from alcohol use and only 7.7% of individuals with AUD receiving treatment.

 These alarming statistics make clear the need for new, innovative therapies for the treatment of AUD.

“Given the prolonged nature of the COVID-19 pandemic, the AUD crisis continues to escalate. For this reason, we have filed for an expedited review of AD04 with the FDA. The acceptance of our manufacturing data, as well as our plan for the proposed clinical study, marks an important milestone as we progress towards evaluating AD04 clinically in the United States. We continue to enroll patients in our landmark ONWARD pivotal Phase 3 clinical trial of AD04 in Europe and look forward to providing further updates as our progress continues,” said William Stilley, Chief Executive Officer of Adial Pharmaceuticals, to press.

The reactivation of the IND allows for Adial to pursue US expedited review programs for AD04. Additionally, Adial can initiate their planned Phase I pharmacokinetics (PK) clinical study, intended to support a New Drug Application (NDA) submission with the FDA.

1. Adial Pharmaceuticals Announces FDA Reactivation of its Investigational New Drug Application for AD04 in Alcohol Use Disorder. News release. 

https://www.accesswire.com/611528/Adial-Pharmaceuticals-Announces-FDA-Reactivation-of-its-Investigational-New-Drug-Application-for-AD04-in-Alcohol-Use-Disorder

2. Alcohol Addiction. Adial Pharmaceuticals. Accessed October 27, 2020. 

https://www.adialpharma.com/alcohol-addiction/

Adial Therapeutics announced the reactivated US Investigational application for their Alcohol Use Disorder therapeutic agent, AD04. 

Treatment on the Horizon for Alcohol Use Disorder 

Jessica Carson brings up a reassuring point: after periods of illness or turmoil, comes a creative epoch. 

at a major mental health organization, Expert in Residence at Georgetown University, and author of Wired This Way. 

After the bubonic plague came the Renaissance? What will follow the COVID-19 pandemic?

Quarantine Through the Lens of Creative History

 and Senior Vice President at Appriss Health. She is a physician and healthcare services researcher, trained in Critical Care and Emergency Medicine, and faculty at Johns Hopkins University School of Medicine.

The reported increase in opioid related overdoses, likely fed by the disturbances of COVID-19, necessitates a need for more widely-accessible Naloxone, an emergency life-saving treatment. 

Naloxone and Combatting the Rising Opioid Fatalities 

It is likely that a large percentage of the global population will eventually be infected with SARS-CoV-2 (the virus that causes coronavirus 19 [COVID-19]), resulting in potentially serious health and mental health consequences. An epidemiologic study done in China at the start of the pandemic found that roughly half of adults in the general population were depressed, and 1 in 5 reported high levels of anxiety.

 Individuals who spent the most time on social media websites were almost twice as likely to report depressed mood or anxiety. The crisis is being made worse by a disruption in social support networks during enforced social distancing. Individuals who were already struggling with mental illness before COVID-19 are now facing even greater challenges. These circumstances may worsen in the context of widespread poverty and hunger, entrenched disparities in health care among minorities and the underserved, and an overall decline in access to health care resulting from economic breakdown in the wake of COVID-19.

In the absence of a well-coordinated strategic initiative aimed at mitigating the physical and mental health impacts of COVID-19, a global epidemic of chronic disease, mental illness, and increased mortality may emerge as long-term consequences of stress-induced medical and psychiatric disorders related to widespread unemployment and loss of employer-based health insurance.

 This article will review complex mental health challenges created by the COVID-19 pandemic, address the limitations of conventional mental health care, comment on the potential benefits of integrative mental health care for enhancing resilience and treating specific mental health conditions, and propose a wide-ranging strategic initiative.

Even after antivirals and vaccines are developed and contain the spread of the viral pandemic, a mental health pandemic could go on for years, fueled by anticipated long-term economic and social impacts. High unemployment rates and declining financial security during recessions have been historically associated with increased suicide rates that may continue 5 to 6 years after a recessionary period has ended.

 During the decade of the Great Depression from 1929 to 1939, the suicide rate rose from 13.9 to 17.4 per 100,000. Traumatic memories of surviving years of hardship during the Great Depression resulted in high rates of anxiety and depressed mood for generations. Economic downturns disproportionately affect the lower income segment of the population, which in the United States are predominantly people of color, but all socioeconomic groups are negatively impacted.

 More recently, the Great Recession of 2007 through 2009 led to a significant increase in rates of cardiovascular disease, cancer, and mental health problems, and worsened the ongoing epidemic of opioid and alcohol abuse.

 Based on history, it is likely that widespread unemployment and food and housing insecurity resulting from economic disruption in the wake of COVID-19 will have similar large-scale impacts on health and mental health, especially among low-income workers and minorities.

Neuropsychiatric sequelae of COVID-19 infection

In addition to mental health problems caused by the economic fall-out of the pandemic, emerging research findings suggest that many individuals who become seriously ill with coronavirus infections experience severe neuropsychiatric complications. A systematic review and meta-analysis of 72 studies on acute and long-term psychiatric complications associated with coronavirus infection—including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and COVID-19—found evidence for delirium in the acute stage of illness, and depressed mood, anxiety, fatigue, and PTSD in the post-illness stage.

 Following recovery from SARS and MERS, over 15% of patients reported persisting insomnia, traumatic memories, mood swings, and impairments in concentration and memory lasting between 6 weeks and 3 years. These findings support a multi-factorial etiology of the mental health impacts of infection with coronaviruses, including direct effects of viral infection on the brain, neuropsychiatric sequelae of cerebrovascular disease, hypoxia and immune-mediated responses resulting in a hyper-inflammatory state (ie, a 

A study done in April 2020 found that a high percentage of hospitalized adults (N=153) with a median age of 71 being treated for COVID-19 experienced neuropsychiatric complications resulting from delirium.

 Cerebrovascular events, including ischemic and hemorrhagic stroke, represented the most common complication, occurring in 62% of patients. Acute alterations in personality, behavior, or cognition was the second most common neuropsychiatric complication, taking place in 31% of hospitalized patients. Almost 60% of individuals with altered mental status fulfilled diagnostic criteria for a specific psychiatric diagnosis. Of the patients with new onset psychiatric disorders, 43% had psychosis, 26% had a dementia-like syndrome, and 17% had a mood disorder. Roughly half of patients who experienced alterations in mental status during hospitalization were aged 60 years or younger. Significantly, 92% reported no previous history of mental illness; however, the authors commented that they were not able to rule out the possibility that psychiatric disorders were present but had not been diagnosed before becoming infected with COVID-19. It is important to note that at the time of writing there are limited data on the acute neuropsychiatric effects of COVID-19, and no data on the prevalence of neuropsychiatric complications in the post-illness phase.

Large prospective studies are needed to determine the prevalence of neuropsychiatric disorders during and following hospitalization for treatment of COVID-19. These will help us to better understand how COVID-19 results in a range of neuropsychiatric complications, to determine how long neuropsychiatric symptoms continue following the acute stages of viral illness, how best to treat neuropsychiatric complications, and to investigate whether those individuals with milder cases of COVID-19 (ie, who are not hospitalized) are at risk of developing similar neuropsychiatric complications.

The direct effects of COVID-19 on brain function are probably compounded by adverse psychological effects such as traumatic memories of intubation and other medical interventions in hospitalized patients, the mental health impacts of prolonged social isolation, anxiety over being infected by a potentially fatal illness, and concerns about infecting others.

Social media: bad, irrelevant, and sometimes helpful

Widespread social isolation in combination with increased reliance on social media for information on COVID-19 may be leading to an elevation in mental health problems globally.

 Due to fake or misleading news reports, many individuals are ignoring recommendations for social distancing, increasing their risk of infection and potentially serious neuropsychiatric complications of COVID-19. At the same time, many are taking extreme measures to avoid any social contact, resulting in feelings of profound isolation, anxiety, and depressed mood. Because of widespread dissemination of unverified or downright fake reports that confuse the public, fear and feelings of loss of control, millions of individuals are relying heavily on social media while sheltering in place. There is growing concern that this trend may result in increased risk of depressed mood, anxiety, PTSD, and other mental health problems.

 Individuals who have recently lost their jobs, ethnic minorities, and the underserved may be at even greater risk.

Although widespread exposure to social media is arguably causing enormous confusion, and worsening already high levels of depression and anxiety, social media platforms can also play important roles during the COVID-19 pandemic. They can educate the public about appropriate safe measures, enhance social support and connectedness, and improve resilience.

 Examples include use of social media platforms to develop and disseminate expert resources aimed at enhancing resilience such as exercise, healthy diet, regular sleep, and engaging in meditation or a mind-body practice.

Call for a strategic initiative and recommendations

Responding to these unprecedented circumstances, in May 2020, the United Nations issued a policy brief: “COVID-19 and the Need for Mental Health Action.”

 The report recommended 3 broad areas of action:

Apply a whole-society approach to promote, protect, and care for mental health

Ensure widespread availability of emergency mental health and psycho-social support

Support recovery from COVID-19 by building mental health services for the future

The COVID-19 pandemic makes the need to address the limitations and inequities of mental health care policies and practices even more urgent. Developing and implementing programs on a large-scale aimed at enhancing resilience and treating individuals struggling with the mental health consequences of COVID-19 deserves the same urgent national and global priority that is being assigned to developing and testing vaccines and antivirals. The highest priority should be given to populations at highest risk, including the unemployed, low-wage workers, African-American individuals, and Hispanic individuals.

 A well-coordinated strategic initiative is needed to restore millions of people to good mental health and will be an essential step in re-starting stalled economies globally and in the United States.

Essential first steps in developing a comprehensive national strategy should include:

Tracking prevalence rates of depression, anxiety, PTSD, and other mental health problems that are taking place in response to the economic and social stresses caused by the pandemic and among individuals who experience neuropsychiatric sequelae following infection with COVID-19

Estimating unmet treatment needs, focusing on underserved populations

Prioritizing treatment of mental health problems that are most prevalent and severe

Developing and implementing a systematic program of interventions and resources that will adequately address needs

The need to re-think limitations of conventional mental health care

In order to be both realistic and effective, a strategic initiative must take into account constraints on mental health care services in the context of a severe economic downturn that has resulted in high rates of joblessness and loss of health benefits among millions of individuals who need care. An equally important and urgent planning task involves identifying those conventional and CAM approaches that are effective, affordable, and widely available for enhancing resilience and treating specific mental health problems. All 3 criteria will be essential in order to successfully implement and scale-up a broad-based national strategy.

Implementing resources that are both effective and cost-competitive calls for a review of limitations of the existing model of mental health care and available conventional treatments of mental health problems. In response to the limitations of the current model of care, in collaborative care patients are seen by a team of primary care providers and behavioral health clinicians who address medical and mental health problems in 1 visit. Studies show that collaborative care is more cost-effective than usual care in all categories measured, including medication costs, inpatient, outpatient, and mental health specialty care, as well as for the management of depressed patients with comorbid, medical disorders, severe anxiety disorders, and serious chronic mental illness.

Although integrative treatment strategies incorporating both CAM and conventional biomedical modalities may initially be costly, downstream savings can be achieved when such integrative strategies yield positive long-term outcomes.

 Systematic reviews of economic modeling studies on compara­tive cost-effectiveness of conventional versus CAM or integrative treatments support that CAM or integrative treatment is cost-effective and may result in cost savings in some cases.

 Finally, higher upfront costs of CAM or integrative health care may be offset by improved work productivity and increased future quality adjusted life years.

The need for effective and affordable CAM and integrative interventions

Many widely used conventional treatments have limited effectiveness, well documented safety problems, and are unaffordable to large numbers of individuals who might otherwise benefit from them, including a growing number of individuals who have recently lost their jobs and no longer have health insurance. Initiatives aimed at enhancing psychological resilience and treating mental health problems should incorporate conventional and CAM approaches that are effective, safe, affordable, and cost-effective. Examples include a regular mindfulness practice for depressed mood, anxiety, insomnia, and PTSD. The National Center for Complementary and Integrative Health is spear-heading a research initiative aimed at investigating non-pharmacologic approaches to stress management in relationship to COVID-19. Topics of specific interest include mindfulness and mind-body approaches that can be used remotely (ie, via apps) to mitigate stresses related to social distancing, and to address deleterious mental health impacts experienced during the active phase and recovery from COVID-19 infection. Other potentially beneficial non-pharmacologic approaches include exercise, nutritional advice, and select natural supplements.

The need for a methodology for developing expert integrative care guidelines

A rigorous methodology for developing expert guidelines for conventional, CAM, and integrative interventions is urgently needed. Along these lines, the RAND Corporation together with the Samueli Institute have developed an efficient and cost-effective approach for conducting expert panels based on work done at the National Institutes of Health Consensus Development Conference and the Institute of Medicine.

 Each expert panel comprises 5 academics and 4 clinicians reflecting equal emphasis on clinical and research expertise. Expert panels use a streamlining approach called Rapid Evidence Assessment of Literature (REAL) to reduce time spent on literature review. The RAND methodology holds promise for reducing costs, improving cost-effectiveness, and reducing time needed to develop integrative protocols addressing the complex physical and mental health needs of individuals affected by COVID-19. This methodology can be equally applied to planning considerations pertaining to biomedicine and CAM modalities and may prove to be a valuable methodology for developing evidence-based protocols in integrative mental health care.

In addition to conventional and non-pharmacologic interventions, the COVID-19 pandemic is an important opportunity for the increasing use of technological innovations in mental health care. Examples include apps, intelligent chat-bots, and digital health platforms aimed at providing personalized psychological support; promoting resilience; and mitigating symptoms of anxiety, depression, insomnia, PTSD, and other mental health impacts of the pandemic.

The essential role of community education

Public education will be an essential tool for conveying accurate information about the role of lifestyle for enhancing emotional and mental wellness. Such health enhancement programs could be widely implemented in the workplace, schools, and communities. Carried out at a community level and coordinated by volunteers, such programs will achieve maximum buy-in and can probably be planned and implemented at little or no cost.

Whole Health Institute recently announced they are spear-heading an initiative to train peer-to-peer whole health coaches. This may be a useful model for a national initiative to train lay-healthcare coaches in every community. It could be emulated in other countries and have a global reach. More specialized programs also need to be developed to address more severe mental health problems such as PTSD, severe depressed mood, and severe anxiety among highly vulnerable populations including the elderly, veterans, and school-aged children.

The need to re-vision social media resources

As previously discussed, social media campaigns can play an important role for disseminating valuable information on lifestyle, enhancing resilience, and providing platforms for communities and health care providers to coordinate planning efforts. Social media interventions have been proven effective for changing perceptions and behaviors on a large scale

, and may become an important part of a coordinated national strategy for psychoeducation and enhancing resilience in the face of COVID-19. The authors of a recently published paper propose that large social media platforms such as Facebook and YouTube should take measures to carefully monitor content to mitigate the negative mental health consequences of fake news, graphic imagery, and inaccurate or distorted posts.

 A coordinated national program aimed at psychoeducation of the general public via social media platforms—even as the outbreak continues—may significantly reduce community spread of infection, enhance resilience, and mitigate the potential short- and long-term psychological impacts of COVID-19.

Successfully implementing an effective mental health care initiative will require shared leadership. It is time for the Department of Health and Human Services, the National Institutes of Mental Health, the American Psychiatric Association, the American Psychological Association, the Institute of Medicine, and experts in mental health care and integrative medicine to join forces and take proactive strategic measures in developing services and resources.

I have argued that a broad range of resources and clinical services are needed to adequately address the anticipated mental health impacts of COVID-19, both for enhancing psychological resilience in healthy individuals and for treating the direct and indirect consequences of the pandemic on mental health. To ensure maximum effectiveness, cost-effectiveness, and availability, the COVID-19 mental health initiative should incorporate both conventional biomedical treatments and alternative approaches, be easily scalable, optimize the role of social media in education and public safety, emphasize community engagement, and be available at little or no cost to millions of Americans who have recently lost their jobs and their health insurance.

is a Psychiatrist in private practice in California and an Adjunct Fellow, National Institute of Complementary Medicine, Health Research Institute, Western Sydney University. His most recent book is

An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future

1. Gao J, Zheng P, Jia Y, et al. Mental health problems and social media exposure during COVID-19 outbreak. 

2. Ahonen EQ, Fujishiro K, Cunningham T, Flynn M. Work as an Inclusive Part of Population Health Inequities Research and Prevention. 

3. Brenner MH. Will There Be an Epidemic of Corollary Illnesses Linked to a COVID-19-Related Recession? 

4. Bhugra D, Bhui K, Wong SYS, Gilman SE, Brenner MH. Oxford Textbook of Public Mental Health. In: 

Social class and mental health: The impact of international recession and austerity.

5. Brenner M. The impact of unemployment on heart disease and stroke mortality in European Union Countries. European Commission. 2016. Accessed October 15, 2020. 

https://op.europa.eu/en/publication-detail/-/publication/8e95d2e7-e422-4dd7-bc43-c2dc9f63f6d7/language-en

6. Rogers JP, Chesney E, Oliver D, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. 

7. Varatharaj A, Thomas N, Ellul MA, et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. 

8. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. 

9. Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. 

10. Wohleb ES, Franklin T, Iwata M, Duman RS. Integrating neuroimmune systems in the neurobiology of depression. 

11. Amsalem D, Dixon LB, Neria YJJp. The Coronavirus disease 2019 (COVID-19) outbreak and mental health: Current risks and recommended actions. 

12. Neria Y, Sullivan GMJJ. Understanding the mental health effects of indirect exposure to mass trauma through the media. 

13. Merchant RM, Lurie N. Social media and emergency preparedness in response to novel coronavirus. 

14. United Nations. Policy Brief: COVID-19 and the Need for Action on Mental Health. May 13, 2020. Accessed October 15, 2020. 

https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf

15. Unützer J, Katon WJ, Fan M-Y, et al. Long-term cost effects of collaborative care for late-life depression. 2008;14(2):95.

16. Katon WJ, Roy-Byrne P, Russo J, Cowley D. Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. 

17. Katon W, Russo J, Lin EH, et al. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. 2012;69(5):506-514.

18. Druss BG, Von Esenwein SA, Compton MT, Zhao L, Leslie DLJAJoP. Budget impact and sustainability of medical care management for persons with serious mental illnesses. 2011;168(11):1171-1178.

19. Grypma L, Haverkamp R, Little S, Unützer JJGhp. Taking an evidence-based model of depression care from research to practice: making lemonade out of depression. 2006;28(2):101-107.

20. Reiss-Brennan B, Briot PC, Savitz LA, Cannon W, Staheli RJJoHM. Cost and quality impact of Intermountain's mental health integration program. 2010;55(2):97.

21. Pelletier KR, Herman PM, Metz RD, Nelson CFJE. Health and medical economics applied to integrative medicine. 2010;6(2):86-99.

22. Herman PM, Craig BM, Caspi OJBC, medicine a. Is complementary and alternative medicine (CAM) cost-effective? A systematic review. 2005;5(1):11.

23. Herman PM, Poindexter BL, Witt CM, Eisenberg DMJBo. Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations. 2012;2(5).

24. Coulter I, Elfenbaum P, Jain S, Jonas WJBrn. SEaRCH™ expert panel process: streamlining the link between evidence and practice. 2016;9(1):16.

25. Thornicroft G, Mehta N, Clement S, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. 2016;387(10023):1123-1132.

While COVID-19 has certainly caused a physical health pandemic, it is taking a heavy toll on mental health too, to the point that strategic action is clearly needed.  

The Mental Health Pandemic Calls for a Strategic Initiative that Emphasizes Integrative Health Care

Substance use disorder (SUD), including opioid use disorder (OUD), 

 a significant proportion of the American population—20.3 million (7.4%) of Americans aged 12 years or older had a SUD in the past year.

 Of these, 2 million people had an OUD from heroin and/or misuse of prescription pain relievers.Although medication-assisted treatment (MAT) with methadone, buprenorphine, or naltrexone for OUD is the most efficacious, evidenced-based treatment that is recommended by the National Institute of Health, 

Substance Abuse and Mental Health Services Administration 

(SAMHSA), and the World Health Organization, only 11% of patients with an OUD are prescribed approved treatment.

Limited access to MAT has been cited as a substantial barrier for patients with OUD; inequities across ethnic and sociodemographic groups speak to the health disparities evident in society. The provision of appropriate treatment and lack thereof are even more troublesome when considering the vulnerable populations that bear the disproportionate burden of SUDs and OUDs—namely, those involved with the corrections system and those with serious mental illness (SMI). It is no secret that a significant 

 of the criminal justice population has an SUD.

Between 62% and 86% of individuals arrested test positive for recent drug use,3 and 64% to 76% of arrestees meet diagnostic criteria for SUD. More than half of individuals with a prescription OUD or heroin use in the past year report contact with the criminal justice system.

 Similarly, in terms of mental illness, 9.2 million Americans over 18 years old, or 3.7% of American adults, had co-occurring SUD and any mental illness in 2018.

In line with the goal of reducing recidivism, a proportion of the criminal justice population is often diverted to drug courts. According to SAMHSA, there are currently 2700 operational drug courts in the United States.

 These courts adjudicate cases involving substance-involved offenders, or individuals who were arrested for a drug-related offense and/or are eligible to enter a drug court program. Typically, an offender is followed by a drug court for 12 to 18 months. The National Drug Court Institute reports that more than 116,000 criminal offenders were served by a drug court program in 2009.

 Additionally, most individuals with SUD do not receive treatment while they are incarcerated, or they are forced to withdraw from treatment they were receiving before incarceration (

Ethical considerations around MAT in caring for these patients are apparent through lenses of health care as a source of harm, paternalism, and violation of rights; through a refusal to provide access to appropriate care; or through the intersection of medicine and epidemiology. These considerations include issues around access to MAT and the context in which consent to MAT is obtained from those to whom it is offered.

MAT is an approved treatment for OUD by the US Food and Drug Administration. The underlying pharmacology of drugs used in MAT and their physiological effects on individuals are well understood. MAT is known to assist in diminishing cravings, and some agents can alleviate the withdrawal symptoms associated with OUD. However, many drug courts and prison facilities do not afford provisions for MAT for incarcerated individuals.

The underlying pharmacology of drugs used in MAT and their physiological effects on individuals are well understood. MAT is known to assist in diminishing cravings, and some agents can alleviate the withdrawal symptoms associated with OUD. 

In the absence of MAT, individuals with OUD are forced to undergo detoxification with full exposure to the negative physiological and psychological withdrawal symptoms that they could easily avoid with MAT, including nausea, vomiting, diarrhea, agitation, anxiety, and suicidality.

 This lack of access to approved and indicated therapy for a disease process could be construed as a punitive measure and borderline cruel and unusual punishment. In fact, detoxification in the absence of MAT is less efficacious than MAT and harmful to human health.

Surveys of drug courts and the US prison systems do find practical reasons for not providing MAT, namely, the cost and lack of access to local providers. However, there are courts that do not permit MAT because of a lack of knowledge and stigma around OUD. Many drug court teams are uncertain about the underlying physiological mechanisms of opioid receptor agonists used in MAT and their efficacy in treating OUD. Some report they believe that patients with OUD use MAT to get high and not for treatment of OUD.4 Further, others think that MAT use for OUD is essentially replacing one addictive substance with another.

The false narrative that MAT reinforces addiction or replaces an illicit substance (heroin) has a negative impact on individuals.

 Additionally, the intersection of medicine and epidemiology is evident when those with SUDs/OUDs who do not have access to MAT turn to unsafe practices, such as the use of unclean needles to inject impure heroin or heroin laced with synthetic fentanyl. This, in turn, leads to increased morbidity and mortality as well as to public health issues of increased transmission of infectious diseases.

The other side of the coin: being processed by a drug court and given the option of either incarceration or MAT. Asking an individual with a mentally incapacitating illness to consent to treatment brings in to question autonomy and validity of consent. Informed consent, by definition, should be voluntary and free of coercion.

 It should be obtained from someone with the capacity to make a decision after they have an understanding of the risks and benefits of available options. Consent under the threat of incarceration, or while incapacitated, is not informed consent and compromises individual 

Many individuals with OUDs/SUDs choose Narcotics Anonymous, peer support, drug-free toxification, or treatment modalities other than MAT.3 Assuming a binary disposition, MAT versus drug-free detoxification is overly punitive and a violation of voluntariness and self-determination of these individuals.

Patients with SUDs/OUDs often contend with unfavorable correctional system interactions as well as SMI, and they predominantly comprise minorities from low-income or limited educational backgrounds and with reduced social support. They are a vulnerable population whom society has largely marginalized.2 Their rights are threatened, and they are afforded subpar and borderline unethical care. The underlying reasons behind this unsettling phenomenon is a lack of health literacy around MAT and stigma associated with OUD in nonclinical settings.

An ethical framework is needed, as well as best practice guidelines highlighting the efficacy of and science behind MAT specifically directed at the correctional system. 

Addressing limitations in knowledge base and highlighting shortcomings in protecting the rights of incarcerated individuals are both essential, in partnership with all stakeholders (including incarcerated patients, rights groups, judges, the correctional system, and medical bodies).

is a fourth-year medical student at Central Michigan University College of Medicine, Saginaw, MI. 

Central Michigan University College of Medicine.

 Key Substance Use and Mental Health Indicators in the United States: Results From the 2018 National Survey on Drug Use and Health. 

(HHS Publication No. PEP19‑5068, NSDUH Series H‑54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2019. Accessed September 10, 2020. 

https://store.samhsa.gov/product/key-substance-use-and-mental-health-indicators-in-the-united-states-results-from-the-2018-national-survey-on-Drug-Use-and-Health/PEP19-5068

2. Winkelman TN, Chang VW, Binswanger IA. Health, 

Polysubstance Use, and Criminal Justice Involvement Among Adults With Varying Levels of Opioid Use

Medication-assisted treatment for opioid use disorders in correctional settings: An ethics review

4. Matusow H, Dickman SL, Rich JD et al. Medication assisted treatment in US drug courts: Results from a nationwide survey of availability, barriers and attitudes. 

5. Substance Abuse and Mental Health Services Administration. Adult Drug Courts and Medication-Assisted Treatment for Opioid Dependence. 

 2014;8(1). Accessed September 10, 2020. 

https://store.samhsa.gov/product/Adult-Drug-Courts-and-Medication-Assisted-Treatment-for-Opioid-Dependence/sma14-4852

When is coercive methadone therapy justified?

. New York: Oxford University Press; 2019.

This article was originally published on August 17, 2020, and has since been updated. -Ed

A significant proportion of incarcerated individuals struggle with with addiction. So what is being done about it? 

The Case for Medication-Assisted Treatment: An Ethical Priority

Imagine your patient is suffering from significant depression and is getting worse despite being on an antidepressant. The patient becomes catatonic and stopped eating, drinking, and talking. A last-ditch effort, with permission from the spouse, leads to an almost immediate and miraculous recovery. 

is Medical Director, Brain Health, Exeter, NH; Editor in Chief,

Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

Join Psychiatric Times’ Editor in Chief John J. Miller, MD, as reflects on his early days as a clinician, when he witnessed the incredible power of the right psychopharmacology. 

Once Upon a Time in Psychiatry 

is the Director of the Division of Child and Adolescent Psychiatry at Weill Cornell Medicine and New York-Presbyterian.

The idea of collaborative care can be daunting and overwhelming, but Dr Justin Mohatt encourages you to try. 

Collaborative Care Models and the State of Child Psychiatry 

Oxcarbazepine (formerly branded as Trileptal) is an anticonvulsant that is structurally very similar to carbamazepine, which is US Food and Drug Administration-approved for acute or mixed mania but not well studied for depression. Both are thought to work by the same mechanism(s). The drug came to market as an anticonvulsant with very little time left on its patent protection, and it very quickly became a generic product. There was not enough time to do any significant studies on other possible uses such as in bipolar disorder before the patent ran out. Hence, there are very little data pertinent to its efficacy or effectiveness for bipolar mania or depression. What data are available are at best inconclusive,

 citing 8 pertinent reports, rate it as “probably effective” for mania—the only medication with that rating in a table of 13 off-label possible alternative treatments.

The only placebo-controlled study was in children and adolescents.

 The study included a total of 116 patients with symptoms of mania aged 7 to 18 years who were randomized to oxcarbazepine or placebo. There was no significant difference on the Young Mania Rating Scale, nor on rate of response defined as a 50% improvement in the scores. However, the response rates were 42% with oxcarbazepine and 26% with placebo, which looks like it could have become a significant difference if the cohort had been larger.

Oxcarbazepine has a somewhat milder adverse effect profile compared with carbamazepine. Probably the most significant risk with oxcarbazepine is 

; this most often occurs in the first 3 months of use, but it can occur later. Although few head-to-head comparisons are available,

 the incidence might be higher in oxcarbazepine than with carbamazepine. The overall rate is about 2% to 3%, but concomitant selective serotonin reuptake inhibitors (which can lower sodium by a different mechanism) probably increase this risk. Sodium monitoring should occur monthly for the first 3 months and every 3 to 6 months thereafter.

Adverse effects that appear less often with oxcarbazepine include liver enzyme elevations (it is not metabolized and is renally excreted), serious rashes including Stevens-Johnson syndrome, leucopenia, sedation, and other rashes. It is a weaker inducer of cytochrome P450 3A4 compared with carbamazepine and thus has fewer drug interactions. Both oxcarbazepine and carbamazepine are weight-neutral, but they can cause double vision and vertigo. Slower titration may minimize these and other adverse effects. Teratogenicity is a severe problem with carbamazepine; the incidence is unclear with oxcarbazepine but it probably should be considered to be an equally high risk in women of child-bearing potential.

Dosage of oxcarbazepine is about one-third higher than with carbamazepine. The same dose has been used for bipolar mania as is used for seizure disorders; begin with 300 mg bid and increase every 3 days by 300 mg to the maximum dose of 2400 mg, if needed and tolerated. Serum levels are not available.

In conclusion, it seems that oxcarbazepine could be a consideration for patients who you want to treat with carbamazepine for mania (as monotherapy or adjunct) but for whom it would be unsafe or who have been unable to tolerate it. It is unlikely to be of value for someone who had an adequate trial of carbamazepine and has not responded. The evidence base for treating or preventing bipolar depression is very weak for both.

is associate professor of psychiatry, Harvard Medical School, and Consulting Psychiatrist, US Department of Veterans Affairs, National Telemental Health Center, Bipolar Disorders Telehealth Program, Brockton, MA. He is a member of 

Editorial Board. The author reports no conflicts of interest concerning the subject matter of this article.

1. Vasudev A, Macritchie K, Vasudev K, et al. Oxcarbazepine for acute affective episodes in bipolar disorder. 

The Maudsley Prescribing Guidelines in Psychiatry

13th Edition. Hoboken, NJ: Wiley Blackwell; 2018: 237.

3. Wagner KD, Kowatch RA, Emslie GJ,et al. A double-blind, randomized, placebo-controlled trial of oxcarbazepine in the treatment of bipolar disorder in children and adolescents. 

Oxcarbazepine might be considered for patients who you want to treat with carbamazepine for mania (as monotherapy or adjunct) but for whom it would be unsafe or who have been unable to tolerate it. 