Heidi Anne Duerr, MPH

“Our task in the next 20 minutes is to go through a whirlwind tour of the treatments for opioid use disorder [OUD],” Edward V. Nunes, MD, told attendees of the 

 “And the idea I want to sell is that psychiatry should really lead the way on this. This is a national priority and crisis, and psychiatry has a lot to offer in terms of treatment… we have the expertise.”

Medication is the cornerstone of treatment for OUDs, and psychiatrists are the experts in this area, explained Nunes, who is professor of psychiatry at Columbia University Irving Medical Center, research psychiatrist at New York State Psychiatric Institute, and principal investigator of the Greater New York Node of the National Institute on Drug Abuse (NIDA) Clinical Trials Network. Unfortunately, most people with OUDs are not receiving effective medication treatment. This may be why there is a high mortality rate (1% annually), due largely to overdose and suicide. There are currently 3 main options available: methadone, buprenorphine, and extended release injection naltrexone, Nunes noted.

Methadone is an oral full opioid agonist with slow absorption and a slow elimination (ie, long half-life).When titrated to an effective dose range of at least 80 mg/day, it induces tolerance in the brain’s opioid system, which results in a tolerance blockade for illicit opioid. “So when a patient gets up on a dose of 

, you know that dose has gotten high enough for this patient when they say, ‘I took some heroin and nothing happened. I was wasting my money, so I stopped using it.’,” Nunes shared.

Importantly, methadone is effective, not just in efficacy but also with retention, Nunes said. In clinical trials lasting more than 6 months, 70% of patients were retained. Of those, he noted 50% were found to be in sustained abstinence. “Most importantly, because of inducing tolerance, it protects against overdose and death,” Nunes added.

There are limitations to this strategy, Nunes told attendees, with accessibility and acceptability being important issues. Methadone is only available in 

, and at least half of US communities do not have a methadone clinic within a reasonable distance, he reported. Also, daily attendance is required for the first 3 to 6 months. Direct observation is necessary because if you raise a dose too quickly, it can result in an overdose, he said. There is also the potential for diversion.

Nunes noted methadone clinics run a little differently outside of the United States. “Other countries, including Canada, have more flexible models such as primary care and pharmacy based methadone,” he explained. “So, hopefully in the future the United States will begin working with some of these models to make it widely available. In the meantime, if you have a methadone clinic in your community, by all means, think about referring for methadone maintenance.”

Buprenorphine maintenance is a second option for addressing OUDs. 

 is a high affinity mu partial agonist and kappa antagonist with less opioid-like effects and thus less adverse effects, Nunes told attendees. It sticks really tightly to the receptor, he explained, so it is long-acting and it is safer, with less risk of respiratory depression. Perhaps more importantly, it is much more convenient than methadone, as it can be prescribed by any physician who gets an 

 from SAMHSA. A previously required course is no longer needed for physicians, he said, but it is still required for nurse practitioners and physician assistants to prescribe. Buprenorphine is available in a sublingual dose as tablets or films, with dose ranging from 8 to 32 mg/day. An extended release injection is also available, he said, with dose at 300 mg or 100 mg which has a 28 day duration.

Like methadone, there are some limitations to this treatment, Nunes noted. Retention is less favorable with buprenorphine, with rates close to 40% to 50% over 6 months. Ironically, he said because there is less tolerance and less withdrawal, it is easier for patients to walk away from treatment, so clinicians have to work harder to motivate patients to stay with the program. Similarly, patients need to abstain from opioids long enough to manifest withdrawal symptoms before initiating treatment. At that time, he explained a test dose is used. There are microdosing strategies available if you want to start sooner, Nunes noted.

Overall, both methadone and buprenorphine are effective strategies, Nunes said. “There's going to be some ongoing drug use, and that's grist for the mill. But these medicines are very powerful at reducing and often eliminating the opioid use,” he told attendees. Younger age and severity of OUD are associated with worse adherence and therefore worse outcomes, he added. “Staying on methadone or buprenorphine is what predicts long term abstinence severity.”

Naltrexone, another high affinity opioid receptor antagonist, binds to the opioid receptors very tightly, and actually blocks the effects of other opioids, Nunes explained. Further good news is limited adverse effects; he reported that patients generally feel well on naltrexone. However, patients must be fully detoxified before initiating treatment, he said, which present a real barrier, especially for more severe patients. This results in the need to hospitalize patients, which is a limitation. Another option, Nunes explained, was to induce with ascending doses of naltrexone and clonidine and other nonopioid medications that attenuate withdrawal. Once initiation is successful, natrexone’s efficacy is comparable with buprenorphine. Nunes noted naltrexone should be accompanied by strong motivational counseling.

“Pay close attention to overdose risk when choosing 

,” Nunes cautioned attendees,“especially if the patient has a particularly high risk of overdose, or a history of overdoses. When you take up high doses of opioids, I would be inclined to go with methadone.”

Nunes reminded attendees to consider psychosocial treatment and counselling. Not only is psychosocial treatment a requirement for methadone, but it also provides what may be much-needed structure. Inpatient and residential treatment may be especially helpful because it removes the patient from toxic environments as well as access to drugs. Plus, it also provides an opportunity to initiate the aforementioned medications.

Ultimately, Nunes told attendees treating OUDs is not unlike leveraging other psychopharmacological treatments. He reminded clinicians to keep it simple and remember the 3 As:

Articles

Opioid use disorder—how can we battle the epidemic of overdoses? 

A Whirlwind Tour of OUD Treatment Strategies

“Is there one state-of-the-art treatment for depression? No, that was the dilemma I faced in trying to prepare for this talk,” Sidney Zisook, MD, told attendees at the 

“There is no state-of-the-art treatment because 

 [MDD] is such a broad, diverse, heterogeneous group of symptoms,” explained Zisook, who is distinguished professor at the University of California, San Diego, and a previous recipient of the 

. “In fact, there are 227 possible combinations of symptoms that will allow a person to meet the DSM criteria for major depressive disorder. And, in addition to the symptomatic heterogeneity, there are a host of other issues that affect this: severity—mild symptoms versus very severe problems; clinical features—are there anxious features, atypical features, or melancholic features? All of these may lead us to different approaches that we may take with that patient.”

Because of this heterogeneity and the many combinations, there are a number of issues and features that should be assessed for each patient. Zisook discussed a recent review that revealed 14 key areas: symptom profile, clinical subtypes, severity, neurocognition, functioning and quality of life, clinical staging, personality traits, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, early and recent environmental exposures, protective factors, resilience, and dysfunctional cognitive schema.

Thus, the best care practice—which is really what makes for state-of-the-art treatment for MDD—begins and continues with a thorough history, Zisook said. “A really thorough history begins with lab studies, physical exam, etc,” he said. “But the initial assessment isn't enough. We want to repeat the workup for patients who aren't doing well over time. I can't tell you how many times in my career, when I redid my initial assessment 6 months down the line and somebody wasn't having a good response, how different that history was and how I now—for the first time—learned about their drinking history and the cocktails they had every night. Or their early life trauma that was very much affecting their day-to-day life as an adult, etc. So not only do you do good assessment to begin with, repeat it intermittently as you have a better relationship with the patient to get a better, fuller picture of who they are.”

This includes checking for coocurring conditions and ensuring treatment for those conditions, too, Zisook said.

Similarly, he said it is important to use measurement-based care to inform decisions. “Several studies

 have found that if you measure symptoms, if you measure side effects, even with a global side effect measure along the way, share those with the patients, and develop a diary of symptoms and tolerance, you'll actually end up with better results,” Zisook reported.

Then, clinicians should dip into the wide variety of choices from what he called the “2022 Antidepressant Tool Kit.” In terms of medications, Zisook said all FDA-approved antidepressants (ie, tricyclics, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, serotonin modulators, and atypical antidepressants, and novel nonmonoamines) are equally effective with some differing adverse effects.

When discussing medication treatment personalization, the topic of 

 often comes up, said Zisook. “There was a lot of excitement about pharmacogenetic testing a few years ago, a lot of that excitement has died down, because it hasn't really proven to have a dramatic impact on our ability to personalize medications,” he told attendees.

However, testing can provide information on the genes involved in the metabolism of antidepressants (eg, CYP2D6, 2C19, 1A2, 2C9, 342, and 2B6), how the drug may be metabolized in patients, and whether the medications should be used as usual, with caution, or with extra caution and increased monitoring. “If they [patients] are a very poor metabolizer, they may end up with a very high dose of the medication that you're providing in their system, and they may be more prone to significant side effects adversity and tolerance, etc. You may need to go slower or lower or avoid certain medications,” he advised attendees.

Brain stimulation options (ie, bright light therapy, electroconvulsive therapy, transcranial magnetic stimulation, and vagus nerve stimulation) are also effective strategies in the tool kit, he noted.

Furthermore, Zisook reminded attendees not to overlook the 

. “A recent survey showed only about 20% of psychiatrists do psychotherapy in their offices, even though we all know that psychotherapy plus meds better than meds alone.”

Lifestyle aids, like exercise, are also important, he noted. “I tell all my patients, ‘When you're feeling more energetic, when you're up to it, start exercising. Get out of the house, take advantage the sunlight.’ They may not be able to do it initially. But I plant the seed early on and go back to it.”

The therapeutic alliance is key, Zisook said, and sometimes may be overlooked. He shared results from an NIMH study that found psychiatrists can “augment the effects” of both the medications as well as placebo.

“Those patients who had the best results even with placebo were the ones that maximized the nontherapeutic, nonspecific factors that are common to psychotherapy that's effective, like developing a therapeutic alliance: getting a trustful, empathetic, and collaborative relationship with a patient,” he said.

“Take advantage of those factors—and yourself,” Zisook advised. “This may mean spending more than 20 minutes with a patient. It may mean seeing their family. It may mean talking about their life independent of their depressive symptoms. But that relationship is critical in helping many of our patients get better.”

Zisook concluded by reminding attendees of their network of support, and the importance of engaging colleagues as needed. “Never worry alone,” he said. “It's always so nice when you're treating people with depression—especially difficult to treat depression—to have a colleague, other people that you can work with, you can consult with, to talk about patients. And I've always found that a critical part of my overall practice.”

The clinical characterization of the adult patient with depression aimed at personalization of management. 

2. Rush AJ, Sackeim HA, Conway CR, et al. 

Clinical research challenges posed by difficult-to-treat depression.

8 Key Issues in the world of major depressive disorder. 

Psychiatrist effects in the psychopharmacological treatment of depression.

What Is State of the Art Treatment for MDD?

Although psychotherapy is first-line treatment for posttraumatic stress disorder (PTSD), there are a few psychopharmacological options that may be useful, Mark B. Hamner, MD, told attendees at the 

Antidepressants are currently considered the mainstay medication for 

, Hamner said, and sertraline and paroxetine are the 2 selective serotonin reuptake inhibitors approved by the FDA for this indication. Hamner is professor of psychiatry and behavioral sciences at the Medical University of South Carolina as well as the director of psychopharmacology research and medical director of the PTSD Clinical Team in the Department of Veterans Affairs Medical Center in Charleston.

Venlafaxine, a serotonin and noradrenaline reuptake inhibitor, has also shown efficacy in clinical trials, he reported. Specifically, in a 6-month placebo-controlled randomized trial (RCT) (N=329), venlafaxine (mean dose = 221.5 mg/day) has been shown to be helpful in reducing re-experiencing and avoidance/numbing; however, it did not seem to address hyperarousal. He also discussed a 12-week RCT of venlafaxine, placebo

 In addition to improvement as measured by Clinician-Administered PTSD Scale (CAPS), investigators found remission in 30.2% of patients on venlafaxine versus 24.3% on sertraline and 19.6% on placebo.

Hamner said other classes of the medications have been discussed for addressing PTSD. Although 

 have been considered, he noted they are not indicated per current treatment guidelines. Mixed data is the name of the game for other classes, according to Hamner. For antipsychotics, for instance, one VA cooperative study of risperidone was negative, while another RCT of quetiapine was positive, he said.

 A current study of hypnotics is in progress, he added. 

Antiadrenergic agents have also seen mixed data. The α1-adrenoreceptor antagonist 

 has also been of interest, Hamner reported, with some efficacy in alleviating nightmares associated with PTSD in military veterans. However, Hamner also reported results of a large RCT VA cooperative study (N=304, 13 sties) in which participants were randomly assigned to receive prazosin or placebo for 26 weeks.

 Investigators failed to find a significant differences between the prazosin group and the placebo group in the mean change from baseline in the CAPS item B2 score, in the mean change in Pittsburgh Sleep Quality Index (PSQI) score, or in the Clinical Global Impression of Change (CGIC) score, he said.

“More studies are needed of medications alone or in combination,” Hamner concluded. He further reminded attendees, “Psychotherapy is an essential, first line treatment for PTSD; evidence-based psychotherapies that are trauma-focused have larger treatment effect sizes than antidepressant medications.”

1. Davidson J, Baldwin D, Stein DJ, et al. Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled trial. 

2. Davidson J, Rothbaum BO, Tucker P, Asnis G, Benattia I, Musgnung JJ. Venlafaxine extended release in posttraumatic stress disorder: a sertraline- and placebo-controlled study [published correction appears in J Clin Psychopharmacol. 2006 Oct;26(5):473. Dosage error in article text]. 

3. VA/DoD Clinical Practice Guidelines: Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017. https://www.healthquality.va.gov/guidelines/MH/ptsd/ Accessed August 18, 2022.

4. Raskind MA, Peskind ER, Chow B, et al. Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans. 

Despite mixed data, there are some psychopharmacological options for treating PTSD.

Exploring Psychopharmacology for PTSD

 fosters innovative perspectives on peace via the arts. By looking to artists from various disciplines (eg, painting, sculpting, music, photography, and poetry), the festival hopes to cross cultural boundaries and cultivate open dialogues, healing, and reconciliation. With his impressive work in the arts and healing, this year 

Diversity and Inclusion Editor, will be a featured speaker.

We invited Dr Clark to share his thoughts on the festival, and how the arts and psychiatry can and should work closely with one another.

: How has the arts helped you to find peace and healing? How do you leverage the arts in your clinical practice to promote understanding and resiliency?

: The arts provide a perpetual sense of inward renewal and transformation for my mind, body, and soul. We all seek to find balance and improve self-regulation throughout our lives. Writing poetry has allowed me to strive toward these goals.

I first started writing poetry when I was medical school and used poetry to transcend living with clinical depression and cope with the arduous journey of medical school. It remains a cathartic antidote for me. It also has helped me become more vulnerable in regard to sharing my work with a wider audience.

I encourage my colleagues and my patients to tap into their creative side. We are multi-dimensional beings who must embrace our authenticity as we seek to find meaning and purpose in our lives. The arts serve as the mouthpiece that unites humanity and fosters humility.

: This will be my first time attending the International Peace Festival. After the South Carolina Philharmonic world premiere of Three Song to Poems by composer Dick Goodwin, DMA, in February 2022, I have been determined to share my work on a global stage. I received positive feedback from the Festival after they listened to the performance. Months later, much to my surprise, they invited me to be a keynote speaker for the festival.

I am most looking forward to the experience of being at festival that promotes peace and healing through multiple forms of art. I believe it will be a gratifying experience to be in a space that fosters transformation, reconciliation, and love.

: Can you tell us a bit about your talk at the festival as well as some of the other speakers?

: I consider it an honor and a blessing to be one of the featured speakers. I will be a part of a panel highlighting the intersectionality between music and medicine specifically focuses on mental health. I plan to talk about my service on the South Carolina Philharmonic board of directors and the creation of the 

, which has had a positive impact on patients and their families in our state. I will also talk about how I utilize poetry and music as a psychiatrist to help illuminate several topics in our society, including trauma, Black mental health, diversity, equity, and inclusion (DEI), and burnout.

The executive team has put together a diverse group of speakers which include, poets, journalists, musicians, composers, and chief executive officers who are have a shared interest in promoting harmony within humanity.

I recently had the opportunity to join a Zoom call with 2 of the speakers, Clifton Joseph and Kostantinos Matzaleris. In addition to this experience, we have begun brainstorming further ways we can collaborate in the future. They are both change agents who have done remarkable things throughout their careers. (You can read more about them at 

https://internationalpeacefestival.com/speakers

.)I am looking forward to their hearing about their experiences and invaluable contributions to help their communities flourish.

: Your commitment to social justice is impressive. Have you always been drawn to issues of “bettering the world?” Do you think it is a common trait among psychiatrists?

: I am of the belief that we are created to serve as vessels of change and light in our communities. Each of us has a gift that can be used to make the world a better place. I believe God has blessed me with the gift of creativity. When I implement this gift, I believe it glorifies Him and blesses others.

Poetry is my way of seeing, hearing, and advocating for humanity. I believe psychiatrists are committed to promoting humanity which beckons social justice.

The festival takes place September 21 – 25, 2022, in Toronto. Readers interested in attending the festival can learn more at 

is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

Psychiatric Times Diversity and Inclusion Editor shares insights on the arts, humanity, and peace.

Psychiatrist Featured at Upcoming Peace Festival

In its first year back in-person since the COVID-19 pandemic, the American Psychiatric Association 2022 Annual Meeting featured more than 300 sessions and 1000 posters discussing clinical updates, diversity and health equity, and technological issues. The meeting’s theme, “Social Determinants of Mental Health,” attracted leaders in the field from across the globe. Here you will find selected highlights. Additional coverage can be found at 

More Than a Knockout: Structural Brain Effects in MMA Sparring

In a first-of-its-kind study, researchers examined the practice sparring’s effects of mixed martial arts (MMA) fighters and resulting brain changes.

Although previous studies have looked at other sports that involve repetitive brain injury, the real risk for MMA fighters occur during practice sessions, explained study co-author Aaron I. Esagoff, a medical student at Johns Hopkins University School of Medicine. While fights and matches only happen a few times per year, individuals can spend hundreds of hours sparring and practicing. MMA is a hybrid combat sport that includes moves from boxing, wrestling, karate, judo, and jujitsu.

“With MMA and a lot of combat sports, you are going to get hit in the head a good amount. And when you get hit a lot of times, that can lead to damage and disease,” Esagoff told attendees. The increasing awareness of repetitive brain trauma and its relationship to neuropsychiatric sequela inspired Esagoff and colleagues to conduct the study of MMA fighters.

To better understand the effects of the repetitive head impacts, the investigators conducted a cross-sectional study of 92 active professional MMA fighters, looking at the relationship between customary sparring practice rounds per week on white matter hyperintensity volume and regional brain volumes.

In doing so, Esagoff and colleagues found customary sparring practice rounds per week were significantly associated with increased white matter hyperintensity volume, which he noted may be indicative of damage (eg, axonal injury, vascular damage, etc). However, the investigators also found that customary sparring practice rounds per week were associated with increased relative size of the left and right caudate nucleus. The authors hypothesized that practice may help protect from injuries during official fights that damage the caudate.

“The one takeaway would be that sparring and practice is not all good or all bad, as there are some good effects, some not-as-good effects,” concluded Esagoff. “But it’s all an association for now; we’re not able to conclude anything with confidence.”

Esagoff’s co-authors included Michael J.C. Bray, MS; Andres A. Pasuizaca; Matthew E. Peters, MD; Bharat R. Narapareddy, MD; and Charles B. Bernick, MD.

Artificial Intelligence Revolution Holds Enormous Potential for Psychiatry

Artificial intelligence (AI) is here to stay, and it’s really very important for the psychiatric field to take a leading role in developing it,” said P. Murali Doraiswamy, MBBS, FRCP, of the Duke University School of Medicine in Durham, North Carolina.

Doraiswamy was joined in a panel discussion by Robert M. Califf, MD, MACC, commissioner of food and drugs for the FDA, and moderator Samantha Boardman, MD, psychiatrist and author of Everyday Vitality: Turning Stress Into Strength.

“If I [were] a computer programmer describing the unmet needs in the mental health field, I would use a formula…something like this: 40, 40, 30, 0. This means only 40% of [individuals] who need care get access to the care they want; of those, only 40% get optimal care; of those, only 30% achieve remission; and 0%...get preventive care in terms of resilience,” Doraiswamy said. “That’s the problem in this field—and the hope and promise is that AI and technology can help with some of this.”

Doraiswamy noted that $4 billion has been invested in AI, which has been doubling every 3 months for the past few years and transforming multiple fields. In psychiatry, digital health coaching, stigma reduction, triage and suicide prediction, clinical decision support, and therapeutic apps have already had an impact, with therapeutic wearables, robots and virtual reality avatars, protocol standardization, quality control and practice management, and population forecasting on the horizon.

Mental health and wellness apps are particularly lucrative, with more than 5000 currently on the market and around 250 million individuals having accessed them in the past 2.5 years. Although some of these apps are FDA-approved—such as EndeavorRx for the treatment of pediatric attention-deficit/hyperactivity disorder and Somryst for chronic insomnia—it is important to note that many are neither approved nor overseen by the FDA unless they make a disease claim. In addition, many of these digital tools also provide inaccurate information, send data to third parties, and are based on “black box” algorithms rather than randomized controlled trials. However, recent data show that 82% of individuals believe robots can support their mental health better than humans can, because robots are unbiased, judgment free, and able to provide quick answers.

Clinicians have cited potential harms of AI, including diagnostic and treatment errors; a loss in creative clinical thinking; greater risks of dehumanization and jeopardization of the therapeutic process due to lack of empathy; and less privacy and more fatalism in general. Clinicians also worry that the machine’s reaching a diagnosis could become a “black box” process and that, if time saved is used by administrators to increase patient loads, it might increase clinician burnout.

Another potential concern for clinicians is job security given the fully automated psychiatrist, which is another form of AI in development. Doraiswamy emphasized that a development like this should be regarded as an enhancement of psychiatric practice. “This is not going to replace you,” said Doraiswamy. “This is a personal assistant that’s going to be sitting in the waiting room doing the initial interview intake, get all the intake ready, and then summarize this information and have it ready for you so that you can make a diagnostic assessment.”

Clinicians have also cited benefits of AI, including better outcomes through more standardized protocols and elimination of human error; less bias in regard to race or gender; and scalability of treatment. They say AI can encourage patients to answer truthfully and accept support more objectively, use big data more efficiently than humans, provide practical guidance for trainees, and help elucidate etiologies of diseases that are not well understood.

The evidence for the predictive benefits of AI for psychiatry is also growing. Recent research has found support that AI may be able to detect Alzheimer disease 5 years before diagnosis and predict depressive episodes and risk of suicide. In addition, it is possible that machine learning may be able to anticipate a mental health crisis using only data from electronic health records. “By and large, this shows you the promise,” noted Doraiswamy. Because DeepMind—owned by Google—recently released a general-purpose AI agent, “it’s probable that you could have one AI program that could help with all 159 diseases in the DSM-5,” Doraiswamy told attendees.

To maximize the potential benefits of AI and ensure that psychiatry leads this revolution, Doraiswamy recommended that the field develop clinical practice guidelines; provide proper education and training; ensure that cases are relevant and human centered; advocate for equitable, accountable AI; implement quality improvement methods into workflow; create benchmarks for “trusted and safe” apps; and work with payers to develop appropriate reimbursement.

“We need to step back and acknowledge that digitization in our society and broad access to the internet are having profound effects that we don’t yet understand—and that as we develop technologies with the plasticity that these technologies have, as opposed to traditional medical devices, you can change the software very quickly,” Califf said. “It’s a tremendous potential benefit, but it also carries very specific risks that we need to be aware of.”

“Some very reasonable [individuals] might argue that AI and psychiatry don’t belong even in the same sentence—that AI should play no role whatsoever in mental health care, and that the psychotherapeutic relationship is sacrosanct,” Boardman concluded. “But in a world where there are so many unmet mental health needs, I think there’s a very good argument that AI can not only improve care and diagnostics and increase access, but also reduce stigma and even flag potential issues and symptoms before they appear and reduce burnout among professionals.”

New Weapon in the Fight Against Opioid Use Disorders

The opioid epidemic has raged on despite the development of evidence-based treatment for opioid use disorders,” explained Kimberly Hu, MD. “About 70% of the nearly 71,000 drug overdose deaths in 8 states involved opioids. That’s a huge, staggering number.”

Recognizing the role that insufficient access to medications plays in this epidemic, Hu and colleagues at the Ohio State University Wexner Medical Center designed and implemented an opioid use disorder (OUD) curriculum for third-year medical students. In the study, the students (n=405) were provided with in-person or virtual buprenorphine waiver training and in-person clinical experiences between January 2019 and April 2021. Pre- and post-intervention tests, along with self-reported clinical management surveys, assessed the students’ ability to screen patients with OUD and manage acute and chronic pain. Paired sample t-tests were estimated to assess improvement in knowledge and approach to clinical management principles.

Hu, a resident at the Ohio State University Wexner Medical Center, and colleagues found a statistically significant increase in both their knowledge as seen in the pre- and post-test scores as well as their self-reported understanding of management principles. A follow-up study at the end of the year also provided positive feedback. Hu reported: “83% [of the participants] said that they felt they knew how to manage acute pain, about 62% felt that they knew how to manage chronic pain, and about 77% said that they knew how to screen the patient for opioid use disorder.”

This is important no matter which specialty the students pursue, as these students will be able to “link patients with resources early and make sure that there aren’t patients slipping through the cracks,” Hu explained.

She noted that educating third-year medical students gives them—and their future patients—an advantage. “They’re a little over halfway through medical school, and then they’ll go into residency in a number of different specialties. So giving them this knowledge early helps them to incorporate [the information and skills] as they continue their training.”

Hu noted that the educational program is ongoing and supported by the Substance Abuse and Mental Health Services Administration. Her study co-authors included Julie Niedermier, MD; Amanda Start, PhD; Casia Horseman, MD; and Julie Teater, MD.

“If we can educate the next generation physicians and increase access to care, this is one way we can combat the opioid crisis,” Hu concluded.

In a disaster, we naturally tend to pay attention toward the most immediate victims, so people who are impacted physically and with physical injuries and damages,” Gaëlle Rached, MD, MSc, told attendees during a new research presentation at the APA annual meeting. But what about the family members who live thousands of miles away?

Rached, a research postdoctoral fellow at Northwestern University, shared details about the events of August 4, 2020, when the residents of Beirut experienced a massive explosion as a result of improperly stored ammonium nitrate at the city’s port. More than 200 individuals were killed, and many more were injured and left homeless. Although Rached was in the city and saw firsthand the devastation and trauma, she found herself taken aback by the reports from expat friends and colleagues.

“They heard about the blast from social media, and they tried reaching out to their families, but they weren’t able to reach them,” she told attendees. “The lines weren’t connecting. They spent hours trying to reach them and thinking and imagining the worst… Can you imagine sitting at home looking at these headlines and wondering what your family is going through? Can you imagine seeing these videos shared over on social media and being stuck abroad due to COVID, not being able to help?”

As she talked with her colleagues about these experiences, she realized that the traumatic experiences were similar, “but somehow a little bit different.”

In general, expatriates are exposed to stressful living conditions, which makes them more susceptible to developing mental health problems, Rached noted. Yet their general mental health is not well studied, and even less is known about such in the context of traumatic events. Thus, Rached and colleagues conducted a 7-month study to examine the impact of the Beirut explosion on expats.

The study consisted of 670 Lebanese citizens or first generation from Lebanese descent who were residing abroad (not in Lebanon) and at least 18 years old. Of that population, 268 experienced the explosion and/or had close family members physically impacted by it. The median age was 31, and the majority (62.2%) were female. Participants came from all over the world, with the highest percentages coming from the United States and France. Study co-authors included Muriel Slim; Dimitri Fiani, MD; Margarita Abi Zeid Daou, MD; and Souraya Torbey, MD.

Participants were screened using the Hopkins Symptoms Checklist and the PTSD Checklist for DSM-5. Preliminary analysis found almost 60% of the 268 who had more personal experience had scores on the PTSD Checklist indicative of PTSD. Furthermore, about 41% of participants screened higher than the threshold for anxiety and depression on the Hopkins Symptom Checklist. Both younger age and female sex were associated with higher scores, even months after the event occurred.

Rached explained their results show expatriates’ mental health are negatively affected by traumatic events in their home countries:

Regardless of how long the expat has been away from their home country

Regardless of if they experienced the event or witnessed it firsthand

“My simple message would be that there are 200 million expats around the world right now. Look out for expats in your life—your friends, your coworkers, your colleagues—especially when the country is going through traumatic events,” Rached concluded.

Clearing the “Brain Fog” in Long COVID

How can we “clear the fog” surrounding brain fog? Experts addressed the cognitive dysfunction, or brain fog, observed in patients with long COVID—as well as patients with fibromyalgia or chronic fatigue syndrome or those undergoing chemotherapy treatment.

Maria Tiamson-Kassab, MD, of the Moores Cancer Center at UC San Diego Health in California, introduced the session, which was delivered on behalf of the Academy of Consultation-Liaison Psychiatry. Durga Roy, MD, FACLP, of Johns Hopkins Bayview Neuropsychiatry Clinic and Johns Hopkins University School of Medicine in Baltimore, Maryland, discussed symptoms and pathophysiology of brain fog in long COVID, as well as some ways clinicians can help patients with brain fog after long COVID. Additional speakers included Jon Levenson, MD, of Columbia University Irving Medical Center, and Susan Abbey, MD, FRCPC, of the University of Toronto.

Tiamson-Kassab explained that brain fog is a nonmedical term used to describe what patients feel in any condition that causes confusion, memory loss, inability to concentrate or focus, and difficulty with word finding or multitasking. It is a symptom in many conditions, including long COVID, fibromyalgia, chronic fatigue syndrome, pregnancy, multiple sclerosis, and systemic lupus erythematosus, as well as in cancer treatments and certain medications. Neurocognitive domains affected in brain fog include planning; decision-making; processing speed; complex, divided, and selective sustained attention; free and cued recall; and working, procedural, and autobiographical memory.

Cognitive dysfunction is a particular concern in long COVID, as many patients have reported symptoms such as brain fog weeks or months after SARS-CoV-2 infection, Roy explained. Current definitions of long COVID differ. The National institute for Health and Care Excellence defines it as a constellation of symptoms that develop during or following SARS-CoV-2 infection that persist for 12 weeks or more; the World Health Organization defines it as persistent symptoms occurring 3 months from onset in individuals with past confirmed or probable SARS-CoV-2 infection and persisting for at least 2 months; and the CDC defines it as a range of symptoms that can last weeks or months after initial SARS-CoV-2 infection and can appear weeks after infection. In all cases, the symptoms cannot be sufficiently explained by any alternative diagnosis, and they can present even if the initial SARS-CoV-2 infection was mild or asymptomatic.

Although a range of symptoms may present, “fatigue and cognitive impairment appear to be the most debilitating symptoms of long COVID,” Roy explained. However, the exact cause of brain fog and other symptoms in long COVID is not yet clear. “We have to be cognizant of the fact that, potentially, anxiety and depression could be factors that are driving the fatigue and cognitive impairment,” Roy said. “And pathophysiology can stem from numerous hypotheses, neuroinflammation, or neurotropism, but the idea is that the frontal limbic pathway seems to consistently be something that we’re hearing about when it comes to cognitive problems in long COVID.”

In terms of treatment, Roy recommended both pharmacologic and nonpharmacologic interventions targeting mental fatigue and cognition. Pharmacologic interventions may include medications such as methylphenidate, donepezil, modafinil, luteolin, nicotinamide riboside, vitamin C or probiotic supplementation, monoclonal antibodies, or adaptogens. Suggested nonpharmacologic interventions include cognitive behavioral therapy, graded exercise therapy, pacing, and rehabilitation.

With studies on brain fog in long COVID still new and in development, Roy emphasized a need for more research to improve treatment and patient quality of life. “This is definitely a syndrome that we don’t know very much about,” Roy said. “It’s something that we really need to study more in order to get a better grasp on what’s going on.”

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Approximately 2 million people are in prisons and jails in the United States, and it has been estimated that about one-third (or more) receive mental health care while within the system. Although movies and the media like to portray a dismal and scary situation, the truth about correctional psychiatry is far from that. In fact, care in these facilities can rival the best care in other institutions, and the field may present unique career opportunities while addressing issues that often lead to burnout.

So what is it like to practice psychiatry behind bars? 

 invited Amar Mehta, MD, deputy director of the statewide mental health program at the California Department of Corrections and Rehabilitation, to share insight and experiences.

: According to some estimates, as many as 37% and 44% of individuals in state and federal prisons and jails, respectively, have received a mental health disorder diagnosis. Based on your experience, are these numbers accurate? What are the most common diagnoses in your facilities?

California, the state with the highest population, now has about 100,000 inmates in the state prison system. That’s the second highest number behind Texas and roughly equivalent to the lowest 22 states combined. Almost exactly one-third of the inmates, 33% (31,873 of 96,270), are currently receiving regular, ongoing mental health treatment. That is just a single slice in time, of course, as there are always patients cycling through the system. We try to be as accessible as possible to anyone who wants to tackle these often long-standing issues while incarcerated.

According to some studies, about 65% of prison inmates have a substance use disorder, with another 20% were under the influence of drugs or alcohol at the time of their crime. We know there is a large nexus between substance use disorders and other mental illnesses, especially trauma, and we work hard to identify and treat as many as we can while we have the shared opportunity with these patients.

There also is a high prevalence of mood and anxiety disorders, sometimes related to their situation but very often predating their incarceration and without being recognized.

There are also…psychotic disorders, although we make every effort to treat people with primary, pervasive, and chronic psychotic disorders who are nonviolent in hospital settings over prison settings. There are also personality disorders, of course, with a wide range of estimates.

: How often do individuals arrive with a diagnosis versus receive a diagnosis after incarceration?

All inmates are initially transferred through one of our reception centers for classification and assignment, and they are all screened for mental illness in that process. About 23% to 33% screen into mental health care from that initial step, and that roughly correlates with our total prevalence of psychiatric disorders in the whole prison population (33%). Although a substantial proportion of these individuals had mental health involvement prior to their arrival, for many patients this is their first opportunity to address those issues with the attention they deserve.

: Does mental health stigma continue into the correctional psychiatry system? What role does psychoeducation play in this setting?

 Although stigma has decreased throughout American society in the last couple of decades, there are still misconceptions and biases about mental illness and it still may be perceived as a weakness rather than an illness.

Many groups in prison culture don’t allow their peers to receive these services, no matter how much they may be suffering. Mental health staff have worked to be nonjudgmental, nonthreatening, and approachable while providing services like skills-based groups for people that do not officially belong to the mental health program.

Psychoeducation is a key part of all mental health treatment, but perhaps more than ever in this cohort. Many of our patients have not previously encountered accurate information about mental illness, and this socioeconomic group is chronically underserved in many areas of health care, especially mental health. Thus, psychoeducation is an important part of both treatment and educating the general prison population to recognize signs and symptoms that could benefit from help.

: What issues are involved in discharge planning?

Every institution has a prerelease coordinator, and there are many factors that must be considered (eg, medical illnesses, substance abuse treatment, other mental health disorders, etc).

Arranging services in every county for all of these can be daunting for a trained professional, let alone an inmate-patient. Thus there are many groups that participate in this process in California, such as the Council on Criminal Justice and Behavioral Health, Department of Health Care Services CalAIM [California Advancing and Innovating Medi-Cal] Justice-Involved Advisory Workgroup, and California Behavioral Health Planning Council. All work in conjunction with community agencies, although resources are always woefully inadequate to meet all the needs of these patients.

: What are the top treatment challenges in correctional psychiatry today, and how do they differ from those in mainstream psychiatry?

Health care staffing is a nationwide—and indeed, worldwide—issue. Severe shortages throughout the country make hiring an extremely competitive environment, with special challenges in overcoming the stigma of prison work.

The fact is that these patients have a huge capacity to improve their lives, far more than the average person. The work that is done with them in a clinical setting echoes throughout their families and communities and can be some of the most rewarding work for clinicians. Although some illnesses are deeply rooted and slow to change, this is the perfect place for our patients to work on these issues and their mental health.

In addition, limits imposed on correctional psychiatry by conventions and inertia can make it harder to remain nimble and keep up with the most advanced treatment modalities, including telepsychiatry and emerging psychopharmacological and technological breakthroughs.

: It sounds as though these challenges can be overwhelming. How do you address them?

 Quite simply: Through focused, targeted battles. We have made huge strides in establishing the largest correctional telepsychiatry program in the country, and we work hard every day to ensure that our well-trained physicians can practice psychiatry to the fullness of their abilities.

: Some of the complaints and struggles from psychiatric clinicians revolve around coverage of care, including psychopharmacology. Are these experiences similar in correctional care settings?

 One of the best things about working in prison is the focus of attention we are able to bring to the treatment of relevant symptoms. Because our patients have fully state-sponsored health care, our physicians do not have to seek authorization from insurance companies. Laboratory testing is at the discretion of the provider, including [obtaining] blood levels for a very wide variety of medications.

Due to the volume of patients in our system, there are collective bargaining agreements for certain medications. However, the formulary is robust. In addition, nonformulary medications do not require a specific external approval process, and their use is largely left up to the provider to determine clinical appropriateness.

Some specific medications are restricted, such as benzodiazepines primarily prescribed for catatonia, but this can also be seen as a benefit because of the challenges faced by providers in the community.

: In some ways, correctional settings may have advantages compared with practicing in the general community. What are other benefits of working in a correctional setting? What attracted you to the field and practice setting?

 One big advantage is that no patient in our system is ever completely lost to follow-up. They have the right to refuse treatment, but as long as they participate, they are in a constantly monitored setting with good communication about their level of functioning. Similarly, if laboratory testing is required, it will happen promptly or you will be informed of any refusal promptly. This allows for rapid decisions on titrations and next steps. Relationships with the patient are not complicated by disability evaluations, barriers from insurance coverage, or friction from many common controlled substances.

Incarcerated individuals are disproportionately representative of severely underserved populations, and these settings also house the highest concentration of severely mentally ill patients in the United States. Prisons constitute a tightly controlled environment that drastically reduces the variables that can drive a community provider crazy, which I definitely like. I am part of a huge team of like-minded colleagues that work together toward the same goals, and we have stable and equal compensation, good benefits, and a very accommodating work-life balance.

: What are some myths about correctional psychiatry that you would like to dispel?

There are a few myths in correctional psychiatry that need to be addressed.

1. “People in prisons are bad people, and they deserve bad things happening to them. Criminals don’t matter as long as they’re locked up, and we can just forget about them.”

At least 95% of all inmates in the United States will be released back into the community. And we incarcerate a lot of people. So whatever happens to them while they are in custody or a correctional setting, they will take that experience back out into the general public.

We need to be setting up these individuals with the best chance to succeed after their release. Currently, the United States has depressingly high rates of re-offending and that is a failure on all of our parts as a society. These individuals can succeed if given the right resources; we could have less crimes committed and less people in prisons. Mental health treatment is a great first step toward making that kind of change a reality.

2. “It’s too dangerous to work in a prison.”

I have worked in emergency departments, inpatient hospitals, outpatient clinics, jails, and prisons in multiple states. Patients in prisons tend to be much more stable than their counterparts in jails because they have been sentenced and have been in custody for some time.

This comparison extends to emergency departments as well, to a degree; some inmates will, of course, require treatment at the level of an emergency department at some point, but long periods of decompensation without recognition are rarer with so many eyes on the patient at all times.

Inpatient hospitals may have patients with mental illness who are violent, and these situations generally are handled by health care staff, possibly augmented by security guards. Alternatively, they can transfer the patient. Prisons have trained custody officers throughout the facility who monitor the environment at all times and respond immediately to emergencies to protect staff and other inmates. Plus, outpatient clinics have a huge volume of patients pass through at any given time, while prisons represent a relatively stable population for defined periods of time.

3. “Only bad doctors go to work in prisons.”

As prison salaries have become more competitive due to the need for quality health care, highly qualified physicians have increasingly turned to correctional health care settings for their careers. Dedicated and caring providers with a sense of social justice and the desire to help those that need it the most have found long-term, stable jobs at our prisons. Many clinicians are double or triple board certified, and they are committed to the impact they can make by serving this population.

: Thank you for sharing your insights. Is there anything else you want to share with readers?

 Being a psychiatrist for patients in prison is a great way to challenge yourself and achieve the job satisfaction that can only come from knowing your work is critically important. You can elevate your practice of medicine to the highest levels with patients that appreciate your time and effort and stand to benefit a huge amount from your help.

 is deputy director of the Statewide Mental Health Program at the California Department of Corrections and Rehabilitation in Sacramento. Previously, he was the statewide chief of telepsychiatry and directly treated patients in the correctional system for more than 6 years. Dr Mehta is a board-certified physician in adult, child and adolescent, and forensic psychiatry, as well as addiction medicine.

Do you have experiences in correctional psychiatry or other unique areas in psychiatry you would like to share? We’d like to hear about them! Send proposals to 

"The fact is that these patients have a huge capacity to improve their lives, far more than the average person. The work done with them in a clinical setting echoes throughout their families and communities and can be some of the most rewarding work for clinicians."