Heidi Anne Duerr, MPH

put a spotlight on issues in mental health and wellness, the opioid epidemic shined a light on issues in addiction psychiatry. Even the White House has taken an interest in addressing addiction problems, with President Joe Biden sharing his Administration’s inaugural 

To help address the clinical challenges and issues and provide insight into the solutions and care that might best help your patients, 

 welcomes Roueen Rafeyan, MD, DFAPA, FASAM, as Addictions Section Editor. Dr Rafeyan is chief medical officer of Gateway Foundation in Chicago and clinical assistant professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine. 

 asked Dr Rafeyan a few questions by means of an introduction.

When did you first discover you wanted to be a psychiatrist?

 My interest in behavioral health and psychology started early in my high school years. I enjoyed my entire medical school experience, and I enjoyed every rotation. This made a decision for residency training very hard, as every specialty remained an option.

During my psychiatry rotation, the complexity of the disease states as well as the impact on the person and family along with limited treatment options intrigued me and further sparked my interest.

I followed my heart, even though, at the time, psychiatry training was considered waste of medical education. Although I encountered stigma, I chose to pursue my passion. Thirty years later, I have absolutely no regrets; on the contrary, I am proud and happy about my choice.

Pursue your dreams. The only limitations are the ones that are self-imposed. Bank on your strengths, and enjoy the ride.

What do you enjoy most about being a psychiatrist?

 I enjoy being a physician and a healer. Psychiatry is the only field that requires us to consider the whole person. It is not about an organ that is malfunctioning. In fact, we not only treat the person as a whole, but must also consider their close relationships, social functioning, and family dynamics. The impact of our treatment expands beyond the person, and we can have generational impact.

What most interests you in the field of addictions?

 What interests me the most in field of addiction are the challenges and ever-evolving landscape.

Although the “disease” remains the same, the drugs of abuse are constantly changing with newer synthetic and semisynthetic compounds introduced into market. It requires us as addiction specialists to remain up to date and continue to improve our knowledge in order to provide appropriate care.

What has changed the most since you entered the field?

 So much has changed since I started addiction medicine:

- Recognition has increased significantly. Both the medical community and general public are more aware of its impact.

- Increasingly more residents are showing interest in pursuing further training in addiction medicine.

- Addiction medicine now has its own board certification process and is recognized by the American Board of Medical Specialties.

What are the biggest challenges facing (general) psychiatry today? In addiction psychiatry?

 We are in a much better place now in both psychiatry and addiction medicine, however, there are still many challenges in psychiatry:

- We are facing a serious shortage of psychiatrists, and our approach to inpatient care has changed so much over the years that many times inpatient care has become more of crisis stabilization.

- Coordination of inpatient and outpatient care remains broken, resulting in excessive utilization of services and poorer outcomes.

- Access to psychiatric treatment still remains restricted.

Addiction medicine faces all those challenges and more:

- There is an even greater shortage of addiction specialists, Not many general psychiatrists are interested in supporting these needs.

- Delivery of addiction treatment is fragmented. Historically, treatment has been provided in various settings, by various providers and standards of treatment can be different in each setting.

- The general public are usually not aware of the evidenced base treatment modalities.

- We need more standardized evidence based treatments for addiction across all treatment centers.

If you could impart wisdom on your younger self/earlier in your career in psychiatry, what would it be?

 My career has been very fulfilling, and I have enjoyed the path that has brought me here. I want to share with our early career colleagues an important point:

What do you hope to share with readers as the 

 I would like to share with our readers that addiction psychiatry is a needed and integral part of all fields of medicine, and more so in the field of psychiatry.

I am looking forward to bringing articles and knowledge relevant to readers’ practices and being avaluable resource for common approaches and latest treatment options in addiction medicine.

Do you have questions or suggestions for Dr Rafeyan? Email him via 

Articles

A Conversation With an Addictions Psychiatrist

, there are more than 5 million children and adults who live with a permanent brain injury-related disability, and at least 2.8 million individuals in the US sustain a traumatic brain injury every year. To help bring attention to what can be a preventable disability, and to focus on ways to support patients with 

, March is commemorated as Brain Injury Awareness Month.

 invited Matthew J. Ashley, MD, JD, to discuss some of the overlap between brain injuries and psychiatric symptomology and illness.

What should psychiatrists be aware of to better help their patients prevent brain injury?

 is a problem that would be wonderful to solve. Unfortunately, human beings are pretty poor at assigning relative risk to low probability events. I suppose the most practical advice I can offer is to pay attention to the most common situations that result in TBI and try to educate others about those risks.

The most common cause of TBI isn’t car accidents, believe it or not, but falls. So if your patient works in an industrial job where there is a risk of an on-the-job injury, remind them to follow safety protocols.

Similarly, remind patients to wear a seatbelt. And, if you ride anything with two wheels—not just a motorcycle but also a bicycle—then please wear a helmet and operate the vehicle defensively.

Much attention has been paid to brain injuries as a result of accidents and sports, what are some other common causes of brain injuries? How do the causes of brain injury impact treatment and prognosis?

 The most common cause overall is falling, and even a ground-level falls, if suffered in the right way, can cause a significant brain injury. Other high-risk activities might seem obvious once we consider the nature of the activities, but it might not seem so obvious otherwise. This would include equestrian activities, downhill activities, skateboarding, and the like. Essentially, anything where someone is operating at a height above ground or accelerating themselves through space rapidly.

Firearm-related incidents, whether accidental or intentional and related to assault or suicide, are another common cause.

Lastly, although it doesn’t cause traumatic brain injury, another common and often preventable cause of brain injury is anoxic injury, which can be due to many causes, including cardiac arrest or respiratory arrest. Both are, unfortunately, all too common as a consequence of drug overdose. The cause of the injury can definitely have an impact on a patient’s prognosis. That is a complicated discussion, and every patient is, of course, unique.

. What are the most common neuropsychiatric symptoms associated with brain injury from the virus or time on respirators?

 As I mentioned, respiratory or cardiac arrest can result in anoxic brain injury. COVID-19 also has an association with ischemic stroke, which is another form of brain injury altogether.

We are still learning the other more direct consequences of COVID-19 on the brain, but many effects have been reported, ranging from anosmia (ie, lack of smell), cognitive impairments (which has sometimes been colloquially referred to as 

), to more severe forms of encephalitis that occur later on in the course of disease as what is presumably an autoimmune consequence.

In addition, there is post-ICU syndrome, including the traumatic experience of critical illness, the social isolation, and any other form of critical illness myopathy or neuropathy that patients might experience after a long ICU course.

 With the attention in the popular press around TBIs, have we seen a decrease in their prevalence?

 This is hard to determine. With increased awareness of TBI, it is possible that we have increased our detection of milder cases, which would result in seemingly higher prevalence numbers. Conversely, with awareness and improved adherence to safety measures such as seatbelts, helmets, and concussion protocols, we probably reduce the actual number of cases that are occurring, but it is pretty difficult to understand all of that entirely.

Does treatment for brain injury differ for patients with serious mental illness?

Obviously, there are some differences, in the sense that we have to concomitantly treat both the underlying mental health disorder along with the brain injury, but the fundamentals of treatment for brain injury don’t change all that much. And, perhaps I have a bias, but I believe that the comprehensive, cognitive, behavioral, medical, and therapeutic treatment paradigm that we use to treat traumatic brain injury likely has other, coincidental benefits for individuals with other mental health disorders as well.

Anything else you want psychiatrists to know about brain injury?

I would say that every psychiatrist should know that there is help out there for TBI survivors, that comprehensive and dedicated programs exist, and they can be beneficial even long after the initial injury.

is the chief medical officer for Centre for Neuro Skills, which operates postacute brain injury rehabilitation programs. He also serves as visiting assistant clinical professor in the department of neurology at the University of California, Los Angeles.

To help bring attention to what can be a preventable disability, and to focus on ways to support patients with brain injury, March is commemorated as Brain Injury Awareness Month.

Bringing Awareness to Brain Injury Awareness Month

The Sigourney Trust announced this month that Robin A. Deutsch, PhD, will succeed 

, as analyst co-trustee. Myerson served a 10-year term in the position.

The Sigourney Trust is an independent nonprofit organization that “recognizes and rewards outstanding work” employing psychoanalytic thinking and practice. The Trust was founded by Mary Sigourney in 1989; thus far, there have been 136 

“As a practicing clinical psychoanalyst, I am passionate about what psychoanalytic thinking brings to the clinical encounter. Mary Sigourney established The Sigourney Trust and Award because she was passionate about psychoanalytic thinking writ large: in clinical theory and practice, in the arts, humanities and sciences, and humanitarian endeavors,” Deutsch said in a press statement.

 “I am honored to join the Sigourney Trust as the newest Analyst Co-trustee entrusted to further Mary’s vision.”

Attorney co-trustee Barbara Sherland, JD, reflected on the change: “As the field of psychoanalysis evolves, The Sigourney Trust has refined and repositioned itself to achieve Mary Sigourney’s vision. Bill’s astute contributions were instrumental in navigating these changes and in seeking more inclusiveness and diversity.”

 She added, "The Sigourney Award has significantly increased its international presence and impact through Bill’s partnership and guidance. Robin and I are dedicated to carrying on Bill’s excellent work.” 

Deutsch previously served as president of the North American Psychoanalytic Confederation. In addition, she is a Training and Supervising Analyst at the San Francisco Center for Psychoanalysis, a Personal Analyst at the Psychoanalytic Institute of Northern California, and on faculty at the San Francisco Center for Psychoanalysis.

“Ten years ago, very few awards were conferred, and very little work was being done for projects that we call ‘applied psychoanalytic endeavors, or for ventures that weren’t theoretic or solely academic,’ but that actually impact people’s lives,” Myerson said.

 “I am confident that Robin’s fresh perspectives and exceptional experience in the field will provide guidance needed to further expand the reach and impact of The Sigourney Award. Her outstanding international experience will be especially valuable.”

1. The Sigourney Trust Press Release. Robin A. Deutsch PhD Named New Analyst Co-Trustee For The Sigourney Trust. February 9, 2022. 

The Trust renews its commitment to the field of psychoanalysis with this new appointment.

New Co-Trustee Named for the Sigourney Award 

Steven Pliszka, MD, chair of The American Professional Society of ADHD [attention-deficit/hyperactivity disorder] and Related Disorders (APSARD) annual program committee, joined Jeffrey Newcorn, MD, APSARD president, in welcoming attendees to their virtual 2022 Annual Meeting, noting the conference was putting attendees “on the ground floor of exciting developments in the field.” Pliszka said the conference would highlight issues in genetics, neuroimaging, psychological variables, and environmental variables. “I think we’re moving to really integrating all these different aspects so we can think much more broadly about where ADHD fits into psychopathology in general,” he added. “And it will get us thinking more about new ways to intervene and to treat people.”

The 4-day meeting was held January 13 to 16, 2022. In-depth coverage can be found online at 

www.psychiatrictimes.com/conferences/apsard

As separate groups, college students with ADHD and college students who identify as a sexuality and gender minority (SGM) have increased risk for functional impairments, psychiatric comorbidities, and risky behaviors.

 According to Destiny Orantes, PhD, from Syracuse University, and colleagues, previous research had not considered if these outcomes are further increased in SGM students who have ADHD. Orantes shared findings from their recent research in a poster presentation.

The Mental Health of SGM Youth: Embracing Affirmation

The study assessed functional impairments, psychiatric comorbidities, and engagement in risky behaviors in 4 groups: (1) SGM students with ADHD, (2) SGM students without ADHD, (3) non-SGM students with ADHD, and (4) non-SGM students without ADHD. Data from the American College Health Association-National College Health Assessment 2019-2021 III were used. The researchers also sought to examine the prevalence of ADHD in SGM college students.

They found ADHD prevalence increased in SGM populations: 15% compared with 8% in non-SGM individuals. Additionally, SGM students with ADHD reported the highest levels of functional impairments, substance use, and psychiatric comorbidities.

The research results suggest, Orantes said, that future studies should consider the underlying reasons for SGM students having high rates of ADHD, and how best to reduce these negative outcomes. Specifically, treatment plans should take into account the separate difficulties students face from their ADHD diagnosis and their SGM identities, as well as how best to target the risky behaviors and comorbidities. 

1. Auerbach RP, Mortier P, Bruffaerts R, et al; WHO WMH-ICS Collaborators. 

Mental disorder comorbidity and suicidal thoughts and behaviors in the World Health Organization World Mental Health Surveys International College Student initiative.

“The [APSARD] task force was launched in relation to the amazing societal changes that are happening...in association with the awareness that equity means creating fair, equitable opportunities for all of us,” Martin Katzman, MD, FRCP(C), APSARD Health Equity Task Force chair, told attendees. “We’re hoping to build connections within the APSARD community, to enhance diversity of the organization, and to reach out across boundaries as well as to partner within all of our communities to raise awareness and to increase opportunities for treatment for populations that may not get the same access to treatment.”

Amy Glasofer, DPN, RN, nurse scientist with Virtua, shared an analysis of 41 studies relating to ADHD, race, ethnicity, and disparity; Catherine Dingley, PhD, RN, FNP, FAAN, associate professor in the Nursing Department of the University of Las Vegas, Nevada, also worked on the project.

They found 66.7% of studies noted Black children were significantly less likely than white children to be diagnosed with ADHD, and 65% of Black children with ADHD were significantly less likely than white children to receive medication. In addition, compared to white children, she noted Black children were more likely to discontinue medication and more likely to experience gaps in treatment; less likely to receive an α2 agonist alone; and more likely to receive significantly lower doses of stimulant. The findings suggest that, although diagnostic disparities have been reduced over time, treatment disparities still exist for minority children with ADHD.

1. Katzman M, Higgins N, Glasofer A, et al. Introducing the APSARD Health Equity Task Force. Presented at 2022 APSARD Conference. January 14, 2022.

“ADHD in preschool children is a valid and reliable condition,” reported Ann Childress, MD, president of the Center for Psychiatry and Behavioral Medicine, Inc, in Las Vegas, Nevada.

Comorbidity Issues in Gender Diverse Youth: The Tangled Web

False Allegations of Abuse Can Be a Strategy in Child Custody Litigation

According to the 2014 National Survey of Diagnosis and Treatment of ADHD and Tourette’s, 30% of children diagnosed with ADHD receive their diagnosis before age 6; 16% receive the diagnosis at 4 years or younger.

 Impairment can be great for these patients, Childress said. For example, an epidemiological review of preschoolers diagnosed with ADHD found more than 40% had been suspended from school or daycare and about 16% had been expelled.

 In comparison, less than 1% of young children without ADHD were suspended.

The actions of young children with ADHD pose safety risks to themselves due the higher levels of hyperactive impulsivity, she said. “These are kids who are running out in traffic. They’re jumping off of things and breaking bones. They’re doing things that are dangerous, and they really need treatment for their safety,” she explained.

Childress reviewed efficacy and safety data for a number of common medications, noting some small behavior improvements as a result of the study medications. However, medications were associated with adverse events, including insomnia, gastrointestinal issues, irritability, sedation, and repetitive behaviors and thoughts. She also noted not all of these medications have been approved for the youngest patients.

Fortunately, there is good evidence for the efficacy of nonpharmacological interventions for preschoolers with ADHD, Childress reported. The New Forest Therapy, Helping the Noncompliant Child, and the Incredible Years series were among the programs she noted that have demonstrated efficacy. Furthermore, she spoke highly of parent training models that foster the implementation of positive reinforcement to promote positive behaviors; ignoring low-level provocative behaviors; and responding in a clear, consistent, and safe manner to unacceptable behaviors.

“You have to carefully consider both developmental aspects and comorbidity when you’re establishing a diagnosis, and the medication efficacy and tolerability profile may not look as good in the little guys as it does in older children,” she concluded.

1. Visser SN, Zablotsky B, Holbrook JR, et al. 

Diagnostic experiences of children with attention-deficit/hyperactivity disorder.

The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity disorder: a review.

Catch up on all the latest in ADHD from the APSARD virtual 2022 Annual Meeting. 

Spotlight on Issues in ADHD

was established by President Lyndon B. Johnson in December 1963 as a response to a joint resolution request by Congress. Ever since, government, health care, and private entities have set aside February as the month to particularly pay attention to heart health to prevent morbidity and mortality.

With increasing research pointing to a strong link between mental health, psychiatric illness, and cardiac well-being, the 

has flourished in recent years. As such, there are ample opportunities to support patients’ and help improve their overall hearth health.

 asked Richard J. Contrada, PhD, professor in the department of psychology and core faculty at Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, to share some insights and tips in honor of American Heart Month. Contrada has conducted research on psychological aspects of physical health and has published more than 100 articles, chapters, and books. His work has been supported by the National Institute of Health Mental Health and Aging Institutes, US Army, Fetzer Institute, and Charles A. Dana Foundation.

How does psychosocial stress affect cardiac health? Have psychosocial stressors associated with the pandemic resulted in increased heart-related morbidity/mortality?

 For any single heart condition, the effects of psychosocial stress depends on a number of different qualifying factors, such as stage of disease. That said, coronary artery disease is responsible for many cardiac conditions, including angina pectoris and myocardial infarction. It appears that chronic psychosocial stress—for example, stress associated with one’s occupation—may promote coronary artery disease, which usually takes several decades to develop.

 By contrast, once coronary artery disease has developed, acute forms of stress—such asan episode of anger or being in the vicinity of a terrorist attack—may precipitate clinical coronary heart disease.

It is too soon to tell with a high degree of confidence what the effects of stress related to the pandemic may be on coronary artery disease related morbidity and mortality. The optimal study design for addressing this question would involve a follow-up period of at least several years. But, there is reason for concern: One response to stress is avoidance, and there is evidence that the pandemic has led to a reduction in cardiovascular diagnostic testing.

 Of course, this avoidance issue extends to other chronic disorders as well.

Where has research focused in terms of psychosocial stress and cardiac issues?

A lot of research has focused on emotional traits and conditions,

 such as anger/hostility, depression, and anxiety-related disorders such as posttraumatic stress disorder.

What are the pathways that link psychosocial stressors with poor cardiac health?

There are 3 main pathways through which psychosocial factors may contribute to heart disease. The first involves the direct biological effects of stress and emotions that may be associated with mental health problems. These include short-term cardiovascular changes, such as elevations in blood pressure and cardiac performance, the release of stress hormones that in turn alter metabolism of glucose and lipids (eg, cholesterol), increases in blood coagulability, and disturbances in heart rhythm, to name just a few. Excessive inflammation, a product of the immune system, also may be involved. Over time, these insults are thought to promote the development of coronary artery disease and may precipitate acute cardiac events.

The second major pathway is behavioral. Psychosocial stress and emotion can be involved in the regulation of health-damaging behaviors, such as cigarette smoking and poor diet.

The third involves psychological and behavioral reactions to symptoms and signs of disease, which may delay treatment-seeking or undermine medication adherence in individuals already diagnosed with heart disease.

What can psychiatrists do to support their patients’ cardiac health?

Psychiatrists can help prevent cardiac events by managing mental health problems involving negative emotions and unhealthy behaviors. They can also encourage patients to undergo regular checkups with their primary care physicians and refer patients to a cardiologist if they report what appear to be symptoms of heart disease. Where available, patients may be referred to heart disease prevention programs. This is especially important as patients enter and advance through middle age as well as if they are at high risk for cardiac problems due to risk factors such as cigarette smoking or being overweight/obese.

 Mental health problems, especially amidst a pandemic, warrant heightened attention from health care providers. It is important not to lose sight of chronic physical conditions, like heart disease, for which lifestyle change and medical care as indicated can make a life and death difference.

. Association Between Work-Related Stress and Coronary Heart Disease: A Review of Prospective Studies Through the Job Strain, Effort-Reward Balance, and Organizational Justice Models

Acute and Subacute Triggers of Cardiovascular Events

3. Einstein AJ, Shaw LJ, Hirschfeld C, et al. 

International Impact of COVID-19 on the Diagnosis of Heart Disease

4. Davidson KW, Alcántara C, Miller GE. 

Selected psychological comorbidities in coronary heart disease: Challenges and grand opportunities

 Post-traumatic stress disorder (PTSD) as a systemic disorder: Pathways to cardiovascular disease

. 2021. Accessed February 10, 2022. https://psycnet.apa.org/record/2022-07255-001