Heidi Anne Duerr, MPH

Is It a Psychiatric Disorder or a TBI Medical Mimic?

Too often, the medical issues associated with traumatic brain injury (TBI) are mistaken for psychiatric disorders, and patients are mistakenly referred to psychiatrists for treatment, Gregory J. O’Shanick, MDDLFAPA, told attendees.

O’Shanick, medical director of the Center for Neurorehabilitation Services in Richmond, Virginia, reminded psychiatrists to leverage their medical knowledge when assessing patients to help distinguish TBI-related medical mimics and true psychiatric diagnoses.

As the prevalence of TBI has increased, so too has 

research linking psychiatric disorders and TBI

 Jennie Ponsford, PhD, and colleagues explored this phenomenon and found that only about 23% and 21% of individuals had a pre-TBI history of a mood disorder or an anxiety disorder, respectively.

 They found an increase in psychiatric symptomology within the first year after TBI; mood and anxiety symptoms were most common (prevalence, 17.2%-62.0% and 10.3%-34.2%, respectively). Interestingly, O’Shanick noted depression is 4 to 6 times more common in patients with TBI than in the general population, and it is the most common cause of depression in men.

It is possible, he explained, that some of these mood disturbances and anxiety symptoms may be better explained as a medical consequence of TBI—or a signal of homeostatic disruption. In such cases, providing psychopharmacological treatment might improve symptoms but will not address the underlying cause.

To illustrate this issue, O’Shanick discussed examples of phobias misattributed to psychiatric diagnoses. For instance, if an individual has unrecognized balance and visual issues as a result of TBI, they may feel a sense of anxiety when in crowds. Instead of recognizing that the uneasiness is due to stability issues, the person may inappropriately link the feeling to an anxiety disorder.

“As physicians, we need to figure that out,” O’Shanick emphasized.

Fortunately, a few simple questions and exercises can help determine the root cause of the psychiatric symptoms. For example, to determine if agoraphobia symptoms may actually be vestibular in nature, ask your patient if they need to touch the wall to prevent falling when closing their eyes in the shower. Or, if the patients feels anxious in a crowded area like a store or mall, ask if pushing a cart or stroller, or holding on to another person, makes them feel better. If they answer yes, a few simple follow-up tests (eg, the Balance Error Scoring System and Fukuda Stepping Test) can confirm the presence of the medical mimic. Referrals for vestibular physical therapy and a neuro-ENT consultation may prove useful for such patients.

Similarly, to determine if there is social phobia or vergence, ask your patient if they are having trouble seeing or reading books at a normal distance. Then, check their near point of convergence and conduct a cover test. Consider a referral to a neuro-optometrist.

In other cases, a central auditory processing disorder may be confused with attention-deficit/hyperactivity disorder. Ask your patient if they have better sustained attention for visual vs verbal interactions, or if they have trouble understanding what people say if they cannot see their faces or mouths. Weber and Rinne tests can also prove useful, and a referral to an audiologist is indicated.

Posttraumatic neuroendocrine (PTNE) disorders may be relatively common in patients with TBI,

 and mood symptoms are associated with PTNE, O’Shanick explained. Psychiatrists should inquire about changes in menses, sex drive, cold intolerance, and skin and hair dryness to elucidate if PTNE is a potential cause of the mood symptoms. Lab studies should be considered, including free thyroxine, thyroid-stimulating hormone, follicle-stimulating hormone, luteinizing hormone, immunoglobulin-1, estradiol/testosterone, and AM/PM cortisol. In considering TBI in these cases, O’Shanick reminded attendees that they should not overlook intimate partner violence and child abuse.

Finally, O’Shanick illuminated the inherent biases in the Minnesota Multiphasic Personality Inventory-2 that could lead to incorrect diagnoses. For instance, stomach trouble and headaches score positively on the hypochondriasis scale, but both of these symptos may be related to TBI and TBI treatments. Similarly, positive scores on the hysteria scale result from the patient noting they are unable to work, feel sad, and have trouble sleeping, all of which are associated with TBI.

Ultimately, the psychiatrist is in the ideal position to leverage their medical and behavioral knowledge to support these patients.

“Hopefully, [these insights] will allow you to think a little bit differently when patients come into your office,” O’Shanick concluded. “Maybe ask some increased questions when it comes to injury-related issues, concussion-related issues… to see if there are some other types of medical issues behind some of the anxieties that your patients have. At the end, you may just find that you’re practicing … much more successfully and ultimately helping your patients.”

1. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths. CDC. 2014. Accessed May 2, 2021. 

https://www.cdc.gov/traumaticbraininjury/pdf/TBI-Surveillance-Report-FINAL_508.pdf

2. Ponsford J, Alway Y, Gould KR. Epidemiology and natural history of psychiatric disorders after TBI. 

3. Beyer C, Zaytsev J, Donegan D, et al. The effects of traumatic brain injury on pituitary function: a systematic review and meta-analysis. 

Ketamine: Not a Simple Treatment, but a Worthy One

"This is not a simple treatment or a treatment to take lightly,” Richard C. Shelton, MD, said during the Q+A portion of the presentation “Ketamine for Depression: Is the Hype Holding Up? Mechanisms and Evidence.” “On the other hand, we’ve seen remarkable results.”

Shelton, director of research of the Huntsville Regional Medical Campus of the University of Alabama, Birmingham (UAB), School of Medicine; the Charles B. Ireland Professor in UAB’s Department of Psychiatry and Behavioral Neurobiology; and director of the UAB Depression and Suicide Center, began with a discussion of ketamine’s functions in the brain. He discussed how it restores the regulatory processes for patients with depression and other mood disorders, using the results of a 

“Stressful experiences cause a reduction or retraction of spines and synapses. The brain is less able to control or regulate the emotional state,” Shelton explained.

With ketamine administration, there is an almost immediate increase in formation of critical spine and synaptic proteins.

“When you add ketamine to the system, you produce a rapid return and restoration of those spines and synapses. We see an effect within 24 hours,” Shelton continued. “Ketamine has the ability to restore the regulatory control to the brain and helps, theoretically, to normalize mood.”

Shelton shared data from 8 studies that investigated ketamine; they found ketamine produced a rapid, robust effect for patients with severe treatment-resistant depression.

 Data from additional studies demonstrated how ketamine functioned for patients with suicidal ideation.

“The good news: Ketamine really seemed to work in these patients with highly treatment-resistant depression,” Shelton said.

Shelton also addressed key concerns regarding ketamine, especially how it may be a challenge to prescribe. First, the US Food and Drug Administration requires a “somewhat cumbersome” risk evaluation and mitigation strategy program, which requires registration by the clinic, provider, and patient. There are prior authorization hurdles as well as reimbursement issues, he added. Nonetheless, Shelton finds ketamine is more than worth the attendant logistical struggles.

“When I treated my first patient with IV ketamine in 2012, it was just amazing to see the effect occur within 24 hours,” Shelton said.

1. Li N, Liu R-J, Dwyer JM, et al. Glutamate N-methyl-D-aspartate receptor antagonists rapidly reverse behavioral and synaptic deficits caused by chronic stress exposure.

2. Berman RM, Narasimhan M, Sanacora G, et al. A randomized clinical trial of repetitive transcranial magnetic stimulation in the treatment of major depression. 

3. Zarate CA Jr, Singh JB, Carlson PJ, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. 

4. Singh JB, Fedgchin M, Daly EJ, et al. A double-blind, randomized, placebo-controlled, dose-frequency study of intravenous ketamine in patients with treatment-resistant depression. 

5. Daly EJ, Singh JB. Adjunctive intranasal esketamine in treatment-resistant depression—reply. 

6. Fedgchin M, Trivedi M, Daly EJ, et al. Efficacy and safety of fixed-dose esketamine nasal spray combined with a new oral antidepressant in treatment-resistant depression: results of a randomized, double-blind, active-controlled study (TRANSFORM-1). 

7. Popova V, Daly EJ, Trivedi M, et al. Efficacy and safety of flexibly dosed esketamine nasal spray combined with a newly initiated oral antidepressant in treatment-resistant depression: a randomized double-blind active-controlled study. 

8. Daly EJ, Trivedi M, Janik A, et al. Efficacy of esketamine nasal spray plus oral antidepressant treatment for relapse prevention in patients with treatment-resistant depression: a randomized clinical trial. 

9. Wajs E, Aluisio L, Holder R, et al. Esketamine nasal spray plus oral antidepressant in patients with treatment-resistant depression: assessment of long-term safety in a phase 3, open-label study (SUSTAIN-2). 

10. Wilkinson ST, Ballard ED, Bloch MH, et al. The effect of a single dose of intravenous ketamine on suicidal ideation: a systematic review and individual participant data meta-analysis. 

11. Canuso CM, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: results of a double-blind, randomized, placebo-controlled study. 

12. Fu D-J, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). 

13. Ionescu DF, Fu DJ, Qiu X, et al. Esketamine nasal spray for rapid reduction of depressive symptoms in patients with major depressive disorder who have active suicide ideation with intent: results of a phase 3, double-blind, randomized study (ASPIRE II). 

Experts Express Concern Over Excited Delirium Syndrome Diagnosis

There is universal confusion around excited delirium syndrome (ExDS): What is it and how should it be treated? In short, we do not know all the answers, and no comprehensive treatment guidelines or formal criteria exist, according to a panel presentation. Representing the fields of emergency medicine, psychiatry, psychology, and emergency medical service (EMS), the expert panel consisted of Leslie Zun, MD, MBA; Thom Dunn, PhD; Julie Owen, MD, MBA; and Sarah E. Slocum, MD.

Recent events have brought to light the importance of clarifying the differential diagnosis, signs and symptoms, and universal treatment protocols of ExDS, which to date remain unclear.

In the last year, the world witnessed George Floyd dying at the hands of a police officer. In 2019, Elijah McClain, aged 23 years, a massage therapist, was placed in a chokehold by law enforcement and sedated by EMS with 500 mg of ketamine, a tactic that is legal in Colorado to control ExDS. By the time he arrived at the hospital, he was brain dead; he died 3 days later.

How McClain died is a matter of dispute, but 1 thing is clear: These and many, many more incidents in the public eye have shone a spotlight on the use of force by police and in emergency settings.

Dunn, a psychologist who is involved in emergency medical services, shared an ultimately tragic example of ExDS in a hospital setting in which an adult male Black patient demonstrated signs of the condition. The presence of police seemed to intensify the patient’s agitation. He began to sweat profusely, stripped naked, shouted incomprehensibly, and flailed his arms. After multiple attempts to restrain him, police tased him. Emergency staff then administered ketamine, and he subsequently died.

In 2020, the American Psychiatric Association released a 

DSM-5 recognizes Delirium, hyperactive type, but the symptoms of this condition differ in many ways from the symptoms typically attributed to excited delirium (eg, superhuman strength, impervious to pain, etc). Recent data suggest that persons being detained by the police and described as having ‘excited delirium have frequently received medication from emergency medical technicians (EMTs) intended to rapidly sedate them…In some reported cases, it is questionable whether the person identified as having an ‘excited delirium’ actually had any medical condition warranting its use.

The discussion concluded with Slocum’s call for action: “We really need to address this condition as a group and figure out what’s going to be best for that patient.”

1. American Psychiatric Association. Position statement on concerns about use of the term “excited delirium” and appropriate medical management in out-of-hospital contexts. December 2020. Accessed May 22, 2021. 

https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf

"Ethical dilemmas arise when multiple ethical responsibilities stand in tension with each other,” Charles Dike, MBChB, MPH, told the attendees.

During the discussion, one issue stood out: the possible conflict between psychiatrists’ duties to their individual patients and their duties to promote the good of the public as a whole.

This conflict has become particularly pressing this past year due to the global pandemic, and the panelists considered the problem from several angles as they answered previously submitted questions.

One question concerned confidentiality: What should be done when a patient reports that their parents are sending the patient’s sibling to school, despite the child’s positive SARS-COV-2 virus results?

Daniel J. Anzia, MD, a member of the expert panel, explained, “The participation in public health endeavors is a long-standing, recognized potential exception to the obligation of psychiatrists, and all physicians, to maintain confidentiality.” Past department chair for psychiatry at Advocate Lutheran General Hospital in Park Ridge, Illinois, Anzia said that ideally, the patient—who was no longer a minor—would make the report to the school, and then inform the family that public health officials might be contacting them. But, he added, if the patient refused, “it is permissible for the psychiatrist to make such a report.”

Another questioner asked what psychiatrists should do if patients insisted on being seen in person, even at the height of the pandemic. Panel member Patricia (Tia) Powell, MD, director of the Montefiore Einstein Center for Bioethics in the Bronx, New York, told attendees that they are not required to put themselves at physical risk. “Among our many obligations as psychiatrists is to provide a safe space in which we can offer therapy for our patients. That includes keeping the patient and psychiatrist safe from each other in terms of communicating the virus,” she explained.

In addition, Powell noted that many psychiatrists have extended their knowledge and use of telehealth, discharging their obligation to offer care in person by working with patients to make telehealth possible. If the patient refuses telehealth, protective gear, and vaccination, she said, “it could be legitimate for a psychiatrist to say, ‘At this time, I’m not able to continue working with you.’”

Similarly, are psychiatrists obligated to get an available COVID-19 vaccine? Although “a psychiatrist has a right to refuse the vaccine, the psychiatrist should consider their wider obligations of such a decision, including an unspoken statement—to the psychiatrist’s colleagues and patients—that the psychiatrist does not trust the vaccine,” said Dike, associate professor of psychiatry at Yale School of Medicine and associate program director of its Law and Psychiatry Fellowship. “This could discourage vulnerable patients from taking what could be a life-saving intervention.”

What are the obligations of a psychiatrist to a new patient who has yet to be seen? The panel was presented with a situation in which a new patient reports suicidal thoughts on a previsit questionnaire, and then does not come to the appointment or answer calls. Should the psychiatrist send someone to check on the patient?

Panelist Rebecca Brendel, MD, JD, detected a potential conflict between the psychiatrist’s duty to the individual patient and the public at large. “We’d hate to say we’re not going to screen patients for suicidality because it’s too hard to figure out what to do with the information,” explained Brendel, assistant professor of psychiatry at Harvard Medical School and director of its Master in Bioethics program. However, she noted the need for a follow-up mechanism that does not overstep the bounds of a nascent doctor-patient relationship by violating the prospective patient’s rights to privacy and confidentiality.

One of the more controversial topics over the past few years has been what psychiatrists—or, more broadly, the APA—should say about the national psyche and potentially dangerous political leaders or movements. Brendel quickly reaffirmed the Goldwater Rule, but she also insisted that “psychiatrists can participate in public life by adding insight and knowledge about mental health more generally.” For instance, psychiatrists might use their knowledge of history and psychology to “comment about what might lead groups of persons to become susceptible to certain beliefs, [or] be prone to questioning authority in violent ways. [Psychiatrists can] also…be thinking about how unrest or extremism or discriminatory views might affect certain members of our society, and in particular their mental health.”

The panel reminded attendees that ethics resources and official APA opinions can be found on the APA’s Ethics webpage: 

https://www.psychiatry.org/psychiatrists/practice/ethics

. Queries can be submitted to the APA’s Ethics Committee staff liaison for further guidance at apaethics@psych.org. Alternately,

readers can submit ethical dilemmas to our Ethics Editor via 

Articles

The 2021 American Psychiatric Association Virtual Annual Meeting brought together leaders in psychiatry to discuss hot topics including diversity, COVID-19, mood disorders, and more.

Challenging Diagnoses, New Treatments, and Clinical Conundrums Discussed at Annual Meeting

 and traumas have the potential for long-term mental health implications, noted 

 National Institute of Mental Health (NIMH) Director, so it is no surprise that the simultaneous nationwide crises of 2020 posed significant threats to mental health. Fortunately, lessons learned from previous events and preliminary research point to a relatively positive outlook, he told attendees of the 

2021 American Psychiatric Association Annual Meeting

The past year presented a dangerous pandemic, with unprecedented morbidity and mortality numbers and mitigation strategies that resulted in isolation and economic strife. On top of that, the United States saw natural disasters and a reckoning around the systemic racial injustice that has plagued this country for years. Individually, each crisis had the possibility of a negative impact on mental health; together, they had the potential to be catastrophic.

Fortunately, lessons from previous traumas have found most individuals (90%) who are exposed to trauma improve within a year or so. However, there is a significant minority who may have long-term or chronic experiences with mental illness, Gordon explained. Specifically, studies have shown there are 

 The first group consists of individuals whose levels of symptomology following the trauma are low and remain low; they generally do not require clinical attention. The second and third groups have either immediate (within 1 to 3 months following trauma) or delayed (between 3 and 6 months post-trauma) increased symptomology, but usually recover. The final group has a sustained or chronic time course, and symptoms last beyond 6 months.

Although improvement is often due to treatment, Gordon noted other factors often predict recovery versus negative outcomes. Risk factors for long-term or chronic experiences include: few social supports, a history of trauma or mental illness, direct exposure to death or injuries, severe acute reactions to disaster, and ongoing stressors such occupational and financial strain. Having these risk factors does not equate to long-term issues, Gordon explained, but increases the risk of such. He added that having multiple factors further increases the risk of chronic symptoms.

Study after study has indicated that meeting immediate needs after a trauma helps to reduce the long-term impact, Gordon explained. For instance, after a hurricane, it is important to make sure victims have a safe place to stay and food. Similarly, treating new or worsening mental illness is very important, he said. After Hurricane Katrina, half the residents met criteria for a diagnosable DSM condition, Gordon shared, but only half received treatment and even less received evidence-based treatment. “We put people at risk when we don’t identify that they have symptoms, and don’t help them cope or get them treatment,” Gordon explained.

There is already data on the COVID-19 pandemic, Gordon reported. Building on previous traumas and risk factors, it was not a surprise that contracting COVID-19 increased the risk for long-term mental health issues. Individuals with 

, especially schizophrenia, were found at higher risk for developing trauma-related mental health issues.

 The same study found the likelihood of new onset psychiatric disorders following COVID-19 infection was 6%, which is 2 to 3 times the rate as that with the flu. The incidence of any psychiatric diagnosis within the first 3 months after infection rose to 18% when including those with previous psychiatric disorders. The majority of the new onset symptoms were mood or anxiety-related. Gordon said the NIMH is embarking on a multi-institute study to further explore these data.

Similarly, the pandemic affected individuals who did not contract the virus, Gordon added. Data from the 

Centers for Disease Control and Prevention

 indicated that most adults had some symptoms, including mood, substance use, and suicide ideation. Rates of suicidal ideation was disturbingly high among young adults, he said, with about 18% noting they seriously considered suicide in the previous 30 days, double the number than would be normally expected.

 Gordon cautioned, however, that this data is a result of self-reports of mental illness, not diagnosed illnesses. Still, he said he would not be surprised if future studies found an increased rate of psychiatric diagnoses during the pandemic.

Yet, the picture is not all bleak, Gordon said. He referred to unpublished data from the 

, which consists of a number of managed care organizations, that looked at electronic health records. In each system, the number of visits for self-harm diagnosis (including self-injurious behavior and suicide attempt) remained steady over time, even through the pandemic.

The pandemic also illuminated the inequities of health care in the United States, with certain minorities at increased risk of adverse events associated with COVID-19, Gordon said. Of great concern was the shift to telehealth in the early days of the pandemic, and the possibility of telehealth exacerbating access to care issues for vulnerable populations. 

The Mental Health Research Network looked at the number of mental health visits in person, via phone, and via video both before and during the pandemic, and the data revealed some promising news. The numbers of visits among White non-Hispanic patients, African-American patients, and Hispanic patients were similar, with a huge drop in in-person visits at the beginning of the pandemic, when a slow upward shift was found for voice and video visits, Gordon reported. Although there were fewer visits during the pandemic, the rates were similar among all groups. Gordon said more research is needed across wider swaths of populations to confirm these findings, but he believes the increased popularity and availability of smartphones helped forestall access issues.

Unfortunately, Gordon noted not all the news was good: There was a dramatic increase in suicide rates among Black youth. Blacks have been relatively protected against suicide when compared with Whites in the United States, he noted, although it is not quite certain why. For some reason, he added, that is changing in Black youth, especially males, and that is troubling.

Gordon added that the NIMH is addressing the growing awareness of broad systemic racism on 2 fronts: an increase in diversity in the workforce and an increase focus in disparity research. For instance, Gordon discussed the April 21, 2020, webinar cohosted with SAMHSA, “

Responding to the Alarm Addressing Black Youth Suicide

On a broader scale, the NIMH has taken the lead with a number of NIH organizations to further explore, measure, and address the social and economic impacts of COVID-19 on mental health, especially among vulnerable populations (eg, older adults, frontline workers, racial and ethnic minorities, etc). To date, the NIMH and working group members have funded 28 longitudinal studies, 15 digital health studies, and 9 community health studies looking at substance use and other mental health outcomes as well as public health mitigation impact and adherence. Gordon expects the information learned from these studies will not only help address issues from the pandemic, but also inform future disaster response.

In terms of the pandemic, there are still many uncertainties, which continues the risk of new and exacerbated mental health issues, Gordon warned. “We don’t know when it will end, there is increased exposure to morbidity and mortality (at this point we all know someone who has had COVID-19), there is continued social economic vulnerability, and preexisting mental health problems,” all of which are risk factors for poor outcomes, he explained.

Still, research shows there are ways to foster resiliency and prevent negative outcomes, and Gordon encouraged attendees to focus on those endeavors. Psychiatrists can help patients focus on the hope for the future and remind patients they have some control over their situations. They can encourage patients to find ways to meet their immediate needs. And, they can inspire healthy coping habits.

1. deRoon-Cassini TA, Mancini AD, Rusch MD, Bonanno GA. 

Psychopathology and resilience following traumatic injury: a latent growth mixture model analysis.

2. Taquet M, Luciano S, Geddes JR, Harrison PJ. 

Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA

3. Czeisler MÉ , Lane RI, Petrosky E, et al. 

Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020

Joshua A. Gordon, MD, PhD, National Institute of Mental Health Director, leverages lessons from past natural disasters and traumas to foster resiliency and inform future research endeavors.

Amidst Multiple Crises, NIMH Pursues Research to Improve Outcomes

“Globally, as of the 25th of April, there have been close to 150 million cases and over 3 million deaths,” 

2021 Annual Meeting of the American Psychiatric Association

 (APA). “In the United States, we now have over 32 million cases, and about 570,000 deaths, making this unquestionably the worst pandemic of infectious disease that the planet has experienced in over 100 years since the 

Fauci, who became the face of COVID-19 in the United States, providing a voice of reason and information from the onset of the pandemic, was invited to deliver the William C. Menninger Memorial Lecture. In introducing Fauci, APA President Jeffrey Geller, MD, MPH, commended Fauci for his “communication of science, the courage in the face of adversity, and the energy he brings to his work,” adding that this commitment “should inspire all of us.”

In his talk, “Lessons Learned and Remaining Challenges,” Fauci succinctly reviewed the epidemiology, clinical course, therapeutics, and vaccines associated with COVID-19, providing attendees with a clear picture of where we have been, where we are, and where we need to go.

Fauci acknowledged the progress we have made in the fight against the pandemic. However, he warned, “Even though we are now below the late fall extraordinary peak [of cases] that we saw that went into the early winter of January and early February [of more than 200,000 new cases per day], we are now stuck on plateau that is precarious, at around 60,000 new infections a day.”

The looming variants have become a particular concern. Currently, the B.1.1.7, originally found in the United Kingdom, has become the predominant variant in the United States, he said. Fortunately, the vaccines seem to do well against this variant, he added. Other variants include B.1.351, originally found in South Africa and problematic on multiple fronts; P.1, originally found in Brazil; B.1.427/B.1.429, originally found in California; and B.1.526 originally found in New York.

The unusual aspect of the virus is that at least a third, and as much as 40%, of the individuals who are infected never have symptoms, yet the virus has been deadly in so many individuals, Fauci noted. Because of this, about 35% of all transmissions were from presymptomatic individuals and 24% from those who never developed symptoms. This, he said, added to the complication of controlling the spread of the virus.

Currently, there are 3 types of test for SARS-CoV-2: molecular tests that detect genetic material from virus; antigen tests that detect proteins from the virus; and antibody tests that detect proteins in the blood made in response to the virus. Symptoms and affects include 

 (eg, bilateral cerebral infarcts), hyperinflammation, acute respiratory distress syndrome, cardiac function, hypercoagulability, acute kidney injury, and multisystem inflammatory syndrome in children.

In addition to the acute infection, there is a syndrome called “

” or “post-acute sequela of COVID,” which appears to affect between 10% and 30% of individuals, Fauci noted.

 In these cases, patients report persistent symptoms for as long as 9 months following acute illness, with fatigue being most common. Myalgias, temperature disruption, sleep disorders, and cognitive difficulties nicknamed “brain fog” have also been noted.

The pandemic’s effects, especially on mental health, have not been limited to patients infected with the virus. Fauci pointed to a new study of 5470 US adults that found 41% reported 

trauma or stressor-related disorder symptoms

 (26%), substance use issues (13%), and suicide ideation (11%) were most common among respondents.

Another concern, according to Fauci, is the continued 

, despite studies noting high safety and efficacy data worldwide, even against the more troublesome variants. “There are a number of reasons why people don’t want to take the vaccine, and we just have to address each of them,” he added.

, the top reason for not getting the vaccine was that it was too new/not enough information/unsure about long-term effects (17%).

 Other concerns included: don’t believe it is effective (8%), don’t need it (8%), concern over ingredients (8%), concern over side effects (7%), lack of trust of vaccines in general (6%), among others. As a result, there was a concerted effort to have well-known officials receive their vaccines in a public way, including leaders like Fauci, President Joe Biden, Vice President Kamala Harris, and Reverend Jesse Jackson. There also have been outreach programs to the Navajo Nation, and the US Department of Health and Human Services launched a National Network of Trusted Voices.

There have been “considerable challenges,” Fauci concluded, “but we are doing extraordinarily well. And we hope the next few weeks we see a dramatic remediation in the number of cases.”

1. Logue JK, Franko NM, McCulloch DJ et al. 

Sequelae in adults at 6 months after COVID-19 infection

2. Czeisler MÉ, Lane RI, Wiley JF, et al. 

Follow-up survey of US adult reports of mental health, substance use, and suicidal ideation during the COVID-19 pandemic, September 2020

3. Hamel L, Lopes L, Kearney A, Brodie M. 

. KFF. March 30, 2021. Accessed May 3, 2021. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-march-2021/

In his William C. Menninger Memorial Lecture, Anthony S. Fauci, MD, shared lessons learned and remaining challenges for the COVID-19 pandemic, especially in terms of mental health and behavioral issues. 

Fauci Addresses Attendees at APA Annual Meeting

Too often, the medical issues associated with traumatic brain injury are mistaken as psychiatric disorders, and patients are referred to psychiatrists for treatment, Gregory J. O’Shanick, MD, DLFAPA, told attendees of the 2021 

American Psychiatric Association Virtual Annual Meeting

O’Shanick, who is the medical director of the 

in Richmond, Virginia, urged psychiatrists to leverage their medical knowledge when assessing patients to determine when the diagnosis is a psychiatric disorder and when patients are presenting with medical mimics associated with traumatic brain injury (TBI). He shared his frustration with psychiatry’s loss of medical identity, especially as it related to brain injury medicine. In his 40-year career, he found “all too often, physicians, both MDs and DOs, psychiatrists, [were] missing basic neurologic issues that we as physicians should catch. If we are to be vocal regarding the necessity of having a MD and DO to ultimately provide oversight of care for those with behavioral disorders and writing prescriptions for psychotropic medications, we must not relinquish the use of those tools and skills that were taught to us in medical school.”

The prevalence of TBI has increased over the last 10 or so years, O’Shanick explained, although he acknowledged that the increase may be partially due to increased awareness. According to 

 from the Centers for Disease Control and Prevention, there was a 53% increase from 2006 to 2014 in TBI-related emergency department visits, hospitalizations, and deaths. In older adults and the very young, falls account for the number 1 cause of TBI.

 A combination of motor vehicle accidents, sports, falls, and other activities were the cause for the “very active” and maybe not as cautious young adult population (aged 15 years to 24 years).

Meanwhile, research has found a link between psychiatric disorders and TBI, O’Shanick noted, with an increase of disorders following TBI.

 Jennie Ponsford, PhD, and colleagues explored this phenomenon and found that only about 23% and 21% of individuals had a pre-TBI history of a mood disorder or anxiety disorder, respectively. They found an increase in psychiatric symptomology within the first year after TBI, with a stabilization at the 5-year point. Mood and anxiety symptoms were most common in patients with TBI, with 17.2% to 62% presenting with mood symptoms and 10.3% to 34.2% with anxiety symptoms. Interestingly, he noted depression is 4 to 6 times more common in patients with TBI than the general population, and is the most common cause of depression in men (as opposed to women, for whom menopause is the number one cause).

It is possible, he explained, that some of these mood disturbances and anxiety symptoms may be better explained as a medical consequence of TBI—or a signal of homeostatic disruption. In such cases, providing psychopharmacological treatment might help the patient with the symptoms, but will not address the underlying cause.

O’Shanick provided an example of a phobia being misattributed. He pointed to an individual who is afraid of a jumping off a diving board. They go up the stairs, walk to the edge, realize they are frightened, and go back down. They have conditioned themselves to be afraid—there is a learned component.

Next, he presented the case of an individual who has unrecognized balance and visual issues as a result of TBI. The person goes into a crowd and feels a sense of anxiety, because they have trouble feeling and remaining stable, and the learned component may be inappropriately linked to an anxiety disorder.

“As a physician, we need to figure that out,” O’Shanick emphasized.

Fortunately, a toolkit to help decipher these TBI-related medical mimics is relatively inexpensive, O’Shanick shared. All you need is a pen, index card, blindfold (or ask your patient to close their eyes), a sofa cushion, a tuning fork (which can be procured online for about $6), and a few questions. For example, to determine if the issue is 

 or a vestibular in nature, ask your patient if they need to touch the wall when closing their eyes in the shower to prevent falling. Or, if they feel anxious in a crowded area like a store or mall, does pushing a cart or stroller or holding on to someone make them feel better? If so, there are a few simple follow-up tests (eg, the Balance Error Scoring System and Fukuda Stepping Test) to help confirm the medical mimic. A referral for vestibular physical therapy and a neuro-ENT may prove useful for such patients.

Similarly, to determine if there is social phobia or vergence, ask your patient if they are having trouble seeing/reading books at a normal distance. Then, check near point convergence and conduct a cover test. A referral to a neuro-optometrist should be considered.

Sometimes a central auditory processing disorder may be confused with 

. It is especially important to decipher the difference, O’Shanick explained, because stimulants will worsen the central auditory processing disorder. Ask your patient if they have better sustained attention for visual vs verbal interactions, or if they have trouble understanding what people say if they cannot see their faces or mouths. Weber and Rinne tests can also prove useful, and a referral to an audiologist is indicated.

, posttraumatic neuroendocrine (PTNE) disorders may be relatively common in patients with TBI,

 and mood symptoms are associated with PTNE, O’Shanick explained. Psychiatrists should inquire about changes in menses, sex drive, cold intolerance, and skin and hair dryness to elucidate if PTNE is a potential cause of the mood symptoms. Lab studies should be considered, including 

, TSH, FSH, LH, IG-1, estradiol/testosterone, and am/pm cortisol. In considering TBI in these cases, O’Shanick reminded attendees that they should not overlook 

Finally, O’Shanick illuminated inherent biases in the Minnesota Multiphasic Personality Inventory-2, which might lead to an incorrect diagnosis. For instance, stomach trouble and headaches score positively on the hypochondriasis scale, but both may be related to TBI and TBI treatments. Similarly, positive scores on the hysteria scale result from noting they are unable to work, feel sad, and have trouble sleeping, all of which are associated with TBI.

Ultimately, the psychiatrist is the ideal position to leverage their medical and behavioral knowledge to support these patients.

“Hopefully this will allow you to think a little bit differently when patients come into your office,” O’Shannick concluded. “Maybe ask some increased questions when it comes to injury related issues, concussion related issues… and to see if there is some other types of medical issues behind some of the anxieties that your patients have. At the end, you may just find that you’re practicing … much more successfully and ultimately helping your patients.”

1. CDC. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths. 2014. Accessed May 2, 2021. 

2. Ponsford J, Always Y, Gould KR. Epidemiology and natural history of psychiatric disorders after TBI. 

3. Beyer C, Zaytsev J, Donegan D, et al. 

The effects of traumatic brain injury on pituitary function: a systematic review and meta-analysis

Too often, the medical issues associated with traumatic brain injury are mistakenly diagnosed as psychiatric disorders. A few simple questions and tests can elucidate the real culprit and lead to appropriate treatment.

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