Heidi Anne Duerr, MPH

There are 13 million adults with borderline personality disorder (BPD) in the United States and, of that number, 1.5 million are adolescents, Carl Fleisher, MD, told attendees of the 2021 Annual 

 World CME Conference. To best support them, there are 3 things you need to do, added Fleisher, assistant clinical professor of psychiatry at University of California Los Angeles Health.

To kick off the discussion, Fleisher shared the case example of “Hannah,” a 16 year old girl who presents wondering if she has BPD after Googling her experience. Specifically, she has rapid mood swings, feels numb more often than sad, and cuts herself superficially several times a week. She has 1 friend and spends all of her time with that friend in fear the friend will desert her. She is interested in boys, but she avoids them. Hannah does not voice her needs to parents, teachers, or friend; instead, she goes along with whatever they want or like.

The first thing to do, therefore, is to make the diagnosis, Fleischer said. To do so, there are 9 criteria to consider, and sometimes it feels like they are all over the map. As such, the patient might not see the connections, so it is important to help draw them for patients. One way to do that, he explained, is to use a model of interpersonal hypersensitivity. Since we all want and need to be in relationships, and we are hypersensitive, we may have a fear of abandonment. From there, you can talk about the other symptoms.

 for rapid assessment of patients. It helps patients think things through, he explained. It also provides an opportunity for further discussion, as the clinician may have a different perspective than the patient does on a particular item.

Most patients are relieved when they finally receive a diagnosis, Fleischer said. He shared the following patient perspective: “It explained a lot of things and I felt an enormous sense of relief that there was an explanation for the way I was.”

The second thing is to refer to helpful resources, including psychoeducation, support, and treatment strategies, Fleisher said. He recommended a number of resources both for patients and their clinicians: the National Education Alliance for Borderline Personality Disorder, Mentalizing Initiative, the Anne Freud National Centre for Children and Families, and McLean’s Borderline Personality Disorder center.

In terms of treatments, there are 4 evidence-based psychotherapy modalities, Fleisher said. They include dialectical behavioral therapy, transference-focused psychotherapy, mentalizing-based therapy, and good psychiatric management, which is not an orientation but more of framework for clinicians. “It is also possible also that a plain old talk therapy is an adequate treatment for borderline personality disorder, especially if you have nothing else,” he told attendees.

It is also important to consider psychoeducation and family support, Fleischer added. He shared the results of a study looking at the impact of 6 weeks of psychoeducation on patients. The investigators found that symptoms reduced greatly—by about half—and stayed low for 2 months after the intervention protocol.

 Similarly, since caregivers and family members are under a lot of stress and strain, it is important to broaden the treatment lens and provide support to them, too.

Unfortunately, Fleischer noted there are no medications approved by the US Food and Drug Administration to specifically treat BPD. Likewise, there is no medication that is uniformly helpful. Too often, patients find themselves on multiple medications, he said, and polypharmacy poses a significant danger because of adverse effects, like weight gain associated with antipsychotics.

“We can do a whole hour-long talk on just medication for BPD, but the short of it would be: If you're going to use medication to treat one of the comorbid illnesses that BPD presents with, as opposed to this BPD itself, then you can try that,” Fleisher told attendees. “But if we're going to try to treat the symptoms of BPD itself like lability, paranoia, that sort of thing, then it may be that we want to consider a brief trial of medication to get people through a crisis.” After using the medications in a way that is helpful, it is important to consider taking it away, because we do not expect them to be helpful in the long-term and do not want to cause a problem of polypharmacy, he added.

The third thing to do is to monitor the effectiveness of the treatment, Fleischer said. Start with baseline measurements on the areas you and the patient want to address, be it self-harm, work performance, risky behaviors, and quality of life and relationships.

With these 3 things in mind, Fleisher concluded, clinicians can best support their patients with BPD. As he told attendees, “Borderline personality disorder is worth treating, and people with BPD are very rewarding to work with.”

1. Lester R, Prescott L, McCormack M, Sampson M; North West Boroughs Healthcare, NHS Foundation Trust. 

Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review.

2. Ridolfi ME, Rossi R, Occhialini G, Gunderson JG. 

A Clinical Trial of a Psychoeducation Group Intervention for Patients With Borderline Personality Disorder

 2019;81(1):19m12753. Published 2019 Dec 31.

Articles

These 3 essential steps best support patients with borderline personality disorder, according to Carl Fleisher, MD. 

Borderline Personality Disorder: 3 Things You Need To Do for Patients

“There appears to be at least 3 types of major depressive disorder (MDD) based on pharmacology,”Sheldon Preskorn, MD, told attendees of the 2021 Annual 

TM World CME Conference. Preskorn, professor in the Department of Psychiatry and Behavioral Sciences at University of Kansas School of Medicine and Psychopharmacology Section Editor of 

, was also named Educator of the Year at the conference.

The first type of MDD responds to biogenic amine antidepressants. This group represents about 60% to 65% of patients, he added. The next group is nonresponsive to biogenic amine antidepressants, but responsive to glutaminergic (NMDA) antidepressants, and represents about 25% of patients. The third group is nonresponsive to both biogenic amine and glutaminergic antidepressants; this group represents about 15% of patients with MDD.

To get a clearer understanding of this philosophy, Preskorn turned to the Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study, which was funded by the National Institutes of Mental Health to determine the effectiveness of different treatments for MDD in cases in that failed to respond to initial treatment with an antidepressant. In the study, the initial treatment was citalopram. If MDD was not responsive to treatment, patients were switched to bupropion SR, sertraline, or venlafaxine XR, or treatment was augmented with bupropion SR or buspirone.

 In cases that remained unresponsive, participants were switched to mirtazapine or nortriptyline, or had augmentation with lithium of triiodothyronine. Finally, if treatment still failed, participants were switched to tranylcypromine or mirtazapine combined with venlafaxine SR.

What was noteworthy, Preskorn explained, was that acute outcomes worsened with increasing number of prior treatment failures. In the group with no or limited prior medications, 27.5% achieved remission, as measured by HAM-D 17. Those in the group with 1 prior failure saw remission rates drop to 21.1%. And those with 2 and 3 prior failures saw remission rates drop to 16.2% and 6.9%, respectively.

“If you're like me, you see these patients every day in the clinic, because we usually get patients after they have already been tried on an antidepressant in primary care.” 

“If you're like me, you see these patients every day in the clinic, because we usually get patients after they have already been tried on an antidepressant in primary care,” Preskorn said. “So we always are getting someone who has probably not benefited from treatment. And, not only did they not benefit, they also were much more likely to relapse.”

In looking at current treatment strategies, Preskorn said we know the vast majority of people initially receive a selective serotonin reuptake inhibitor. Next, most likely is either a serotonin-norepinephrine reuptake inhibitor or a norepinephrine dopamine reuptake inhibitor. If that does not work, he explained there is the likelihood of augmentation with atypical antipsychotics or other kinds of medications, or a new drug like esketamine. If you still are not seeing a proper response, you would move into monoamine oxidase inhibitors or various kinds of electrical treatments such as transcranial magnetic stimulation.

"There is no requirement that a new drug is superior to antidepressants, be it superior either in efficacy or tolerability… new, does not mean improved."

So, why is there so little benefit from switching among them the various antidepressants, Preskorn asked the audience. “First and foremost, you have to realize that the FDA only requires superiority over placebo for approval. There is no requirement that a new drug is superior to antidepressants, be it superior either in efficacy or tolerability… 

“The second thing is psychiatric drug development for antidepressants and antipsychotics has, for 60 years, mainly been reshuffling the relative receptor binding affinity of biogenic amine mechanisms of action,” he added. “So they all work on the same neurotransmitter system.”

To better help understand the situation, Preskorn gave the example of a patient with pneumonia. Out of the patients treated with penicillin 1, a certain percentage will get better. For those who do not, they receive penicillin 2, and a smaller percentage is likely to get better because you have the infectious agent causing the pneumonia does not respond to penicillin.

Although shuffling identical mechanisms has not necessarily improved efficacy, Preskorn noted it has improved safety and tolerability. “That's the reason why SSRIs, SNRIs, and other newer antidepressants have replaced tricyclic antidepressants—not because they are more efficacious, but because they are safer and better tolerated,” he explained. Preskorn added it is also why there is a meaningful subset of patients with seemingly treatment resistant depression, because they are not responding to biogenic amine antidepressants.

1. Rush AJ, Trivedi MH, Wisniewski SR, et al. 

Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression.

2. Trivedi MH, Rush AJ, Wisniewski SR, et al. 

Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice.

3. Fava M, Rush AJ, Wisniewski SR, et al.

 A comparison of mirtazapine and nortriptyline following two consecutive failed medication treatments for depressed outpatients: a STAR*D report.

4. McGrath PJ, Stewart JW, Fava M, et al. 

Tranylcypromine versus venlafaxine plus mirtazapine following three failed antidepressant medication trials for depression: a STAR*D report.

Sheldon Preskorn, MD, shares insights into drug mechanisms and delivery to better help patients with major depressive disorder. 

Understanding Major Depressive Disorder and Treatment Resistance

“I think the DSM gives you one sense of depression,” Sidney Zisook, MD, told attendees of the 2021 Annual 

 World CME Conference. “But I think it's very, very one dimensional. A better way of really understanding what it is to be depressed and the diagnosis is getting firsthand accounts from those who have dealt with depression.”

Zisook, director of the University of California, San Diego (UCSD) Residency Training Program, Distinguished Professor of Psychiatry at UCSD, and last year’s Educator of the Year awardee, shared insights from several famous folks about their experiences with depression. Of depression, David Foster Wallace said:

It is a level of psychic pain wholly incompatible with human life as we know it. It is a sense of radical and thoroughgoing evil not just as a feature but as the essence of conscious existence. It is a sense of poisoning that pervades the self at the self’s most elementary levels. It is a nausea of the cells and soul.

This quote, and others like it, show a sense of hopelessness, even suicidality, more than other aspects of depression, including those recognized by the DSM 5, he noted.

To better understand the current state of diagnosis, Zisook took attendees back in time to discuss the various iterations of depression in the DSM, from being classified as psychoneurotic disorder in DSM I in 1952 through the psychoanalytic approaches through the specifiers in DSM IV. Changes continued into DSM 5, where we now have a variety of disorders: major depressive disorder, disruptive mood dysregulation disorder, persistent depressive disorders, substance- and medication-induced depressive disorder, premenstrual dysphoric disorder, depressive disorder due to another medical condition, and other specified (or unspecified) depressive disorder.

To help illustrate the problems associated with the current system, Zisook shared 2 case examples. Ms A is a 30 year old married woman complaining of stress. Upon further exploration, you learn she has been tearful and increasingly sad since her mother received a diagnosis of cancer. She has little motivation, is overeating and gaining weight, and sleeps about 12 hours a day. She has never felt like this before.

On the other hand, Mr B is a 60 year old man who is brought to you by the police after found wandering on the Coronado Bridge. He is unshaven, slovenly, and demonstrates psychomotor retardation. He shows no interest in answering questions, but an informant tells you he has not been eating or drinking for weeks. He has expressed feeling miserable and worthless. He had a similar episode 30 years prior; he achieved full recovery after responding to electroconvulsive therapy.

“What do they have in common?” Zisook asked rhetorically. “Definitely nothing except the diagnosis of major depressive disorder—without any overlap in functioning.”

In reviewing DSM 5 criteria, he posed a few questions for the authors of DSM 6 to consider. For instance, why must symptoms last 2 weeks? “This never made much sense to me,” he said. “Somebody is undergoing a horrible situation—they lost their job, they've lost their family, they've lost their money—they've never been depressed before, and the depression is relatively mild, moderate. You don't want to label them with a major depressive disorder in 2 weeks. Give me more time to see what happens. Let them take care of some of the situations.”

“On the other hand,” Zisook added, “if they had a history of severe major depressive disorder, and for the last 2 days they're despondent, hopeless, feeling worthless, feeling suicidal, you have got to wait another 12 days to make the diagnosis.”

To better understand the diagnosis, again Zisook looked to patients. He discussed studies conducted by Mark Zimmerman, MD, and colleagues looking at what was needed for patients with depression to consider themselves in remission.

 The top 3 features were: positive mental health, such as optimism and self-confidence; a return to one’s usual, normal self; and a return to a usual level of functioning. Interestingly, one-quarter of respondents who were mildly symptomatic and, per HAM-D scores, not in remission considered themselves remitters. As such, they reported better quality of life, less functional impairment due to depression, higher positive mental health scores, and better coping ability.

I diagnose depression not by counting the number of symptoms for a certain number of weeks. But is the low mood persistent, is it there most of the time, has it been there for a while? It is pervasive—affecting the way you work, the way you interact with other people, the way you function, the way you parent, etc. For me that's better than the screening questionnaire or the DSM 5 criteria.

So, how does Zisook define and diagnosis depression? “There are screening instruments, which is fine for looking at depression,” he told attendees. “But I think there's nothing to substitute for clinical inquiry. And I diagnose depression not by counting the number of symptoms for a certain number of weeks. But is the low mood persistent, is it there most of the time, has it been there for a while? It is pervasive—affecting the way you work, the way you interact with other people, the way you function, the way you parent, etc. For me that's better than the screening questionnaire or the DSM 5 criteria.”

He also reminded attendees that differential diagnosis is very important, adding “Always look for bipolar disorder or general medical conditions.” Bereavement and burnout also need special attention, he explained, since those are often misdiagnosed and/or confused with depression. A careful examination of the criteria and symptoms will help to distinguish the disorders.

Zisook concluded by saying, “I think our diagnostic concepts are a work in progress in terms of helping us communicate with each other, helping us take into account what patients are saying about what it feels like to be depressed, and helping us to prescribe very personalized medications.”

1. Zimmerman M, McGlinchey JB, Posternak MA, et al. 

How should remission from depression be defined? The depressed patient's perspective

2. Zimmerman M, Martinez J, Attiullah N, et al. 

Why do some depressed outpatients who are not in remission according to the hamilton depression rating scale nonetheless consider themselves to be in remission?

Sidney Zisook, MD, shares insights into defining depression diagnosis.

Defining and Diagnosing Depression: Clinical and Patient-Oriented Perspectives

“For us to say that this has been a time of change, stress, and loss is an understatement,” 

. “Because the COVID pandemic has fundamentally taken the rug from underneath our feet, change the fabric of how we live our lives, how we work, and understandably, the amount of change and stress is very palpable and the amount of loss is even more.”

Iglewicz, assistant clinical professor of psychiatry at the University of California at San Diego, shared insights on the impact of COVID-19 on health care workers, specifically looking at burnout. In addition to the regular stressors, health care professionals faced many challenges during the height of the pandemic. Work-life balance was disrupted, there were longer shifts, and fears about personal risk and risk to family members abounded, she explained. There also were increased home-life demands associated with children’s virtual school, caregiver burdens, and a general sense of lack of control.

A recent study of COVID-19 and stressors looked at close to 21,000 health care professionals between May and October 2020 and found alarming rates of burnout and stress, Iglewicz reported.

 Investigators found that 61% feared exposure transmission, 38% reported anxiety or depression, 43% reported work overload, and 49% reported burnout. Not surprisingly, there were some gender and racial differences, she said. Higher rates of burnout were found among females and those from minoritized backgrounds.

Despite the pandemic’s impact on stress, Iglewicz reminded attendees that burnout has been an issue for years, and it has even garnered media attention due to its very real consequences. In health care, burnout can impact patients, the health care system, and the induvial, she explained. In patient care, burnout leads to worse patient outcomes and increased medical errors, Iglewicz said. On systems level, there is a drop in productivity as well as a great cost in replacing clinicians. On an individual level, burnout can lead to substance use and abuse, depression and suicidal ideation, and even an increase in motor vehicle accidents, she said.

Fortunately, there was some improvement in burnout found before the pandemic, Iglewicz explained. She shared details from a study by Tait D. Shanafelt, MD, and colleagues, that looked at rates of burnout in 2011, 2014, and 2017.

 There were a lot of interventions between 2014 and 2017, she noted, and, accordingly, Shanafelt et al found a slight decrease in burnout reports in the 2017 data. Interestingly, she said psychiatrists had some of the lowest reported rates of burnout. “But it's still unacceptable,” Iglewicz added, “as about 50% of psychiatrists are experiencing burnout.”

“Maybe we have gotten some of this wrong,” Iglewicz said of the attempts to address burnout. She used the analogy of the straw that broke the camels back. “We put our focus on trying to make that camel stronger. Tell the camel to meditate, teach that camel to be more mindful, tell that camel: You better sleep more, better eat healthier. Encourage that camel to exercise, and coach that camel to be more resilient.”

“We realized that there was a flaw,” she explained, “because we were essentially blaming the victim.”

Then the shift to address burnout fell on the habitat, Iglewicz said. Things like electronic health records, excessive workloads, and clerical burdens were addressed. Although these are important aspects, it still involved finger-pointing. She suggested it would be more productive to move to an understanding and self-introspective perspective.

Since words have meaning, Iglewicz entertained the idea of changing the term 

. She suggested “loss of meaning.” Essentially, folks enter medicine with idealistic notions, and now their work no longer matches those notions and they have a loss of meaning in their work

Similarly, she suggested considering burnout as unresolved grief. In other words, she said, there is so much to mourn in terms of why people entered the medical field. With this definition, it allows you to face the limitations and begin to accept it. 

Finally, burnout in the health care field may be code for depression, she suggested. There is no stigma associated with the term 

; it is tossed around casually in conversations, the media, and the like. There is still, however, stigma associated with depression. Looking at the issues associated with both, Iglewicz said there really is a very fine line between depression and burnout.

So, what can be done to address burnout, loss of meaning, and unresolved grief? The first step, she said, is that clinicians must become reformed perfectionists. “The same traits that helped us get into medical school comes with a price,” she said. She noted perfectionism, detail-oriented focus, desire for control, empathy, and competitiveness. Whenever possible, she said try to turn down the level perfectionism, even in your personal life. Let the struggles, hurdles, and adversities refine you, not define you, she explained.

It is also important to engage in system level change, she added. And, although it should not be a singular focus, self-care is indeed important, she said.

She then shared 5 antidotes to burnout: find a health relationship with anger, pick your battles, practice ordinary kindness and compassion, support one another and seek out support when needed, and live with contradictory truths.

Iglewicz took the opportunity to conclude her talk with a contradictory truth that rings very true on the subject of burnout: “We're all stronger than we know. Simultaneously, we are all more vulnerable than we'd like to acknowledge.”

1. Prasad K, McLoughlin C, Stillman M, et al. P

revalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: a national cross-sectional survey study

2. Shanafelt TD, West CP, Sinsky C, et al. 

Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017

Health care workers have always been prone to stress and burnout, and the COVID-19 pandemic exacerbated the issue. What do we know about burnout and how can we prevent and address it? 

Finding Antidotes to Burnout Through Contradictory Truths

Virtual schooling during the pandemic presented challenges that might have long-term effects on children and adolescents, according to 

. Wagner discussed findings from numerous studies looking at the well-being of youth and their parents as a result of virtual instruction at the 

2021 Annual Psychiatric TimesTM World CME Conference

Wagner, who is professor and chair in the Department of Psychiatry and Behavioral Sciences at University of Texas Medical Branch, reported there have been increases in anxiety, obsessive compulsive disorder, conduct problems, pro-social behavioral problems, sleep issues, and worsening of preexisting mental health disorders. This, in turn, resulted in increased mental health related visits to the emergency department. Children at highest risk for increased psychiatric and behavioral problems included youth who were disadvantaged or refugees as well as those who had a chronic disorder, adverse childhood experiences, a preexisting mental health disorder, added Wagner, who also immediate past president of the American Academy of Child and Adolescent Psychiatry and member of 

The impact of virtual schooling went beyond the computer as a classroom and affected other areas of well-being, Wagner said. In a nationwide survey of parents (N = 1290) of children aged 5 to 12, for instance, children who attended virtual school were more likely to have decreased physical activity as compared with those students attending school in-person and combined in-person and virtual school (62.9%, 30.3%, and 52.1%, respectively.

 Virtual students also reported less time spent outdoors, less time spent with friends virtually, and less time spent with friends in person. Similarly, 24.9% of students attending virtual school reported worsened depression and anxiety compared with 24.7% of those in combined schooling and 15.9% of those attending in-person.

The impact was also felt by the parents. In comparison to parents whose children attended in-person or combined schooling, parents whose children attended virtual school were also more likely to report loss of work, child care challenges, conflict between working and providing child care, emotional distress, and difficulty sleeping.

Negative impact on youth was not seen only in the United States, but also in countries around the world. For instance, Wagner discussed the results of a cross-sectional survey of 367 students in Saudi Arabia.

 The investigators found 55% of respondents had moderate stress while 30.2% had high stress levels.

Youth with attention-deficit/hyperactivity disorder (ADHD) and their parents especially struggled with the virtual schooling world, Wagner added. In one study of 239 adolescents, 118 of whom had ADHD, investigators found those with ADHD had fewer routines and more difficulties with remote learning.

 Parents of adolescents with ADHD reported more difficulty in supporting home learning and home school communication. Even parents whose children with ADHD had an individual education program reported remote learning was more challenging. To help support remote learning, 22% of families incurred financial costs.

As a result of the pandemic, Wagner noted the American Academy of Child & Adolescent Psychiatry and the American Psychiatric Association devised a list of recommendations for virtual schooling.

 The groups noted that education, including school attendance, is an essential component of health development. When classroom-based education is not possible, the groups said it is a priority to find methods that optimize social interaction. Importantly, they noted additional resources should be made available for children with special needs, and the mental health of students must be continually addressed. They also advocated for systems that effectively and efficiently identify issues early and have means for interventions.

Ultimately, there are certain things needed to better support a virtual schooling system. “There needs to be access to mental health services, as well as individual educational programs, there also needs to be resources for disadvantaged youth,” Wagner concluded. “Attention has to be directed toward the importance of physical activity. And also, participation in extracurricular activities, as well as other peer group activities.”

1. Verlenden JV, Pampati S, Rasberry CN, et al. 

Association of children's mode of school instruction with child and parent experiences and well-being during the COVID-19 pandemic - COVID Experiences Survey, United States, October 8-November 13, 2020

. 2021;70(11):369-376. Published 2021 Mar 19.

Perceived stress among students in virtual classrooms during the COVID-19 outbreak in KSA. 

3. Becker SP, Breaux R, Cusick CN, et al. 

Remote learning during COVID-19: examining school practices, service continuation, and difficulties for adolescents with and without attention-deficit/hyperactivity disorder

4. American Academy of Child & Adolescent Psychiatry and American Psychiatric Association. American Academy of Child and Adolescent Psychiatry (AACAP) and American Psychiatric Association (APA) Detail Steps Necessary for Safely Reopening Schools This Fall. Press release. July 2020. Accessed September 30, 2021. 

https://www.aacap.org/AACAP/Press/Press_Releases/2020/Needs_Students_During_COVID-19_Era.aspx

The pandemic caused the shut down of schools and resulted in virtual learning for most of the world's children and adolescents. How did they fare?

How Did Virtual Schooling Impact Youth?

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 

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.