Dr Sotsky is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

Conquering Lyme Disease: Science Bridges the Great Divide

 and has interests in medical education, psychotherapy, and medical humanities.

Jennifer Sotsky, MD, MS

The goal of this activity is to better appreciate the controversies surrounding Lyme disease as well as methods to treat the neuropsychiatric sequela.

• Understand the controversies surrounding Lyme disease diagnosis and treatment, including perspectives of different medical communities and patient communities

• Describe common neuropsychiatric presentations of and treatment options for Lyme disease and of posttreatment Lyme disease (PTLD)

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals seeking to improve the care of patients with mental health disorders.

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Since its first appearance in a group of children in Old Lyme, Connecticut in the late 1970s, 

 has proliferated throughout the United States and abroad. Only 30,000 to 40,000 cases are reported to the Centers for Disease Control and Prevention (CDC) per year, although recent studies looking at the time period between 2010 and 2018 estimate the actual number to be more than 10 times higher at approximately 476,000.

 Lyme disease is transmitted when an infected tick bites a human and injects the causative bacteria, 

, into the skin. The majority of transmission in the United States occurs in the Northeast, mid-Atlantic, and upper Midwest, as shown in 

 While 70% to 80% of patients develop an erythema migrans rash,

 the majority of these rashes do not have the classic “bull’s-eye” appearance. Other patients may not recall seeing a rash and may have a flu-like illness with such mild symptoms that they do not seek medical attention. Left untreated, Lyme disease can cause wide-ranging effects, including 

, cranial nerve palsy, meningitis, depression, and 

Even after appropriate diagnosis and antibiotic treatment, some patients continue to experience longer-term symptoms, including 

, cognitive problems, or musculoskeletal pain in a condition known as posttreatment Lyme disease syndrome (PTLDS), sometimes also called posttreatment Lyme disease (PTLD). Studies suggest that approximately 10% to 20% of patients who are treated for Lyme disease with the recommended 2- to 4-week course of antibiotics continue to have nonspecific symptoms afterwards.

 Reported Cases of Lyme Disease—United States, 2018

The Infectious Disease Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) published joint “2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease”

 that included commentary on the terminology chronic Lyme disease, commonly used in the patient community, expressing concern that it lacks an accepted definition and is applied to a highly heterogeneous population who may have weak clinical or laboratory evidence to confirm prior infection with 

. Although the IDSA had previously developed provisional criteria for the more specific subgroup of PTLD, a term preferred by some researchers as it suggests a well-documented prior diagnosis of Lyme disease, they do not mention this term in their latest guidelines and instead refer to “persistent or recurring nonspecific symptoms such as fatigue, 

, or cognitive impairment following recommended treatment for Lyme disease.”

 There continues to be debate and conflict among patients, providers, and researchers about appropriate terminology for patients with chronic symptoms.

The Scope of the Problem and the “Lyme Wars”

There has been conflict and controversy surrounding Lyme disease since its earliest days. In 1970s Connecticut, mothers of children with unusual arthritis symptoms were angered due to feeling dismissed or ignored by public health officials after little was initially done when they told the officials of this unusual clustering of children with arthritis. In the decades following, intense disagreement continued among professional organizations, community doctors, and patients about what is required for a diagnosis of Lyme disease and what constitutes adequate treatment. The most pressing debates today involve how to treat PTLDS.

 Guidelines for Antibiotic Treatment of PTLDS (Summarized)

The recent joint IDSA/AAN/ACR guidelines recommend against repeat antibiotic treatment for patients with persistent or recurring nonspecific symptoms (eg, fatigue) who do not have objective evidence of reinfection with 

 The guidelines define objective evidence of persistent infection or treatment failure as signs of disease activity such as arthritis, meningitis, or neuropathy.

The International Lyme and Associated Diseases Society (ILADS) guidelines (

) recommend “patients with persistent symptoms and signs of Lyme disease be evaluated for other potential causes before instituting additional antibiotic therapy”; however they advocate for “… antibiotic retreatment when a chronic Lyme infection is judged to be a possible cause of the ongoing manifestations and the patient has an impaired quality of life.”

 Some providers adhere to the more rigid IDSA/AAN/ACR guidelines and others follow the more flexible ILADS guidelines, sometimes leading to heated debate. Such debates have also involved patients and their advocates who can feel dismissed or disbelieved. Amid this charged climate that the media have referred to as the “Lyme wars,” physicians and patients alike can feel frightened, alienated, and overwhelmed.

Given the substantial overlap in symptomatology between Lyme disease and common psychiatric disorders, as well as the psychological effects that can result from a 

, many psychiatrists will see patients with documented or suspected Lyme disease. It is important for psychiatrists to keep Lyme disease on their list of differential diagnoses, to be familiar with diagnostic and treatment strategies, and to understand the challenges patients and providers face due to this complex illness. The following case and text will highlight signs and symptoms to look for, as well as diagnostic strategies and management approaches for such patients.

“Christina,” aged 45 years, is a mother of 2 children who presented reporting several months of low mood, fatigue, subjective memory problems, and headaches. She tearfully explained that she could barely function and reported feeling dismissed by her primary doctor. Christina briefly saw a therapist in college for stress related to a relationship breakup, but she otherwise has had no history of psychiatric treatment. She had a recent unremarkable exam, including vitals and basic blood work, by her primary doctor, who referred her to the psychiatry department for 

Christina was started on sertraline 50 mg with some mild improvement in low mood, but had ongoing fatigue, memory issues, and 

. On further discussion, you learned that 3 months prior, Christina visited family in Massachusetts for the July 4th holiday. She remembered returning from the party with a flu-like illness, but she tested negative for COVID-19 infection and on a Lyme enzyme-linked immunosorbent assay (ELISA) antibody test the following week. She did not recall having any tick bites or rashes. After you discussed the case with Christina’s primary doctor, he ordered a repeat Lyme ELISA antibody test, which yielded positive results. She was then given a confirmatory immunoglobulin (Ig) -G Western blot test, which also yielded positive results.

Christina received treatment with a course of doxycycline and experienced improvement in her fatigue, headaches, and mood. Two months later, she returned with worsening fatigue and headaches. Looking to the IDSA/AAN/ACR guidelines, Christina’s primary doctor recommended against retreatment with 

, as he felt there was no clear evidence of reinfection or persistent infection. Christina sought a second opinion from another community physician, who did additional lab testing—including cerebrospinal fluid (CSF) studies—to evaluate for tick-borne coinfections and autoimmune disease. Workup was unremarkable, but given her severe symptoms, he treated her with courses of doxycycline and amoxicillin, and her fatigue and headaches improved. However, she continued to struggle with low mood, leading to conflict with her family. She ultimately improved with increasing sertraline to 150 mg and a course of individual therapy with several family meetings.

Lyme disease can develop after an infected 

 tick bites human skin. Usually, at least 36 hours, and sometimes up to 72 hours of attachment is required to transmit the infection. Notably, 

 ticks may also transmit other infections, including 

, and others. In 70% to 80% of Lyme cases, an erythema migrans rash will develop at the site of the bite, often within 3 to 32 days.

 The rash typically starts as a red patch, that measures approximately 2 or more inches in diameter. This rash is not painful, but it expands over time and may have satellite rashes. As it grows, the initial patch may develop a central clearing, giving it a classic bullseye appearance (

). Most often, Lyme disease rashes do not have the bull’s-eye appearance and a significant percentage of patients do not recall having a rash at all.

 Flu-Like Symptoms During the Early Disseminated Phase of Lyme Disease

Dissemination of infection beyond the initial localized area can result in a multitude of other symptoms in the following weeks to months. Because the initial immunologic response to Lyme disease involves the release of cytokines, many patients will experience moderate to severe flu-like symptoms during the early disseminated phase of infection (

). A flu-like illness during the summer months in a Lyme disease–endemic area should always raise suspicion for possible 

 infection. Patients may also experience arthralgias and myalgias; these typically affect large joints and often migrate from 1 joint or muscle to another. When acute Lyme infection targets the nervous system, the patient could develop a myriad of conditions (

). Less commonly, Lyme disease can also affect the liver to cause a mild hepatitis, the eyes to cause conjunctivitis, and the heart to cause myocarditis or atrioventricular conduction block.

 Neurologic Conditions Related to Acute Lyme Disease

Months to years later, if Lyme disease goes untreated, patients may experience late disseminated–stage symptoms, many of which can overlap with symptoms of primary psychiatric illness. Such patients may develop neurological problems that include 

, encephalomyelitis, and neuropsychiatric symptoms that are less common in the earlier phases of the disease. Lyme encephalopathy involves cognitive problems, specifically impacting short-term memory, verbal fluency, and processing speed, as well as a subjective feeling of brain fog or feeling mentally slowed down. Rarely, it may involve moderate to severe memory loss and personality changes. Lyme encephalomyelitis may result in confusion, hallucinations, 

, mania, abnormal movements, lack of coordination, or seizures. Less dramatic, but more common, are the neuropsychiatric symptoms, such as depression and anxiety, that occur in 40% of individuals with disseminated Lyme disease either before or after initial antibiotic treatment (

, anger outbursts, and symptoms of obsessive-compulsive disorder are uncommon, although they have been reported. A recent nationwide retrospective cohort study in Denmark by Fallon et al demonstrated that individuals with Lyme borreliosis after a hospital-based diagnosis had increased rates of any mental disorder, of affective disorders, of suicide attempts, and of 

 compared to those without Lyme borreliosis.

 Common Neuropsychiatric Symptoms of Lyme Disease

Although psychiatric problems can arise during the illness course, it is important to communicate to patients that most psychiatric symptoms in the general population are unrelated to Lyme disease. Treatment of such potentially disabling psychiatric disorders should not be delayed while trying to determine whether or not a patient has Lyme disease. Patients with preexisting anxiety may catastrophize and hyper-focus on information from the media that presents the most frightening consequences of their possible Lyme disease. It may be helpful to explain that whether or not a patient has Lyme disease, treatment of any cooccurring psychiatric disorder, such as major depression or panic disorder, is an essential part of the path to health.

It is also important to note that anchoring to Lyme disease early on, to the exclusion of consideration of other possibilities, can delay diagnosis of other serious medical conditions. The differential diagnosis for neuropsychiatric Lyme disease and PTLDS is wide and includes other tick-borne diseases, psychiatric disorders, autoimmune disease, multiple sclerosis, 

, fibromyalgia, and others. A 2015 case series published in 

 described patients who were misdiagnosed as having persistent symptoms after Lyme disease, but actually had different malignancies, including pituitary adenoma and Hodgkin’s lymphoma.

 Thus, ensuring that patients have had a thorough medical evaluation and follow-up is critical.

The ideal diagnostic test for Lyme disease would clearly indicate the presence of 

 and activity or resolution of infection. Unfortunately, available tests fall short of this ideal, leading to conflict over diagnosis and treatment.

Two commonly available blood tests for Lyme disease are the ELISA and Western blot assay. The ELISA is an inexpensive, widely available, quantitative assay that reflects the magnitude of the antibody response (IgM and IgG) to spirochetal proteins. The Western blot assay (IgM and IgG) is an antibody-based test that detects binding of serum antibodies to an array of 

 antigens; it previously required interpretation by a skilled laboratory technician, but more recent developments have allowed interpretation by optical scanners. The IgG Western blot is considered highly specific for confirmation of current or past infection with 

, while the IgM Western blot is less specific and may result in false positives.

 Two-Tiered Testing Approach for Lyme Disease

In the 1990s, the CDC recommended a 2-tier testing approach to enhance diagnostic standards (

). The first step involves ordering an ELISA or immunofluorescence assay (an older test that now is less commonly used). If negative results are obtained, no further testing is recommended. If positive or equivocal results are obtained, then the Western blot assay is ordered. A positive result of the Western blot assay supports diagnosis of Lyme disease. A negative result does not necessarily rule it out, as early antibiotic treatment can abrogate the immune response or the assay may have been conducted too early, before the 2 to 3-week interval required for antibody development.

A central problem, therefore, in the 2-tiered method is that sensitivity varies considerably depending upon on how early in the course of infection a patient is tested and on the specific manifestations of 

. Studies suggest that sensitivity of the 2-tier approach in early Lyme disease is poor, and only 29% to 45% of patients with Lyme disease will test positive; many may have false-negative assay results, such as early on in Christina’s case.

 Although sensitivity is excellent for Lyme arthritis, it is lower in disseminated neurologic conditions related to Lyme disease. Equally problematic is that a patient may test positive on an antibody test due to past exposure, and a positive test does not indicate treatment failure. The newer C6 ELISA and VlsE/pepC10 ELISA have improved sensitivity, although they are still far from ideal. In 2019, the CDC updated its recommendation to allow a second enzyme immunoassay, such as the C6 ELISA or VlsE/pepC10 ELISA, to be a reasonable substitute for the Western blot assay.

For suspected neurologic Lyme disease, lumbar puncture is indicated. In central neurologic Lyme disease, CSF analysis typically shows elevated lymphocyte and protein levels with normal glucose levels. Comparing the ratio of antibody levels in the CSF to blood collected on the same day allows determination of the intrathecal index which can provide strong evidence in support of the diagnosis of neurologic Lyme disease. The presence of 

 DNA on polymerase chain reaction testing is also strong evidence for Lyme disease; however, this test has substantial rates of false negatives among patients with neurologic Lyme disease and thus should not be used to disqualify a patient for antibiotic treatment. Structural and functional MRI as well as single-photon emission computed tomography and positron emission tomography scans have been used adjunctively to aid in diagnosis, but they are not sensitive or specific and may be costly or impractical in some clinical settings.

Neuropsychological testing may be helpful in supporting a diagnosis or measuring response to treatment, with studies showing the most consistently identified deficits in adults with Lyme disease to be problems with verbal memory, information processing speed, and memory-related tasks.

 However, this too can be costly and it yields nonspecific results.

Given the limitations of available tests, diagnosis for Lyme disease must be made considering factors such as the patient’s history of tick exposure, time spent in Lyme disease–endemic areas, clinical symptoms, and laboratory findings. Exciting developments are underway in Lyme disease testing, such as urine-based proteomic assays, blood-based metagenomic assays, and point of care tests, that hopefully will improve diagnostic accuracy and reduce delays in the provision of treatment.

Because the diagnosis of Lyme disease is easy to confirm when the erythema migrans rash is present, the research community previously focused its efforts on studying the treatment of early Lyme disease; there have been fewer controlled studies of the later manifestations. Treatment of erythema migrans in adults includes a 10-day course of doxycycline or a 14-day course of cefuroxime or amoxicillin. This results in remission and apparent cure in most cases. Adults with Lyme arthritis can be treated with 28 days of oral doxycycline or amoxicillin. If 

 persist, additional antibiotic therapy is recommended with 2 to 4 weeks of IV ceftriaxone. Acute neurologic Lyme disease (including Lyme-disease associated meningitis, cranial neuropathy, radiculoneuropathy, or other peripheral nervous system manifestations) and Lyme-related heart disease requires 14 to 21 days of IV ceftriaxone, cefotaxime, penicillin G, or oral doxycycline.

 IV antibiotic therapy is preferred for patients hospitalized with Lyme carditis. IV antibiotic therapy is also recommended over oral antibiotics when parenchyma of the brain or spinal cord is involved. The above treatment recommendations are based on the 2020 guidelines created by the IDSA, AAN, and ACR.

 The ILADS treatment guidelines for Lyme disease differ in general by recommending somewhat longer initial courses of antibiotic treatment.

When Lyme-triggered symptoms return or persist despite the standard antibiotic recommendations, considerable controversy arises over how to treat these patients. Approximately 10% to 20% of patients treated for Lyme disease have symptoms that can last for more than 6 months and even years after treatment.

 Common symptoms include muscle and joint pains, brain fog, fatigue, and 

. Such symptoms cause significant distress and functional disability.

There have been 4 controlled studies of repeated antibiotic therapy for patients with PTLDS in the United States. In 2001, Klempner et al conducted 2 studies (1 for Lyme seropositive patients and 1 for seronegative individuals) randomizing patients to either 1 month of IV ceftriaxone followed by 2 months of oral doxycycline or IV placebo followed by oral placebo.

 Ultimately, no difference was found on the self-reported functional disability outcome measure between the antibiotic and placebo groups. The authors also noted that the treatment itself can cause significant risk, such as 

. In 2003, Krupp et al randomized patients with persistent fatigue after treatment of well-documented Lyme disease to either 1 month of IV ceftriaxone or IV placebo, each followed by 5 months of no treatment.

 Those who received ceftriaxone were significantly more likely than those given placebo to be judged as responders on the fatigue measure at 6 months (69% vs 23%, respectively; P < .01). However, somewhat surprisingly, the authors recommended against retreatment, likely due to the risk of serious adverse events associated with IV antibiotics.

In 2008, Fallon et al randomized patients with Lyme encephalopathy to 10 weeks of IV ceftriaxone or placebo.

 There was overall greater cognitive improvement in the drug-treated group that was apparent at 3 months compared with the placebo group (P = .053), but this improvement was not sustained to 6 months. The authors argued that better treatments resulting in sustained cognitive improvement are needed. When the study was reanalyzed using the methods employed by Krupp et al in their fatigue study, very similar significant findings were found—nearly two thirds showed clinically meaningful reduction in fatigue after IV ceftriaxone compared to only 25% on IV placebo. Interpretation of these 4 studies has varied significantly from the IDSA/AAN/ACR guidelines, which largely recommend against retreatment with antibiotics for patients with PTLDS, to ILADS and others who argue retreatment should be considered for debilitating fatigue, as the only randomized controlled trial designed to assess fatigue found significant and clinically meaningful improvement on the primary fatigue outcome measure.

Several hypotheses exist to explain persistent symptoms after treatment for Lyme disease. One hypothesis is that such symptoms may represent an immune response to persistent infection with 

. To date, multiple studies in animals have shown that 

 spirochetes can persist following standard recommended antibiotic treatment of a disseminated infection. Less often, case studies in humans have documented persistent bacteria, though it remains unclear whether these spirochetes are metabolically active or causing clinical disease.

 Other hypotheses include postinfectious processes that result in ongoing immune dysregulation, neural network dysregulation such as central sensitization, and preexisting vulnerability to anxiety and somatization.

 However, the exact cause of persistent symptoms is still not well understood, may be complex and multifactorial, and likely differs depending on the patient. A thorough medical evaluation to rule out tick-borne coinfections such as 

Patients with persistent symptoms after Lyme disease treatment may find that their family, friends, and doctors start to question why they still have symptoms, sometimes leading them to feel hurt, disbelieved, and defensive. Ironically, some of the problems typical of PTLDS may well be “in the head” as a result of neural changes induced by the Lyme disease infection or due to the 

 associated with having a relapsing remitting illness. It is, therefore, important to guide patients in considering a trial of therapeutic strategies and to recognize brain- and symptom-focused treatments (eg, use of a serotonin-norepinephrine reuptake inhibitor for depression and pain, psychotherapy for interpersonal and other issues, graded exercise to address deconditioning, 

 and/or medications to improve sleep) that may have direct healing effects on the body.

There is no specific proven treatment for PTLDS at this time, but many patients find that typical treatments offered by psychiatrists can result in decreased pain, increased energy, better cognition, and enhanced quality of life. Additional research is underway internationally to better understand this complex illness, enhance diagnostic accuracy, and improve treatment outcomes.

Lyme disease is a growing public health problem in the United States. If a sensitive and reliable test of active infection were available, much of the conflict around diagnosis and treatment would be diminished. This is the holy grail that scientists continue to seek. It is important to remember that symptoms of PTLDS (eg, fatigue, head/body aches, sleep difficulties, low mood, irritability, memory problems) can overlap substantially with those of common psychiatric disorders. The treatment approach should be based on the cause—persistent infection, postinfectious factors, or another more likely diagnosis. When psychiatric features are present, the psychiatric care should be optimized to enhance the likelihood of reduced suffering and optimal outcome. As a clinician, you should approach patients with PTLDS or chronic Lyme disease symptoms with humility and compassion, assuming they have been disbelieved by many. Advocate for additional medical workup when appropriate and treat their symptoms with appropriately targeted therapies.

is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part-time private practice; she formerly was a chief resident at Columbia’s psychiatry residency program. She is co-author of Conquering Lyme Disease: Science Bridges the Great Divide.

1. Kugeler KJ, Schwartz AM, Delorey MJ, et al. 

Estimating the frequency of Lyme disease diagnoses, United States, 2010-2018.

2. Tickborne diseases of the United States: Lyme disease. Centers for Disease Control and Prevention. Reviewed October 1, 2020. Accessed November 15, 2021. 

https://www.cdc.gov/ticks/tickbornediseases/lyme.html

4. Lantos PM, Rumbaugh J, Bockenstedt LK, et al. 

Clinical practice guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 guidelines for the prevention, diagnosis and treatment of Lyme disease.

Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease.

Lyme disease: a neuropsychiatric illness.

7. Fallon BA, Maden T, Erlangsen A, Benros ME. 

Lyme Borreliosis and association with mental disorders and suicidal behavior: a nationwide Danish cohort study.

Neoplasms misdiagnosed as “chronic Lyme disease.”

Updated CDC recommendation for serologic diagnosis of Lyme disease.

Post-treatment Lyme disease as model of for persistent symptoms in Lyme disease.

Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease.

13. Krupp LB, Hyman LG, Grimson R, et al. 

Study and treatment of post Lyme disease (STOP-LD): a randomized double masked clinical trial.

14. Fallon BA, Keilp JG, Corbera KM, et al. 

A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy.

15. Fallon BA, Petkova E, Keilp JG, Britton CB. 

A Reappraisal of the U.S. Clinical Trials of Post-treatment Lyme Disease Syndrome

Recent progress in Lyme Disease and remaining challenges.

Articles

In this CME article, learn more about the controversies surrounding Lyme disease diagnosis and treatment, and common neuropsychiatric presentations of and treatment options.

Lyme Disease in Psychiatry: Controversies, Chronic Symptoms, and Recent Developments

The initial wave of COVID-19 flooded New York City hospitals with patients who urgently needed medical attention. Despite the potential dangers, psychiatrists and other physicians rushed to their aid. There were examples of inspiring teamwork and mutual support everywhere. At the same time, many physicians found themselves in new and unfamiliar roles, sometimes without the necessary mental health resources to cope with what they were seeing and doing.

, hosts Angela Coombs, MD, and Jennifer Sotsky, MD, talk to 

, about their experiences in the early days of the pandemic.

Many physicians have undergone traumatic experiences during the COVID-19 pandemic. If you or anyone you know needs mental health resources, consider contacting the 

Substance Abuse and Mental Health Services Administration

’s national hotline (800-662-HELP) or the 

is an anesthesiology Critical Care Medicine Fellow at University of California, Los Angeles Health

is a PGY 3 resident and co-chair of the Psychiatry Residents Diversity Alliance at Columbia University Medical Center.

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan.

is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of

and has interests in medical education, psychotherapy, and medical humanities.

Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry

Podcasts

In the early days of the COVID-19 pandemic, physicians were thrust into unfamiliar roles, where they sometimes had to make life and death decisions. Here are a few of their stories. 

Teamwork and Trauma: a Conversation With Kasey Grewe, MD, and Niesha Voigt, MD

During the first wave of COVID-19 cases in New York City, physicians of all kinds took on unfamiliar roles and, in many cases, potentially risked their lives to help their patients.

, a quartet of doctors remember the early, uncertain days the pandemic. Hosts Angela Coombs, MD, and Jennifer Sotsky, MD, talk to 

, about their personal experiences, how the challenges of the pandemic have evolved over time, what has kept them going throughout the year, and why preexisting social inequalities made the pandemic even deadlier in some communities.

is assistant professor of psychiatry at Columbia University Medical Center and program director of its fellowship in Psychosomatic Medicine

is associate professor of medicine and program director of the Internal Medicine Training Program at Columbia University Medical Center.

Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.

When COVID-19 hit New York City, psychiatrists and other clinicians braved uncertainty and danger. Hear their stories on the PsychPearls podcast. 

Facing the First Days of the Pandemic: A Conversation With David Chong, MD, and Sara Nash, MD

 and the Columbia University Breakthrough Session, hosts Angela Coombs, MD, and Jennifer Sotsky, MD, discuss the possibilities and promise of psilocybin to treat psychiatric disorders and in enhancing everyday experiences with 

. Landmark studies and new research about the use of hallucinogens includes potential to treat:

Posttraumatic stress disorder
Substance use disorders


Psilocybin Revisited: The Science Behind the Drug and Its Surprising Therapeutic Potential

Psilocybin (mushrooms) and other hallucinogens from plants and some animal life generate perceptual changes and hallucinations, altered physical sensations, strong emotional reactions, and even dissolution of self.

The question is whether these are 

 or trips and whether they can result in lasting changes in the patient. Over time, some of the brain connections may become disrupted and new circuits may become activated.

Dr Hellerstein is a professor of clinical psychiatry at Columbia University and is conducting clinical trials of psilocybin. His books include 

Heal Your Brain: How the New Neuropsychiatry Can Help You Go from Better to Well

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan.



is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

 and has interests in medical education, psychotherapy, and medical humanities.



Columbia University Department of Psychiatry

 for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.


Research on psilocybin, LSD, and other hallucinogens as psychiatric treatments are in their renaissance, transitioning from banned and illegal to potentially useful in changing life for the better in some patients. More in this podcast.

David Hellerstein, MD: Psychedelic Treatments for Psychiatric Disorders



In this installment of PsychPearls and the Columbia University Breakthrough Session, hosts Angela Coombs, MD, and Jennifer Sotsky, MD, discuss anxiety with 

Anxiety as cultural phenomenon vs individual illness

Help-seeking as a sign of strength and self-knowledge


Dr Albano is professor of medical psychology (in Psychiatry) at Columbia University and director of the 

Columbia University Clinic for Anxiety and Related Disorders

 (CUCARD). She is a clinical psychologist and board-certified in clinical child and adolescent psychology. In addition to serving as director of CUCARD, she also conducts research and trains residents, fellows, and psychology postdoctoral fellows and interns. Her research is focused on the development and testing of psychosocial treatments for anxiety and mood disorders, and in understanding the impact of these disorders on the developing youth. Dr Albano devotes her career to the study and treatment of anxiety and mood disorders in children, adolescents, and young adults. She is an expert diagnostician and cognitive-behavioral therapist. Dr. Albano co-developed a cognitive behavioral treatment program for adolescents with social phobia. She has published more than 90 articles and chapters and is the coauthor of several cognitive behavioral treatment manuals, including 

Anxiety Disorders Interview Schedule (ADIS-IV) Child and Parent Interview Schedules.

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan. 

 is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.



A discussion with professor of medical psychology and director of the Columbia University Clinic for Anxiety and Related Disorders.

Anne Marie Albano, PhD: A Conversation on the Spectrum of Anxiety

What is addiction, and how can psychiatrists best respond to the opioid (and other drug) epidemic? What have we done wrong about it in the medication and other effective treatments for addiction? What does addiction do to the brain?

Lloyd I Sederer, MD, a psychiatrist, public health expert, and writer provides key insights on what we can do to save more lives from overdose deaths.

Dr Sederer is adjunct professor at the Columbia University School of Public Health; director of Columbia Psychiatry Media; Chief Medical Officer of 

. He has been chief medical officer of McLean Hospital; affiliated with Harvard; Mental Health Commissioner of New York City; and Chief Medical Officer of the New York State Office of Mental Health, the nation’s largest state mental health agency. The mission of 

 is to find the causes of and cures for mental illness.

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How can we save more lives and prevent overdose deaths? Lloyd I Sederer, MD, a psychiatrist, expert in public health, and author provides insights.

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