John J. Miller, MD

is medical director, Brain Health, Exeter, NH; editor in chief,

taff psychiatrist, Seacoast Mental Health Center, Exeter, NH; consulting psychiatrist, Exeter Hospital, Exeter, NH; consulting psychiatrist, Insight Meditation Society, Barre, MA.

Videos

Dr. John Miller shows us one of his favorite topics to talk about and practice.  

Mindful Meditation

As of this writing, we are well into August, and the 

 pandemic continues to have a stranglehold on our country and the world. Hearing a lot about how this pandemic is starting to compete with the Great Influenza (H1N1) pandemic from 1918 through 1920, I decided to take a deep dive into learning about this widely referenced pandemic that is estimated to have killed 50 million people worldwide, and more than 600,000 people in the United States. I read with curiosity and amazement 

 which chronicles in great detail the many subplots of this global pandemic that occurred while the world was also being brutalized by World War I.

 Remarkably, many of the same challenges we face in combatting COVID-19 existed during the Great Influenza: educating the public about the importance of social distancing; wearing masks; cancelling large gatherings of people; avoiding indoor crowds; quarantining individuals exposed to the virus; the trial and error of potential treatments; and most importantly, tirelessly working to create an effective vaccine.

As of today (August 18, 2020), 171,343 deaths in the United States hve been attributed to COVID-19. Unlike the Great Influenza, which basically ended 100 years ago, we really do not know how far we are into the COVID-19 pandemic.

 Fortunately, we have top-notch health care providers, scientists, epidemiologists, computer models, and worldwide information integration that collectively give us a huge advantage over the resources available during the Great Influenza. Significantly, we as a world community have had 100 years to research and understand the Great Influenza, which provides a wealth of guidance as to how to best control and ultimately defeat COVID-19.

I was intrigued by John M. Barry’s conclusion in 

“Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one. Lincoln said that first, and best. A leader must make whatever horror exists concrete. Only then will people be able to break it apart.”

This invitation to embrace the truth of what is serves as the foundational first brick of the edifice of knowledge and problem-solving. To be fair, the “truth of what is” is actually only a hypothesis, not objective truth. Any competent scientist will agree with this characterization. In science, we formulate a hypothesis based on observations and, through continued exploration and experimentation, each hypothesis is sculpted to a more sophisticated and refined hypothesis or is discarded. The integrity and confidence in the scientific process results from the countless scientists throughout the world and throughout the millennia that continue to challenge and refine our current hypotheses.

It is likely not a coincidence that 2 of the countries that aggressively implemented the lessons from the Great Influenza, New Zealand and 

, have had among the best viral containment and lowest numbers of death per capita.

 Ideally, science and its ever-evolving hypotheses should remain objective and nonpartisan. In the United States, this has become challenging, as we find ourselves in an extremely partisan political environment with an important presidential election rapidly approaching. As psychiatrists, physicians, and health care providers, let us remember our oath to “do no harm,” and aggressively educate our patients and our nation to modify basic behaviors consistent with the recommendations of the 

, infectious disease experts, renowned epidemiologists, and current hypotheses about managing a pandemic that have been sculpted from the pain and suffering of past pandemics.

An important question to investigate is why are we Americans so divided and argumentative about the consistent public health recommendations from the experts who have spent their careers studying virology, medicine, and epidemiology to best protect ourselves from the possibility of a pandemic such as the one we are facing? There has always been a subset of the American population that opposes accepted recommended norms: anti-vaccines, no blood transfusions, no Western medical treatment, no need for seatbelts, intolerance for anyone’s views that differ, and no need for government, to list a few. Arguably, discussions that stem from these disagreements ultimately create a more open and sophisticated society and validate the liberty and freedom that the First Amendment fosters. But, in my opinion, the current divisions in America that readily dismiss science, medicine, and the lessons learned from other countries and 

have crossed the red line into misinformation and self-righteousness that ultimately increases our illness, pain, suffering, and death. Is the rebelliousness that led to our independence as a nation sewn so deep into the fabric of our culture that it surfaces with any opportunity—regardless of the consequences? What is it about American culture that has led us down a lonelier road than the path taken by so many other countries that are more effectively managing the COVID-19 pandemic? I do not know.

about COVID-19, curious to see where we were, where we have been, and where we are.

 On April 8th there were more than 400,000 cases of COVID-19 and more than 14,000 deaths in the United States; today (August 18, 2020) there are more than 5,400,000 cases of COVID-19 and more than 171,000 deaths.

 I expressed my concern about the misinformation and lack of scientific expert inclusion in policy development around the country—those concerns have intensified. I shared my opinion that our response to the pandemic was fragmented and disorganized, with no united national leadership and database to aggressively track and manage a ruthless virus that did not respect state, county, or city boundaries—we remain fragmented and disorganized.

Last week my wife and my son were tested for COVID-19, and we were told that they should receive their results in 10 days—not only is that unacceptable, it is not an isolated case. To track and manage this virus, we need a rapid turnaround in test results—hours and not days. The scientist in me is greatly saddened by these facts, realizing we could be doing so much better.

We have much to learn about COVID-19, as is the case with any novel virus, pathogen, or disease. However, we have learned a great deal in less than a year of coexisting with this ruthless virus. The complete COVID-19 RNA genome has been sequenced, and there are documented mutations. The daily medical peer-reviewed published literature consistently includes a wide-ranging menu of information across every specialty in any way related to the virus and associated pandemic. We are still learning about how the virus is transmitted—which we now know is quite different depending on the length of time since a person becomes infected, and how symptomatic they are. We still do not know how long antibodies created by viral exposure will render immunity. I am appreciative of the global 

articles that become available every day from researchers in all specialty fields. The pharmaceutical industries are working aggressively and tirelessly to develop a safe and effective vaccine, and manufacturing facilities around the world are ready to join forces for large scale production once an effective vaccine is created.

Why are we Americans so divided and argumentative about the consistent public health recommendations from the experts who have spent their careers studying virology, medicine, and epidemiology to best protect ourselves from the possibility of a pandemic?

For us in psychiatry, there is currently a well-documented increase in anxiety, depression, trauma-related symptoms, substance abuse, and suicidality.

 Risk factors include infection by COVID-19, serious illness or death of a loved one infected by COVID-19, 

, financial distress, job loss, social isolation, and lingering medical/psychiatric symptoms after recovery from the acute COVID-19 infection.

 contains an article on the neuropsychiatric complications by Elliott Martin, MD, who discusses an increase in cases of refractory delirium and persistent encephalopathy at his hospital. A current publication by 

 looked at the prevalence of psychiatric disorders and loneliness in the United Kingdom during the COVID-19 pandemic. Of the 15,530 respondents, 29% reported a psychiatric disorder, and 36% reported feeling lonely sometimes or often. Not surprisingly, they also determined, “Having a job and living with a partner are both significant protective factors for general psychiatric disorders and loneliness.”

We have no idea how the next 12 months will transpire. Will there be a second wave of COVID-19 as the Northern Hemisphere moves into the fall and winter months, and the influenza virus joins in the fray? Has the COVID-19 virus mutated during its travels in the Southern Hemisphere creating a more virulent and/or aggressive virus? When will an FDA-approved effective vaccine become available? How can we enhance trust in science so a COVID-19 vaccine will be welcomed with open arms, so that we can quickly achieve herd immunity? Currently, one-third of people in the United States are saying they will not get vaccinated. Will we develop effective treatments for the seriously ill?

There are also the collateral issues that can add to individual and societal stress, increasing the risk of psychiatric symptoms, substance abuse, hopelessness, fear, and loneliness. These include continued social isolation and the merry-go-round of opening—closing—reopening—reclosing of cities and towns as COVID-19 quiets down and then surges in unpredictable manners. Additionally, the struggle continues with economic uncertainty; unemployment; financial distress; childcare; online versus in-classroom education; and relationship stress.

We have been here before. In fact, we have survived more challenging times. Our United States prevails and excels when we are, in fact, united—not divided. So as we find ourselves in the middle of a pandemic, and all of its associated chaos and confusion, let us once again find our common ground and shared strength and unite as a country to show this pandemic—who we are, and how we rise above our partisan differences to defeat COVID-19—and be stronger for it. After all, the world is watching.

is medical director, Brain Health, Exeter, NH; editor in chief, 

The Great Influenza: The Story of the Deadliest Pandemic in History. 

2. Johns Hopkins University School of Medicine. COVID-19 in the USA. Accessed August 18, 2020. 

3. Baker MG, Wilson N, Anglemyer A. Successful Elimination of Covid-19 Transmission in New Zealand. 

2020 Aug 7 [Epub aead of print]. Accessed August 19, 2020. 

https://www.nejm.org/doi/full/10.1056/NEJMc2025203

4. Kim J, An JA, Min P, et al. How South Korea Responded to the Covid-19 Outbreak in Daegu. 

https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0159

6. Troyer EA, Kohn JN, Honga S. Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms. 

7. Ornell F, Moura HF, Scherer JN, et al. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. 

Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom

Articles

We have been here before. In fact, we have survived more challenging times. The truth serves as the foundational first brick of the edifice of knowledge and problem-solving. 

Pandemics Are Not Partisan

What happens at the molecular level in patients after they ingest a medication? Over the past 30 years, psychiatry has come a long way, especially in better understanding the importance of considering the 

 (CYP) system when prescribing medications.

To best understand these issues, it is helpful to look at clinical examples. Consider a patient who has been diagnosed with breast cancer and is being treated with 

. Tamoxifen, a prodrug, binds poorly to the estrogen receptor, which is the treatment target. The drug has to undergo metabolism through the cytochrome P450 2D6 (CYP2D6) pathway to be transformed into its 2 active metabolites: 4-hydroxytamoxifen and endoxifen. Both metabolites have approximately 100 times more potency at the estrogen receptor than tamoxifen and are considered the active treatment molecules.

In psychiatry, we have 3 commonly prescribed antidepressants—fluoxetine, paroxetine, and bupropion—that very potently inhibit CYP2D6. If a patient is on 1 of these 3 antidepressants as well as tamoxifen, the drug-drug interaction prevents the conversion of the tamoxifen to its active metabolites. In other words, the patient will not receive the benefits of that treatment. If the patient also is genotypically an extensive, intermediate, or a poor metabolizer at the CYP2D6 pathway and 1 of these 3 antidepressants have been prescribed, the CYP2D6 pathway is completely knocked out. The end result is no clinical activity from the tamoxifen, and any benefits of the treatment is negated. This is one dramatic example of how understanding drug-drug interactions at the CYP system can be clinically relevant.

Another example can be found in the underappreciated 

 arena. We know that codeine has very little activity at the mu opioid receptor. When codeine goes through the cytochrome P450 2D6 metabolic pathway, it gets metabolized to morphine, which is roughly 20 times more potent than codeine. The FDA product insert for codeine has a black box warning stating that if a patient is an ultra-rapid metabolizer (approximately 1% of the population) at CYP2D6, the patient is then at risk of respiratory depression and death due to the rapid metabolism of codeine to the much more potent morphine. If a patient is prescribed codeine and they are a poor metabolizer at CYP2D6, or if they are simultaneously taking 1 of those 3 antidepressants that inhibit CYP2D6, most of the codeine will not be metabolized to morphine and the patient may report no 

effect. This is important considering some patients engage in malingering and drug-seeking behaviors; the decreasedanalgesia described by the patient may simply be the consequence of not receiving adequate blood levels of morphine.

This pharmacology extends to 2 other commonly prescribed analgesics: hydrocodone and oxycodone. Both are prodrugs with some analgesic properties, but they are both metabolized by the CYP2D6 enzyme system to their more potent active metabolites hydromorphone and oxymorphone, respectively. As with codeine and morphine, the patient’s CYP2D6 phenotype as well as the presence or absence of any fluoxetine, paroxetine, or bupropion can create a wide range of analgesia that can differ dramatically from patient to patient.

Thus, it is always important to consider the cytochrome P450 pathways when prescribing medications, as the results can be widely different than what you expect.

is Medical Director, Brain Health, Exeter, NH; Editor in Chief, 

Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

This article was originally posted on June 26, 2020, and has since been updated. -Ed

Two examples described here underscore the importance of understanding the cytochrome P450 (CYP) system

Cytochrome P450: You've Come a Long Way

John J. Miller, MD, discusses an increasingly important and clinically relevant issue in psychiatry. According to Dr Miller, "We are at the point in time where we have a much greater sophistication and understanding of what is happening when a drug enters into the brain circuit and interfaces with receptors."

Dr Miller is Medical Director, Brain Health, Exeter, NH; Editor in Chief, 

Drug mechanisms of action are evolving. An area in psychiatry that has become increasingly important clinically is discussed here.

Reconstructing the Nosology of Psychiatric Medications

 by Jerald Kay, MD, and Joel Yager MD, in which they share their assessment of the state of the vast psychiatric literature that regularly bombards us clinicians. The authors reflect on how journal publications have become less relevant to them as clinicians over the decades and describe 2 visceral responses—

—when reading current journal articles. Overall I agree with their assessment, and I encourage reading their delightful article.

Nonetheless, the scientist in me scowled at a few of their opinions. So, I thought it would be worthwhile to travel down a few side roads to share my reflections on the current psychiatric literature as well as the many accomplishments psychiatry has seen since the 1950s. Although I tend to agree with their statement that much of the current publications in psychiatric journals are either redundant with little new information (their 

response) or overly technical to the point of being a remedy for insomnia (their 

response), I aimed to get some perspective.

13 Psychiatric Drugs With Novel Mechanisms: A Timeline

After logging into PubMed, I entered the following search terms, applied the “limit to articles published in the past 5 years” filter, and I was actually not surprised by the results:

antidepressant yielded 24,811 publications;

antipsychoticsyielded 16,393 publications;

pharmacotherapyyielded a whopping 580,107 publications.

It would be naïve and foolish of me to consider reading even 1% of these articles, and I am in full agreement that the vast majority of them would illicit either a 

response. However, every month I find at least 20 or more papers from which I learn something. Every psychiatrist—clinician, academician, researcher, consultant, or some combination thereof—has a unique interest and specialty in our vast and diverse field of psychiatry. Sometimes I find an obscurely titled article from a not-so-famous journal that becomes one of my favorite articles of the month; I would never have stumbled upon such gems without a strategy to enrich the pool of articles that I take the time to read. For each psychiatrist, that strategy will be different, but such a method to whittle down the literature can make the process somewhat of an adventure—often rewarded with a much-appreciated article.

I was also intrigued by the article’s comparison of new pharmacological treatments since 1950 in cardiology (the article’s reference noted 14) versus psychiatry (3 according to the article).

 from which I learned a lot. However, the source of the cardiac versus depression/schizophrenia new treatments was a graph without a published source reference. The presenter showed a slide titled: “Development of New Treatments for Mental Illnesses Compared with Heart Disease,” with the Y axis labeled “# of Mechanistically Distinct Drugs.” The X axis showed bar graphs of “Distinct Drugs” that existed in the 1950s compared to those available today for depression, schizophrenia, and heart disease. The reference for the slide was “Courtesy of: Bill Carlezon and Ed Skolnick.” This is a case where context is critical.

Comparing a pump—which has been exhaustively studied and is extremely well understood—with the human brain—which is the seat of human consciousness, allowing me to write this editorial while simultaneously and automatically managing all of my bodily functions, allowing for emotional responses, and containing the circuitry of language, culture, ethics, and morality—is like comparing our understanding of a meteor with that of a black hole. 

As psychiatrists, we should be so lucky that the anatomy and functionality of the brain is the same as the heart. Comparing a pump—which has been exhaustively studied and is extremely well understood—with the human brain—which is the seat of human consciousness, allowing me to write this editorial while simultaneously and automatically managing all of my bodily functions, allowing for emotional responses, and containing the circuitry of language, culture, ethics, and morality—is like comparing our understanding of a meteor with that of a black hole. We find ourselves empathizing with Isaac Newton’s famous 

I do not know what I may appear to the world, but to myself I seem to have been only like a boy playing on the seashore, and diverting myself in now and then finding a smoother pebble or a prettier shell than ordinary, whilst the great ocean of truth lay all undiscovered before me.

Despite this limited understanding of the human brain, I find it remarkable that we have made so much progress since the 1950s. It was in 1954 that we began using chlorpromazine, our first antipsychotic, and in 1958 and 1959 we started using our first 2 antidepressants, iproniazid and imipramine, respectively. As a psychopharmacologist who relishes understanding psychotropics and their putative mechanisms of action, I continue to be amazed by how much we have learned about pharmacology and the brain since I began medical school in 1982. Although the mechanisms of action of current US Food and Drug Administration-approved drugs for the treatment of depression are limited to 4 neurotransmitter systems (eg, serotonin, norepinephrine, dopamine, and glutamate), the diverse subcomponents of these 4 systems targeted by FDA-approved antidepressants is vast. When you add to this the drugs that we use “off label,” the list of mechanisms of action expands greatly.

In the past 35 years, our portfolio of new pharmacological agents in psychiatry has grown tremendously, providing patients with many new options. Although we certainly have mountains of new information and understanding to explore and it is common to hear frustration regarding the lack of novel breakthroughs in psychiatry, it is important to consider our significant advances (

Sadly, there are challenges in developing novel agents for the many—arguably all psychiatric diagnoses—that have either no or sub-optimal current FDA-approved treatments. As such, the pharmaceutical industry has virtually abandoned new drug development in neuroscience with a few exceptions.

 in 1954 that first suggested that “DNA alone, free of protein, may be able to carry genetic information.” In a mere 46 years, the world scientific community announced the completion of the first map of the entire human genome, and by 2003 they completed the sequencing of all 3 billion base pairs. This remarkable accomplishment paved the way to identify the polymorphic families of genes that code for receptors for a particular neurotransmitter. Today, just for the neurotransmitter serotonin, we have characterized in detail 7 different families of serotonin receptors and approximately 18 different subfamilies—all with unique and divergent roles in our brain’s neurocircuitry. Many of our newer antidepressants and antipsychotics have unique molecular binding affinities at these 18 different targets for serotonin, which I would argue are structurally and functionally different medications.

Pharmacogenomics is in its infancy, with only 4 evidence-based genes in the psychiatrists’ clinical 

(ie, CYP2D6, CYP2C19, HLA-B* 15:02, and HLA-A*31:01).

 Over the next 10 to 20 years, we will likely see a continued expansion of psychiatric pharmacogenomics that will include an array of clinically relevant genes for receptors, cytochrome P450 enzymes, uridine 5’-diphosphate glucuronosyltransferases (UGT) enzymes, promoter sequence variations, and more.

In parallel to this genetic research is the increasing understanding of the complexities of the human genome. We are learning that many psychiatric disorders can have a synergistic risk or protection for unmasking based on the contributions of numerous genes, often across many different chromosomes. In the case of the approximately 100 genes with varying degrees of risk for (or protection from) the development of schizophrenia, there is one of these genes on almost all the 23 different human chromosomes. Additionally, genome-wide association studies have shown that regions of DNA which contain an increased risk for schizophrenia also contain regions of DNA that increases the risk of metabolic disorders.

As a first-year medical student in 1982, I recall seeing my very first human CT scan—the chest, abdomen, and brain. I was blown away by the detail, and I continue to be amazed by the clinical information that can be 

by the now numerous neuroimaging tools available: computed tomography (CT) or computed axial tomography (CAT), positron emission tomography (PET), magnetic resonance imaging (MRI), functional MRIs, functional ultrasound imaging, single-photon emission computed tomography, magnetoencephalography, and others. I have treated patients for whom these techniques have been a primary source of information in differential diagnosis and treatment planning.

In 2011, the FDA approved the imaging agent DaTscan in conjunction with SPECT to determine the density of dopamine transporters to aid in the diagnosis of Parkinson disease. More recently, in May 2020 the FDA-approved Tauvid, an imaging agent used with PET scanning to evaluate patients for Alzheimer disease. This agent is approved for adults with cognitive impairment to quantify the density and location of aggregated tau neurofibrillary tangles to assist in the differential diagnosis of possible Alzheimer. The future of neuroimaging looks very bright!

In this editorial, my goal was to provide a “glass half full” assessment of where we are in psychiatry and the importance of a vast psychiatric literature that can elicit the 

The fascinating history of medicine, which rests on the shoulders of the giants in science, has shown us that we can never predict what obscure research observation or serendipitous finding will open a door to advancements in medicine. For this reason, I am happy to tolerate articles that elicit the 

responses, knowing that somewhere tucked in that vast ocean of publications, I will continue to stumble upon articles that elicit 

What investigating neural pathways can reveal about mental health

2. Isaac Newton - Playing on the Seashore Did Newton Really Say It? Today In Sci. Accessed July 15, 2020. 

https://todayinsci.com/N/Newton_Isaac/NewtonIsaac-PlayingOnTheSeashore.htm

3. Crick FHC. The structure of the hereditary material. 

4. Clinical Pharmacogenetics Implementation Consortium. Accessed July 15, 2020. 

Reflections on the current psychiatric literature as well as the many accomplishments psychiatry has seen since the 1950s.

My Wow and Awesome Responses While Reading the Psychiatric Literature

Slideshows

Some speculate the pharmaceutical industry has virtually abandoned new drug development in neuroscience with a few exceptions. However, it should be noted that progress has been made.

Over the past 3 months I have learned a lot from my patients, some of whom I have been treating for 13 years. If I had to take an exam this past March predicting how my various patients would respond to, and be impacted by, the dramatic events we have endured, I surely would have failed. It has been a stark reminder of the complexities underlying each individual’s constitution, resilience, adaptability, and self-awareness as to how they fit in to the universe’s big picture.

My first surprise was how well several of my patients with significant anxiety disorders were coping with the 

. A recurring theme for a subset of these patients was their satisfaction and sense of mastery at how well they were coping with the societal disruption and global fears. One patient shared how she was intrigued by how anxious many of her friends and co-workers were. When she was asked how she could remain so calm in the face of all of the uncontrollable stressors the pandemic created, she simply stated that she had been challenged by anxiety all of her life and had developed strategies to cope and reframe her relationship to stressors. She told me she experienced a sense of self-mastery.

Another patient who has suffered from severe 

, which created a secondary social anxiety and social avoidance, described feeling guilty because she rather enjoyed the empty streets, closed stores, and social distancing. Her anxiety was increased by the thought of our state re-opening.

Another subset of my patients, many with chronic and severe mental illnesses, were unphased by the pandemic’s intrusion; they shared that nothing had really changed for them. Their day-to-day activities were pretty much the same.

One patient, a man in his 50s with a lifelong history of severe social anxiety and chronic depression of variable intensity, reported a significant increase in anxiety as well as the new onset of severe insomnia. The patient lives alone and has been on disability for decades. His meager disability income combined with food stamps and fuel assistance barely allowed him to pay his monthly bills. With great determination and motivation, about 8 months ago he began a part-time job working 10 to 15 hours a week—his first job in decades. With a little extra money every month, he decided to enroll in a basic cable TV plan, which opened access to 24/7 cable news with all of its fury.

He directly connected his increased anxiety and insomnia to his newfound daily exposure to cable news, which inundated him with reports of a country and a world that had become extremely dangerous and violent. His anxiety and fear increased whenever he stepped out of his apartment. He said he would lay in bed at night with frightening images from the day’s news, unable to sleep, and worried about what tomorrow might bring.

Reflecting on his experience, I was reminded of one of my favorite quotes from J. Krishnamurti, a philosopher who was often described as the “guru’s guru.” He repeatedly stated: “Consciousness is its content.” So simple, yet so profound. I read more Krishnamurti during medical school than any other subject, despite his books not being a part of our curriculum. The insights he stirred up in me, along with my experience with Mindfulness Meditation working with Jon Kabat-Zinn, PhD, in the Department of Medicine’s Stress Reduction and Relaxation Program at the University of Massachusetts Medical Center, were the 2 factors that led to my decision to become a psychiatrist.

“Consciousness is its content”—such a simple phrase; yet it contains the roadmap to peace of mind. In retrospect, many forms of psychotherapy are based on this underlying principle. An obvious example is cognitive behavioral therapy, whereby in order to reframe or modify an automatic thought, perception, or judgement, the first step is to recognize the content of the mind’s narrative that has created the experience. In my view, mindfulness practice is an important part of the triad in Dialectical Behavior Therapy for the same reason. Over the years, I have developed a brief exercise that I use myself—and I teach to many of my patients—to disrupt an unskillful cognitive or emotional loop and choose a healthier content for my mind.

I was reminded of one of my favorite quotes from J. Krishnamurti, a philosopher who was often described as the “guru’s guru.” He repeatedly stated: “Consciousness is its content.”

The first step is the most challenging, and it is strengthening the ability of my mind to recognize when it is filled with content worth removing or changing. As soon as the recognition occurs, the exercise begins:

I wake myself out of the trance of thought that I am in, often by saying the word stop to myself.

 I consciously take a slow, deep breath, sending relaxation throughout my mind and body, and clearing the content of my mind.

Once grounded in the present moment, I reflect on the mind content that was present and consider options on which I should focus my attention.

I choose what appears to be the healthiest and most appropriate mind content with which to fill my consciousness.

Although simple in concept, it is a very challenging exercise to practice. By repeating this exercise over and over, the brain appears to rewire itself so that the mind moves away from the unhealthy content, and increasingly toward healthier content with all of the associated benefits. To be clear, I am using the terms brain and mind loosely.

Returning to my patient who suddenly had access to cable TV, his mind’s content had become filled with the residue of the Breaking News, which is usually jarring and commonly contains content that is unpleasant and fear-provoking. By limiting exposure to this content—by watching enough to remain informed but limiting the amount to decrease agitation and anxiety and fear—a balance may be established to optimize good mental health. After exploring options with this patient, we developed a plan whereby he would watch cable news for 30 minutes, 3 days per week. No prior authorization was needed.

is Medical Director, Brain Health, Exeter, NH; Editor in Chief, P

; Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

A 4-step plan to tackle the worries of the day.

Rx: Limit Watching the News to 30 Minutes, 3X/Week

The last day I met with patients at our clinic was March 16th. By the end of that week, all 10 psychiatrists and 4 psychiatric nurse practitioners at both of our clinic sites had begun treating patients at our own homes through telehealth—something I had never utilized previously. It was a huge adjustment, for me as well as my patients. During this COVID-19 pandemic, our clinic is using the 

My first day practicing via telehealth was quite an adventure, with my initial challenge figuring out how my virtual waiting room worked. When my next scheduled patient was not in my virtual waiting room, I reverted to the old-fashioned technology of calling the patient on the phone. Initially and somewhat surprising, most of my appointments that first day ended up occurring over the telephone. As I spoke with each patient, there were many reasons why many preferred the telephone over doxy.me: no Wi-Fi signal or internet connection at their home, no camera on their wireless phone, averse to the technology involved, or simply not interested in a video/audio appointment—they were happy with the phone.

Interestingly, another subgroup of patients were quite excited about having our appointment through the doxy.me platform. Some of my patients “arrived” 10 to 20 minutes early—at least the message below their name told me that was how long they had been logged into the waiting room. A few patients had their partners join in on the virtual appointment; not surprisingly, they were the ones who usually brought their partner into our routine clinic visits.

I find the telehealth experience disorienting, and it takes up more of my time than a simple face-to-face in-person medication visit. Every evening, I am emailed the following day’s schedule and service tickets, which I need to print out and needs to be completed and returned electronically to the clinic by the end of the day. I have 2 computer screens open in front of me: one screen with the doxy.me platform and the other open to our clinic’s portal with the patients’ charts on the screen along with the eprescribing program. On my lap is my clipboard to write a few notes to refresh my memory when I dictate the documentation for that visit, usually done at the end of the day. I get texts throughout the day to update me about schedule changes or patient related matters that need my attention from our support staff, who remain at the clinics to manage our schedules, the phone calls, and the other administrative work they so effortlessly balance.

Tomorrow—May 11th—begins my 8th week as a telepsychiatrist, and I cannot wait to get my old job back. Call me old-fashioned, but I truly miss walking out to the waiting room to call my patient’s name. My initial glance before my patient sees me usually tells me a lot about how they are doing and what to expect during the appointment. I walk behind the patient to my office and observe the patient’s posture, gait, energy level, and nuances that may suggest a new medical or neurological issue. Which of the 3 available seats in my office will be chosen, and what does that tell me? My initial open-ended question will unleash a torrent of information about how they are doing, derived from the verbal response, body language, subtleties of affect, direct eye-to-eye contact, and that feeling inside of me that is my intuitive response to the reply. Is there any unusual odor? Lots of information can be gleaned from the sense of smell. How will the session end? Will the patient stand up and walk toward the door based on my verbal cues? Do I have to stand, walk toward the door, possibly open it, and gesture the patient out?

I am reminded of my medical training at the 

University of Massachusetts Medical School

 from 1982 through 1986. James Dalen, MD, MPH, cardiologist and Chairman of the Department of Medicine, instilled in me the necessity and value of a comprehensive and thoughtful patient history and physical, which if deciphered correctly often leads to an accurate diagnosis. As a resident in psychiatry, Sheldon Benjamin, MD, taught me the diagnostic pricelessness of a detailed neuropsychiatric evaluation; Zamir Nestelbaum, MD, instructed me to monitor my patients for cogwheeling in the upper arm as a proxy for when the antipsychotic medication was approaching the brain level that would maximize the antipsychotic effectiveness while minimizing neurological adverse effects; and Paul Appelbaum, MD, explained the necessity of sequential questions to collate an ethical and compassionate formulation as to whether the patient being evaluated would likely be deemed by a judge to be competent, or not. Thus, I lose a significant subset of diagnostic tools when I am limited by an audio/video interface with my patients.

I realize the clinical and administrative necessity that telehealth provides for many practitioners and patients alike. In many parts of the US, especially in geographically isolated or expansive areas, there would be no access to treatment without telehealth. There is such a shortage of psychiatrists and psychiatric nurse practitioners that telehealth is the only option that allows clinicians to treat patients who have no other alternatives. And, during a pandemic, telehealth serves as a savior. I have many professional colleagues who thoroughly enjoy practicing psychiatry through telehealth, either part-time or full-time, and they serve an important role in the delivery of good psychiatric treatment. However, for me, I am ready to jump back into the clinic as soon as it is safe to do so. ❒

My initial glance before my patient sees me usually tells me a lot about how they are doing and what to expect during the appointment.

Jumping Into Telehealth

A good night's sleep is foundational to maximal functioning, lowered stress, good reaction time, enhanced cognitive function, and more. For many individuals, when they experience difficulty falling asleep the first inclination is to take some type of medication--a prescription drug for insomnia or an over-the-counter medicine, many types of which are readily available at pharmacies, grocery stores, and convenience stores. Other individuals may turn to cannabis or alcohol. However, all medications or mind-altering agents have adverse effects and risks.

Alternatives exist that can provide lasting benefits to promote predictable, restful sleep through behaviors that enhance the likelihood of falling and staying asleep. Collectively, these behaviors are called "good sleep hygiene." This video will review the many types of behavioral changes that can contribute to falling asleep, staying asleep, and waking up in the morning feeling refreshed.

, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

A good night's sleep is foundational to maximal functioning, lowered stress, good reaction time, and enhanced cognitive function. Strategies discussed here.

Elements of Good Sleep Hygiene

After so many weeks of sheltering in place, watching the news, and not going to restaurants or other public places due to the pandemic, how do we re-engage and re-integrate slowly and maintain calm? Dr John Miller addresses these issues.

After so many weeks of sheltering in place, watching the news, and not going to restaurants or other public places due to the pandemic, how do we re-engage and re-integrate slowly and maintain calm?

Author | John J. Miller, MD

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