Natalie Timoshin

Dr Kogan was scheduled to give the William C. Menninger Memorial Convocation Lecture, “Tchaikovsky: Music and Melancholy” at the 2020 

Annual Meeting in Philadelphia on April 27. When the meeting was cancelled due to 

Richard Kogan, MD, is a virtuoso concert pianist and a distinguished psychiatrist. He is renowned for his lecture – concerts that explore the role of music in healing and the influence of psychological factors and psychiatric and medical illness on the creative output of the great composers in music history. A master storyteller, Dr Kogan has captivated audiences with these programs at music festivals, medical conferences, and scholarly symposia throughout the world.

Dr Kogan is Clinical Professor of Psychiatry at Weill Cornell Medical College, Artistic Director of the Weill Cornell Music and Medicine Program and the Co-Director of Weill Cornell’s Human Sexuality Program. The 

 has praised him for his “exquisite playing” and 

 said that “Kogan has somehow managed to excel at the world’s two most demanding professions.”

Dr Kogan is a graduate of the Juilliard School of Music Pre-College, Harvard College, and Harvard Medical School. He completed a psychiatry residency and academic fellowship at NYU. He has won numerous honors and awards in both music and psychiatry.

Creativity and Mental Illness: Richard Kogan on Rachmaninoff

Music & the Mind: The Life and Works of Robert Schuman

Videos

A virtuoso concert pianist and psychiatrist's "play" on the role of music in healing and the influence of psychological and medical factors on the creative output of the great composers in music history.

Tchaikovsky: Music and Melancholy

Although not a replacement for the 173rd American Psychiatric Annual Meeting, the Spring Highlights Meeting, a free live event with more than 3000 attendees, touched on several important areas in psychiatry on April 25 and 26, 2020. The APA seemingly moved mountains to put together an impressive roster of 15 virtual sessions with key leaders in their respective areas in psychiatry.

APA leadership decided to cancel the 2020 Annual Meeting on March 15th. Scheduled to take place in Philadelphia from April 25 through April 28, the meeting was expected to draw thousands of psychiatrists from across the globe to engage with their colleagues, take in the sessions, and partake in CME activities. Then the 

 pandemic swooped down, bringing hundreds of live events in medicine and beyond to an abrupt end. This year is only one of a handful of APA meetings that did not hold its annual event in person, most notably one that didn’t happen at the end of World War II.

Instead of the live annual meeting, a virtual meeting, the 

APA Spring Highlights Live Virtual Meeting

 was created. A running theme throughout this meeting was the COVID-19 pandemic and the need for mental health treatment now and after the immediate crisis subsides, both for the public and health professionals.

Drs Saul Levin, Bruce Schwartz, and Jeffery Geller kicked off the meeting that took place on Saturday, April 25 and Sunday, April 26. They were followed by 13 psychiatric experts who provided their insights on a number of topics. Presented by Dr Schwartz an additional session, The Annual Business Meeting, took place on Sunday, for APA voting members only.

Saul Levin, MD, CEO and Medical Director of the 

, who oversees programs in prevention and health care disparities, kicked off the opening session by stating the decade is off to a difficult start that presents both challenges and opportunities. He called out the New York State Psychiatric Association as “a shining example of how we should respond in a crisis,” a living example that psychiatrists are physicians first. Calling the COVID-19 pandemic “the most extraordinary crisis of our lifetime,” he thanked all psychiatrists for the extraordinary job they are doing.

The APA is working across party lines to improve mental health care at the state and government level, Dr Levin said. Working closely with departing APA President, Bruce Schwartz, MD, they worked to advance psychiatry, and he congratulated Dr Jeffrey Geller as he takes over the role of APA President: “I know that he will rise to meet the challenges of this coming year and provide the membership with his experience and vision for his presidential year,” he said.

More than ever before, psychiatry will be called to advance care over the course of the decade. Psychiatrists and colleagues “from all over the world will come together with the hard work necessary to meet the challenges of COVID-19 and the issues affecting our patients and the profession.” He also spoke to mental health disparities and the higher mortality rate among African Americans, Native Americans, and other minorities across the US. Incarcerated persons and those in treatment are also suffering, and there is a need for more research funding for the opioid crisis and substance use disorders.

Outgoing 2020 APA President, Bruce Schwartz, MD, Professor, Deputy Chair, and Clinical Director of Psychiatry & Behavioral Sciences at 

Montefiore and the Albert Einstein College of Medicine

 in New York City, noted that the true heroes are the workers who sacrifice their health and well-being and that of their family, as well as residents and fellows, many of whom interrupted their training to provide acute medical care in hospitals and ICUs. “COVID-19 is a visual reminder that we are physicians first . . . This epidemic has made it imperative that mental and health care are to be a priority.”

The trauma of what health care providers have witnessed will have lasting effects, reverberating for years to come: “The entire mental health workforce had to be mobilized and interdisciplinary collaboration is all that allowed us to cope with this emergency. We will need this full workforce to cope with the psychiatric effects after this passes,” he said.

APA President-Elect Jeffrey Geller, MD, MPH, Professor of Psychiatry at the 

University of Massachusetts Medical School 

and Medical Director at a 200-bed psychiatric hospital serving adults and adolescents, also shared his insights. While acknowledging the devastation of COVID-19, he took a sobering glance at psychiatry’s past when patients in the 19th century were deprived of basic human needs.

In 1848, only 5000 of 22,000 patients with mental illness in the US were in hospital. The majority were in jail or worse-many were kept in captivity, “in cages, pens, cellars, and warehouses, and cells, and sold at auction. where they were bound with chains . . . lacerated with ropes, surged with rods, put in severe constraints and strapped upon beds with course hard straps of leather.” At that time Dorethea Dix called on Congress to provide appropriate care for persons with mental illness.

When it comes to psychiatric beds, the situation for people with serious mental illness (SMI) is not that much different today. Dr Gellar noted that the bed shortage continues. In 1955, there was one psychiatric bed for every 300 Americans; today there is one bed for 3000. Consequently, the majority of patients with SMI find themselves incarcerated.

Below are some highlights from the meeting.

Physician Leadership During Times of Crisis

Patrice A. Harris, MD, MA, President of the American Medical Association (AMA) and chair of the AMA's Opioid Task Force, discussed the AMA's multi-faceted response to the COVID-19 pandemic. She discussed efforts to secure resources for physicians; an appeal for science and data to protect public health; and a call to prioritize equity during the pandemic to prevent the widening of existing health gaps between populations.


	The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. Joshua A. Gordon, MD, PhD, Director of the National Institute of Mental Health discussed what NIMH learned so far and outlined research priorities with short-, medium- and long-term timeframes. He also touched on issues of importance to the mental health research community, touching on NIMH priorities in computational psychiatry, neural circuits, and suicide prevention.

Substance Use Disorders in Perinatal Women


	With more than 7 million people who have a substance use disorder, pregnant women are not immune. In this session Kimberly Yonkers, MD, Director of the Psychological Medicine and Center for Wellbeing of Women and Mothers at the Yale School of Medicine, reviewed the epidemiology of substance use in pregnancy. She also discussed the longitudinal course of substance use in pregnancy and consequences of substance use in pregnancy to the mother and infant.

The Substance Abuse and Mental Health Services Administration (SAMHSA): Current and Future Directions


	Elinore McCance-Katz, MD, Assistant Secretary, Mental Health and Substance Use, SAMHSA, presented a discussion about SAMHSA’s mission, which is to reduce the effects of substance misuse and mental illness on US communities. In the past few years SAMHSA has focused on best practices in the diagnosis and treatment of mental illnesses and substance misuse. An overview of current SAMHSA initiatives, priorities and opportunities were reviewed and the audience reminded that psychiatry has a voice in our federal government and SAMHSA is an avenue through which that voice is heard.

Crisis Hotlines are Key to Transforming Care Delivery


	Kimberly Williams, President and CEO of 

 discussed the potential for a national 3-digit number for mental health and suicide prevention, which will more effectively integrate crisis hotlines into the US care delivery system. Vibrant, a leader in the administration of crisis hotlines, provides 24/7 crisis line services to millions throughout the country in partnership with local and federal governments and corporations including managed care and technology companies. It includes New York City’s leading edge, multi-lingual, multi-modal contact center program that responds around the clock to the mental health needs of tens of thousands of New Yorkers.

Global pandemics, such as COVID-19, create profound social, economic, and psychological disruption. Certain populations experience unique adversities and vulnerabilities, resulting from the infectious disease itself as well as society's response to managing it. The scope and magnitude of the COVID-19 pandemic necessitates the use of evidence-based population mental health interventions to augment clinical care. Customized and actionable resources aid psychiatrists, other health care professionals, and organizational leaders to best support patients and communities.

, provided a brief review of global pandemics and their profound social, economic, and psychological disruption especially in populations at increased risk for adversities and vulnerabilities. In addition, he suggested interventions and customized and actionable resources for use by mental health professionals to help patient through the crisis.

Expansion of Psychiatric Practice Through Telepsychiatry During the COVID-19 Era


	In this session Avrim Fishkind, MD, CEO/Consultant, emergency Psychiatry and Psychiatric Emergency Design, Empathis Soul Health, provided an overview of how to use telepsychiatry in the changing landscape of COVID-19 pandemic. He also reviewed the legal, clinical, cultural, and practical aspects of using technology to deliver patient care.

NIAAA 50th Anniversary-Alcohol Use Disorder: The Brain, the Pain, and Alleviating the Shame


	In his presentation, George F. Koob, PhD, Director, 

National Institute on Alcohol Abuse and Alcoholism

 (NIAAA) reminded the audience how far the NIAAA has come in its 50 years of existence. The organization is using a heuristic framework for its research efforts that include neurocircuitry and neurofunctional domains, and he discussed highlights of research findings and how they have translated to diagnosis, prevention, and treatment.

The Role of Synaptic Autoantibodies in Psychiatric Disease


	The discovery of diseases in which autoantibodies against neurotransmitter receptors produce psychiatric symptoms has changed the diagnostic and treatment approach to many neurologic and psychiatric disorders previously considered idiopathic. In this presentation, Joseph Damlau, MD, PhD, Professor, 

Catalan Institute for Research and Advanced Studies

, University of Barcelona, and Adjunct Professor of Neurology at the University of Pennsylvania, used anti-NMDA receptor (NMDAR) encephalitis to exemplify this category of diseases, of which 11 may present with psychiatric symptoms.

, examines narcissistic patients’ incapacity to establish satisfactory love relations. The diagnostic exploration of patients' erotic, emotional, and evaluating aspects of love relations help us understand typical narcissistic failures in these areas. Clinical material illustrates phases, vicissitudes, and prognostic implications of these therapeutic processes.

Black and Gay: A Historical Perspective of Black Gay Men


	In today's more open American society being black and gay carries a double stigma that threatens to deny equal opportunities, status, and standing. Billy Jones, MD, Clinical Professor, Department of Psychiatry, NYU Langone Health, present a historical picture of ongoing, intertwined, natural human conditions the impact they have had on major social changes.

Opportunities and Challenges in Addiction Research


	Scientific advances have increased our understanding of the biological, developmental, and environmental factors involved in drug abuse and addiction and are stimulating further explorations into increasingly targeted strategies for their prevention and treatment. Nora D. Volkow, MD, Director, National Institute on Drug Abuse (NIDA) discussed the better understanding of the brain's neurodevelopmental trajectories we now have, ie, the interaction with social environments and genetics as they relate to vulnerability and resilience to drug use and addiction.

For more information about the meeting as well as continuing education, go to 

https://www.psychiatry.org/psychiatrists/meetings/spring-highlights

Articles

A running theme throughout the virtual meeting was the COVID-19 pandemic and the need for mental health treatment now and after the immediate crisis subsides, both for the public and health professionals.

Pandemic Doesn’t Stop the APA: Virtual Meeting Highlights

On Thursday, March 26, the FDA granted authorization for Somryst

, a prescription-only digital therapeutic that can be accessed on a smart phone or tablet for treatment of chronic insomnia in patients aged 22 years or older. Clinical guidelines from the 

cognitive behavioral therapy for insomnia

 (CBTi) as first-line treatment for chronic insomnia. Somryst uses technology to digitally deliver CBTi to patients. Similar to person-to-person CBTi interventions, Somryst provides 3 primary mechanisms of action to improve symptoms: tailored sleep restriction and consolidation, stimulus control, and personalized cognitive restructuring.

The FDA authorization was based on two randomized controlled trials comprising more than 1400 adults with chronic insomnia. Findings from the first trial suggest that patients saw improvements in 

 severity, sleep onset latency, and wake after sleep onset (time awake at night) by the end of treatment. Moreover, the effects of treatment were sustained at 6 and 12 months follow-up.1 In the second trial, which consisted of 1149 patients with insomnia and 

, a significant reduction in insomnia severity was seen after 9 weeks of treatment, and the benefits were still evident over 12 months follow up.2
	Somryst should be used only under the supervised care of a clinician. Psychiatric Times Advisory Board member John Torous, MD, MBI, director of the digital psychiatry division, Department of Psychiatry, Beth Israel Deaconess Medical Center, a Harvard Medical School affiliated teaching hospital, warns that “The usage data collected in therapy lessons by Somryst are not intended to be used as a standalone assessment of treatment progress.”

:
	• Any disorder exacerbated by sleep restriction (eg, bipolar disorder, schizophrenia, other psychotic spectrum disorders)
	• Untreated obstructive sleep apnea
	• Parasomnias
	• Seizure disorders
	• Individuals at high risk of falls
	• Pregnant women
	• Person with unstable of degenerative illness judged to be worsened by sleep restriction.

Torous noted, “The mental health field has a rich history of using technology as part of care for insomnia, so this news is of course welcome. But it remains to be seen whether this will actually increase access to quality of care. Real world data will be critical for psychiatrists about the implementation challenges and patient experiences with this new product.”

1. Rittenband LM, Thorndike FP, Ingersoll KS, et al. 

Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial

. 2017;74:68-75.
	2. Christensen H, Batterham PJ, Gosling JA, et al. 

Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial

On Thursday, March 26, the FDA granted authorization for SomrystTM, a prescription-only digital therapeutic for treatment of chronic insomnia in patients aged 22 years or older.

FDA Authorizes a Prescription Digital Therapeutic for Insomnia

National Longitudinal Study of Adolescent to Adult Health

 US adolescents in grades 7 to 12 were asked to complete a detailed survey. Subsequent data collection has traced the adolescents to their late 30s and 40s. Findings indicate that the incidence of dying by suicide is 3.5-fold higher in men than in women.

 This disparity may be due to high traditional masculinity (HTM), which includes competitiveness, emotional restriction, and aggression.

Using Add Health data from a previous study that had identified 9 variables associated with suicide,

 undertook a secondary study to determine the role of HTM in suicide. The risk factors included suicide by a family member, being expelled from school, running away from home, using a weapon, being of white race, etc. Their analysis showed a substantial association between HTM and the 9 factors; suicide by a family member had the strongest correlation.

There had been 22 completed suicides; of which 21 were men. Moreover, HTM men were 2.4 times more likely to die by suicide than non-HTM men, but they were 1.45 times less likely to report 

. The HTM men were also more likely to report gun access and had lower depression levels. The researchers concluded that: “In male suicide death, HTM may be an underlying influence increasing the probability of externalizing behavior risk factors, such as anger, violence, gun access, and school problems.”

1. RTI International. The National Longitudinal Study of Adolescent to Adult Health.
	2. Hedegaard H, Curtin SC, Warner M. 

Suicide Mortality in the United States, 1999-2017

. Atlanta GA: Centers for Disease Control and Prevention; 2018.
	3. Coleman D. Traditional masculinity as a risk factor for suicidal ideation: cross-sectional and prospective evidence from a study of young adults. 

. 2015;19:366-384.
	4. Feigelman W, Joiner T, Rosen Z, Silva C. Investigating correlates of suicide among male youth: questioning the close affinity between suicide attempts and deaths. 

. 2016;46:191-205.
	5. Coleman D, Feigelman W, Rosen Z. Association of hight traditional masculinity and risk of suicide death: secondary analysis of the Add Health Survey. 

High traditional masculinity (HTM) men are more likely to die by suicide than non-HTM men, but they are less likely to report suicide ideation.

Manly Men Beware

It turns out that the expansion of Medicaid coverage under the 

 has proven very beneficial to states that adopted it.

 It’s probably not surprising that access to care has improved-especially for low-income and vulnerable populations-which has resulted in better health outcomes. For example, early-stage cancer diagnosis rates have gone up as have certain types of cancer surgery. Treatments (including medication-assisted treatment) for 

 are now covered; and there is improved parity for behavioral health care.

States and providers have seen economic benefits as well. In the early years of the Affordable Care Act, the federal government covered 100% of the cost of the expansion, which resulted in state savings-states were able to offset costs in areas such as behavioral health services and the criminal justice system. Consequently, these states are seeing better economic outcomes with lower rates of unemployment and a reduction in poverty.

What probably wasn’t expected from the expanded coverage, was the beneficial impact on crime. 

 estimate that the expansion reduced the incidence of burglary, vehicle theft, homicide, robbery, and assault. They point out that, “These crime-reduction spillover effects represent an important offset to the government’s cost burden for the ACA Medicaid expansion.”

1. Antonisse L, Garfield R, Rudowitz R, Guth M. 

The Effects of Medicaid Expansion Under the ACA: Updated Findings From a Literature Review

2. He Q, Barkowski S. The effect of health insurance on crime: evidence from that Affordable Care Act Medicaide Expansion. 

Access to care has improved-especially for low-income and vulnerable populations-which has resulted in better health outcomes.

Surprising Benefits of the Expansion of Coverage Under the Affordable Care Act

Although the National Quality Forum recommends a minimum treatment duration of 6 months for 

, many patients discontinue within a few weeks or months of treatment initiation. In an effort to understand whether outcomes were better with longer term use of buprenorphine, 

 looked at adverse outcomes of patients who had been on buprenorphine for at least six months.

The researchers undertook a retrospective longitudinal cohort analysis using a Medicaid claims database (2013-2017) of 12 million beneficiaries annually. The sample included adults aged 18 to 64 years who had received buprenorphine continuously for 180 days or longer (ie, 6 to 9 months, 9 to 12 months, 12 to 15 months, and 15 to 18 months). Primary adverse outcomes included emergency department visits, inpatient hospitalizations, opioid prescriptions, and drug overdose.

Patients who were on buprenorphine for 15 to 18 months had lower rates of emergency department visits, inpatient hospitalizations, and filling opioid prescription in the 6 months following discontinuations. However, use of acute care service and overdose were high for all treatment durations following buprenorphine discontinuation. Although rates of adverse outcomes remained high, the best outcomes were seen with treatment duration of 15 months on longer.

1. Williams AR, Samples H, Crystal S, Olfson M. 

Acute care, prescription opioid use, and overdose following discontinuation of long-term buprenorphine treatment for opioid use disorder

Although 6 months is the recommended duration for buprenorphine treatment, many patients discontinue within a few weeks or months of treatment.

Buprenorphine Treatment for Opioid Use Disorder

 undertook a pilot trial to test the effects of ketamine combined with motivational enhancement therapy on adults with alcohol dependence. The participants (N = 40) were predominantly white and mostly middle-aged and unemployed. On average they were consuming five drinks daily.

 (n = 17) or midazolam (n = 23). In the second week of a five-week motivational enhancement therapy program, participants received either a single 52-minute infusion of ketamine (0.71 mg/kg; n = 17) or midazolam (0.025 mg/kg; n = 23).

Following administration, alcohol use was assessed with abstinence, confirmed by urine ethyl glucuronide testing. A longitudinal model was used to gauge daily abstinence from alcohol over 21 days following ketamine administration.

Compared with midazolam, the ketamine infusion significantly improved abstinence. Moreover, it delayed the time to relapse and reduced the likelihood of heavy drinking days. Infusions were well tolerated, with no discontinuations due to adverse effects.

A single ketamine infusion combined with motivational enhancement therapy for alcohol use disorder: a randomized midazolam-controlled pilot trial

Researchers tested the effects of ketamine combined with motivational enhancement therapy in adults drinking 5 alcoholic beverages per day.

Ketamine Infusion for Alcohol Use Disorder

Slideshows

Recommendations for the use of antipsychotics for the management of behavioral and psychological symptoms of dementia.

8 Strategies for Managing BPSD

A brief synopsis on how to spot major depression in youth.

11 Signs a Young Patient Is Depressed

Climate medicine: What was once on the radar of just a handful of physicians has exploded into awareness, alarm, and sometimes debate and skepticism. No matter how you look at it, psychiatrists are on the front lines.

Author | Natalie Timoshin