Conferences

Six NCCHC Foundation Scholarship Fund winners and over 450 more individuals recently attended the NCCHC’s Correctional Mental Health Care Conference in Denver.

“[The conference provided] a wealth of information to bring back to work. I was especially impacted by the sessions on compassion fatigue and racial trauma. When I think of compassion fatigue, I only considered the perspective of a mental health worker. Not once did I take into account how the custody staff must feel and all that they experience,” said one of the scholarship winners, Lt. Nathan Drew, LICSW, LCSW-C, US Public Health Service. “I truly appreciated the presenter’s specific emphasis on compassion fatigue as it relates to custody staff. It helped me to begin brainstorming ways to better support our custody staff at my facility. Truly thought-provoking!”

Another winner, Kristin Kastner, RN, highlighted the “networking, empowerment, and emphasis on evidence-proven skills/tactics.”

Beyond attending the conference, the scholarship winners had an orientation with 3 mentors on-site: Sharen Barboza, PhD, CCHP-MH, chair of the NCCHC Foundation, and psychologist/consultant; Robin Timme, PsyD, CCHP-MH, CCHP-A, senior expert at Falcon Correctional and Community Services; and Walter Campbell, PhD, CCHP-MH, chief psychologist at Idaho Department of Correction.

Barboza stated, “It is incredibly important to be able to introduce individuals new to the field of correctional health care to NCCHC and all it has to offer through this scholarship program. We received hundreds of applications from clinicians and students across the country. It is so heartening to see such interest in the challenging and meaningful care we provide to those in need. It gives me hope for the future of our incarcerated patients.”

Scholarships for the National Conference on Correctional Health Care will be announced in September and applications for the Spring Conference on Correctional Health Care will open by January 15, 2023. To support the future of correctional health care, successful applicants must be students or those with less than 3 years of experience in correctional health care.

Articles

2022 NCCHC Conference

6 scholarship winners got the privilege of attending this conference. Read more here. 

Scholarship Winners Attend the NCCHC Correctional Mental Health Care Conference

John J. Miller, MD, shares why it is important to differentiate between CBD and THC when discussing cannabis 

2022 Annual Psychiatric Times™ World CME Conference

is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief,

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

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Psychiatric Times World CME Conference

CBD and THC? What's the difference and why does it matter? 

Cannabis: Separating the Conversation on CBD and THC

“Two thirds of the sample said that their psilocybin experience was among the top 5 most meaningful of their entire lifetimes,” shared David B. Yaden, PhD, assistant professor in the Center for Psychedelic and Conscious Research at Johns Hopkins University School of Medicine.

Yaden, in his presentation on “The Evidence for Psychedelics in Psychiatry” at the 

 in San Diego, shared that serotonin molecules actually look quite similar to LSD and psilocybin—thus, serotonergic hallucinogens. “In vitro and in vivo, classic psychedelics increased neurite growth, spine density, and synaptogenesis. For this reason, some of them call these substances psychoplastogens.”

Yaden explained that set and setting for a psychedelic administration session, as the mindset and expectations that an individual brings to the experience, as well as the physical location, can impact the acute subjective effects. “Not all psychedelic experiences are good or euphoric—far from it,” Yaden said.

In a survey of 1993 individuals meant to gauge their single most psychologically difficult or challenging experience—or worst “bad trip”—after consuming psilocybin mushrooms, 39% rated the experience as among the top 5 most challenging experiences of their lifetime, 11% reported putting themselves or others at risk of physical harm, and 2.7% reported getting medical help during the event.

 Despite this, in another study, psilocybin was lowest rated in terms of likelihood of harm to self and others compared to other substances.

In one open-label study, psilocybin was correlated with sustained and substantial decreases in depression.

 These results were replicated in further studies.

“It’s also the only substance type among all of these recreational-use substances that is associated with lower suicide attempts,” Yaden said.

As to how Yaden and his investigative team conducts his research, he explained the process. First, participants must go through a “quite intensive medical psychological screening” to reduce generalizability of these studies. Then, there are a number of preparatory sessions to build rapport and provide psychoeducation, followed by experimental sessions where psilocybin is administered. In these sessions, the participant is lying down on a couch with eyeshades and headphones. Two therapists are always in the room, and the sessions are always recorded. Participants can ask for a therapeutic touch, or a hand to hold. Afterwards, integrative sessions allow participants to discuss their experience.

“Many people use metaphors like climbing a mountain or running a marathon,” Yaden said. “They involve challenge and difficulty, but also moments of meaning and joy.”

Yaden believes this signals that psilocybin is worth further study. “This is controversial; we are trying to figure this out. I think it is important not to rush to a simplistic story, as we are learning from the process. There is evidence for a number of possible therapeutic mechanisms and emotional processing—social, self, and behavioral.”

Psychedelics promote structural and functional neural plasticity.

2. Carbonaro TM, Bradstreet MP, Barrett FS, et al. 

Survey study of challenging experiences after ingesting psilocybin mushrooms: acute and enduring positive and negative consequences.

3. Nutt DJ, King LA, Phillips LD; Independent Scientific Committee on Drugs. 

Drug harms in the UK: a multicriteria decision analysis.

4. Carhart-Harris RL, Bolstridge M, Rucker J, et al. 

Psilocybin with psychological support for treatment-resistant depression: an open-label feasibility study.

Effects of psilocybin-assisted therapy on major depressive disorder: a randomized clinical trial.

6. Carhart-Harris R, Giribaldi B, Watts R, et al. 

Trial of psilocybin versus escitalopram for depression.

One researcher shares his evidence for the usage of psilocybin in psychiatry. 

The Recent Resurgence of Psilocybin: Is It Here to Stay?

“Our task in the next 20 minutes is to go through a whirlwind tour of the treatments for opioid use disorder [OUD],” Edward V. Nunes, MD, told attendees of the 

 “And the idea I want to sell is that psychiatry should really lead the way on this. This is a national priority and crisis, and psychiatry has a lot to offer in terms of treatment… we have the expertise.”

Medication is the cornerstone of treatment for OUDs, and psychiatrists are the experts in this area, explained Nunes, who is professor of psychiatry at Columbia University Irving Medical Center, research psychiatrist at New York State Psychiatric Institute, and principal investigator of the Greater New York Node of the National Institute on Drug Abuse (NIDA) Clinical Trials Network. Unfortunately, most people with OUDs are not receiving effective medication treatment. This may be why there is a high mortality rate (1% annually), due largely to overdose and suicide. There are currently 3 main options available: methadone, buprenorphine, and extended release injection naltrexone, Nunes noted.

Methadone is an oral full opioid agonist with slow absorption and a slow elimination (ie, long half-life).When titrated to an effective dose range of at least 80 mg/day, it induces tolerance in the brain’s opioid system, which results in a tolerance blockade for illicit opioid. “So when a patient gets up on a dose of 

, you know that dose has gotten high enough for this patient when they say, ‘I took some heroin and nothing happened. I was wasting my money, so I stopped using it.’,” Nunes shared.

Importantly, methadone is effective, not just in efficacy but also with retention, Nunes said. In clinical trials lasting more than 6 months, 70% of patients were retained. Of those, he noted 50% were found to be in sustained abstinence. “Most importantly, because of inducing tolerance, it protects against overdose and death,” Nunes added.

There are limitations to this strategy, Nunes told attendees, with accessibility and acceptability being important issues. Methadone is only available in 

, and at least half of US communities do not have a methadone clinic within a reasonable distance, he reported. Also, daily attendance is required for the first 3 to 6 months. Direct observation is necessary because if you raise a dose too quickly, it can result in an overdose, he said. There is also the potential for diversion.

Nunes noted methadone clinics run a little differently outside of the United States. “Other countries, including Canada, have more flexible models such as primary care and pharmacy based methadone,” he explained. “So, hopefully in the future the United States will begin working with some of these models to make it widely available. In the meantime, if you have a methadone clinic in your community, by all means, think about referring for methadone maintenance.”

Buprenorphine maintenance is a second option for addressing OUDs. 

 is a high affinity mu partial agonist and kappa antagonist with less opioid-like effects and thus less adverse effects, Nunes told attendees. It sticks really tightly to the receptor, he explained, so it is long-acting and it is safer, with less risk of respiratory depression. Perhaps more importantly, it is much more convenient than methadone, as it can be prescribed by any physician who gets an 

 from SAMHSA. A previously required course is no longer needed for physicians, he said, but it is still required for nurse practitioners and physician assistants to prescribe. Buprenorphine is available in a sublingual dose as tablets or films, with dose ranging from 8 to 32 mg/day. An extended release injection is also available, he said, with dose at 300 mg or 100 mg which has a 28 day duration.

Like methadone, there are some limitations to this treatment, Nunes noted. Retention is less favorable with buprenorphine, with rates close to 40% to 50% over 6 months. Ironically, he said because there is less tolerance and less withdrawal, it is easier for patients to walk away from treatment, so clinicians have to work harder to motivate patients to stay with the program. Similarly, patients need to abstain from opioids long enough to manifest withdrawal symptoms before initiating treatment. At that time, he explained a test dose is used. There are microdosing strategies available if you want to start sooner, Nunes noted.

Overall, both methadone and buprenorphine are effective strategies, Nunes said. “There's going to be some ongoing drug use, and that's grist for the mill. But these medicines are very powerful at reducing and often eliminating the opioid use,” he told attendees. Younger age and severity of OUD are associated with worse adherence and therefore worse outcomes, he added. “Staying on methadone or buprenorphine is what predicts long term abstinence severity.”

Naltrexone, another high affinity opioid receptor antagonist, binds to the opioid receptors very tightly, and actually blocks the effects of other opioids, Nunes explained. Further good news is limited adverse effects; he reported that patients generally feel well on naltrexone. However, patients must be fully detoxified before initiating treatment, he said, which present a real barrier, especially for more severe patients. This results in the need to hospitalize patients, which is a limitation. Another option, Nunes explained, was to induce with ascending doses of naltrexone and clonidine and other nonopioid medications that attenuate withdrawal. Once initiation is successful, natrexone’s efficacy is comparable with buprenorphine. Nunes noted naltrexone should be accompanied by strong motivational counseling.

“Pay close attention to overdose risk when choosing 

,” Nunes cautioned attendees,“especially if the patient has a particularly high risk of overdose, or a history of overdoses. When you take up high doses of opioids, I would be inclined to go with methadone.”

Nunes reminded attendees to consider psychosocial treatment and counselling. Not only is psychosocial treatment a requirement for methadone, but it also provides what may be much-needed structure. Inpatient and residential treatment may be especially helpful because it removes the patient from toxic environments as well as access to drugs. Plus, it also provides an opportunity to initiate the aforementioned medications.

Ultimately, Nunes told attendees treating OUDs is not unlike leveraging other psychopharmacological treatments. He reminded clinicians to keep it simple and remember the 3 As:

Opioid use disorder—how can we battle the epidemic of overdoses? 

A Whirlwind Tour of OUD Treatment Strategies

In his presentation, “Psychiatric Complications of COVID-19” at the 

 in San Diego, John J. Miller, MD, explored the broad range of psychiatric and neuropsychiatric effects of COVID-19.

“We’ve all seen it and we’re still dealing with them,” said Miller. “The mental health crisis is not only for people with the infection itself, but care for their parents, their families, and us as clinicians.”

According to research, the most common psychiatric symptoms include depression, anxiety, insomnia, posttraumatic stress disorder (PTSD), fear, grief, phobias, social avoidance/isolation, increased substance abuse, suicidal ideation, psychosis, and obsessive-compulsive behaviors.

 One systematic review and meta-analysis of long term physical and mental sequelae found at least 1 sequelae symptom occurred in 50.1% of COVID-19 survivors for up to 12 months after infection. Some of the symptoms included cognitive deficits (19.7%), depression (18.3%), and PTSD (17.9%).

“We know that any type of stress will only bring out underlying genetic and biological and epigenetic vulnerabilities,” Miller said.

As to neuropsychiatric symptoms, some of the most common are delirium (50% of COVID-19 ICU patients), confusion, fatigue, memory impairment, encephalopathy, seizures, cerebral vascular accidents, and more.

“The bottom line is every person is going to have a different trajectory in terms of how their immune system, how their body, the probabilities of their genetics, other psychosocial circumstances, how their comorbidities will impact their journey through the virus.”

SARS-CoV-2 may traverse the olfactory mucosa—causing loss of smell, especially in the original variants—to gain access to infect the brain, potentially through the olfactory tract, vagal nerve, or trigeminal nerve. Damage to endothelial cells can lead to inflammation and thrombi, which can cause direct damage to the brain, Miller shared. He noted that astrocytes appear to be the primary brain cell type infected and can contribute to fatigue and “brain fog.”

“It will probably take us another 5 or 10 years to figure out the real story. At the end of the day, we must say vaccinate, vaccinate, vaccinate, and remember our role as educators and health promoters is to be compassionate and provide accurate education to our patients and communities,” Miller concluded. “No one is safe until everyone is safe.”

A systematic review and meta-analysis of long term physical and mental sequelae of COVID-19 pandemic: call for research priority and action.

3. Manolis TA, Apostolopoulos EJ, Manolis AA, et al. 

COVID-19 infection: a neuropsychiatric perspective.

COVID and the brain: researchers zero in on how damage occurs.

What are the long term psychiatric and neuropsychiatric complications of COVID-19? 

COVID-19: A Direct Viral Attack on the Brain 

“We always want to make sure we weigh the risks of the untreated psychiatric disorder when we are considering treatments, especially medication exposures, for women of reproductive age,” said Marlene Freeman, MD, professor of psychiatry at Harvard Medical School.

In her presentation, “Pregnancy and Postpartum Management of Psychiatric Disorders,” at the 

 in San Diego, Freeman discussed how it is important to focus on antidepressant treatment in women with depression during pregnancy and the postpartum period. Approximately 45% of pregnancies in developed countries are unplanned, shared Freeman, and 75% of teen pregnancies are unplanned.

 Furthermore, 82% of US women have had a child by age 40.

 This is why it is important to tend to psychiatric disorders, which carry risks for both mother and baby if left untreated.

“The risks of the untreated psychiatric disorders impact efficacy and outcomes as well as child development overall,” Freeman said.

Freeman also stated that the absolute risk of selective serotonin reuptake inhibitors (SSRIs) exposure in pregnancy is small, and reproductive safety data on SSRIs exceed what is known about many other medications used in pregnancy. Prevalence of SSRI use during pregnancy is 3% to 7%.

According to recent research, there is no evidence of increased risk for major malformations or cardiovascular malformations in the offspring of women who took SSRIs while pregnant.

Another concern raised about SSRIs there is the potential increased risk of autism. Freeman shared that, through studies and meta-analyses, results have determined that SSRIs are associated with increased risk of autism, but not by cause and effect because you must factor in maternal psychiatric illness, which appears to be the driving factor.

Treatment Recommendations for Postpartum Depression

Approximately 10% to 15% of women experience major depressive episodes post-delivery, and that number increases to 25% to 40% if the woman has a history of major depressive disorder.

“Postpartum depression has been called the most common obstetrical complication,” Freeman said.

Freeman had a number of tips for treating mothers with postpartum depression, including using the lowest effective doses of SSRIs, consulting with perinatal/reproductive psychiatry specialists as needed, and maximizing nonmedication treatments. These nonpharmacologic strategies are (1) maximized social supports, (2) psychoeducation of patient and family, (3) group therapy or support groups, (4) interpersonal therapy, and (5) cognitive behavioral therapy.

“There are a lot of unknowns involved with pregnancy,” Freeman concluded. “We want to make sure that the treatment decisions we make are really collaborative with patients.”

To further support patients and their clinicians, Freeman referred to 

First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects.

Newer antidepressants in pregnancy and rates of major malformations: a meta-analysis of prospective comparative studies.

3. Einarson A, Pistelli A, DeSantis M, et al. 

Evaluation of the risk of congenital cardiovascular defects associated with use of paroxetine during pregnancy.

4. Alwan S, Reefhuis J, Rasmussen SA, et al. 

Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects.

Teratogenicity of SSRIs--serious concern or much ado about little?

The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: a review and clinical aspects.

7. Wogelius P, Nørgaard M, Gislum M, et al. 

Maternal use of selective serotonin reuptake inhibitors and risk of congenital malformations.

8. Huybrechts KF, Palmsten K, Avorn J, et al. 

Antidepressant use in pregnancy and the risk of cardiac defects.

Antidepressant exposure during pregnancy and risk of autism in the offspring, 1: meta-review of meta-analyses.

Treatment of mood disorders during pregnancy and postpartum.

11. Pearlstein T, Howard M, Salisbury A, Zlotnick C. 

12. Branquinho M, de la Fe Rodriguez-Muñoz M, Maia BR, et al. 

Effectiveness of psychological interventions in the treatment of perinatal depression: a systematic review of systematic reviews and meta-analyses.

Treating women of reproductive age who have depression can be difficult. Here’s an overview on the subject from the 2022 Annual Psychiatric Times™ World CME Conference. 

The Importance of Managing Psychiatric Disorders During Pregnancy and Postpartum

John J. Miller, MD, tries to untangle the controversies around psilocybin in this video and in his talk at the 

The resistance against "magic mushrooms"—is it justified? 

Psilocybin: The Complicated Conversation

Brian Hurley, MD, MBA, DFASAM, gives a summary on his talk on medication treatment and psychotherapy for substance use disorders from the 

is the Medical Director of the Substance Abuse Prevention and Control at the Los Angeles County Department of Public Health.

Medication, counseling, and support—just as important in substance use disorder treatment as any other brain disease.

Substance Use Disorder: A Brain Disease

“Real true, posttraumatic stress disorder [PTSD] is going to have an impact, certainly on the next generation and maybe generations after that,” said Rachel Yehuda, PhD.

Yehuda, in the Educator of the Year Lecture at the 

 in San Diego, shared her research on the potential of PTSD being passed genetically through the generations. Studying the Holocaust and 9/11 survivors showed fascinating results.

At a clinic for Holocaust survivors and their families at Mount Sinai School of Medicine, families reported feeling damaged, guilty, anxious, full of morbid grief, and had dysfunctional interpersonal relationships due to fear of loss. Overall, the children of survivors believed that parental Holocaust exposure was involved in their current mental health problems.

Previous research by Yehuda et al showed adult offspring of Holocaust survivors had differential effects of maternal and paternal PTSD in both glucocorticoid receptor sensitivity and vulnerability to psychiatric disorder. With both maternal and paternal PTSD, offspring had lower GR-1F promoter methylation; with just paternal PTSD, offspring had GR-1F promoter hypermethylation.

 Furthermore, Holocaust exposure induced intergenerational effects on FKBP5 methylation; specifically, Holocaust survivors and their adult children showed a nongenotype dependent change in methylation compared to their respective controls.

 This was the first demonstration of an association of preconception parental trauma with epigenetic alterations that is evident in both exposed parent and offspring.

Similar findings resulted from Yehuda’s work on the effects on 9/11. For example, in a post-9/11 program surveilling women who were pregnant, Yehuda and researchers collected salivary cortisol from mothers and babies.

 “What we found is that the mothers that felt PTSD, their cortisol levels were lower, but it’s also lower in babies, which was really wild,” said Yehuda. “But here’s the kicker: Both cortisol levels are lowest in the babies of mothers with PTSD who were exposed in the third trimester.”

This research suggests maternal PTSD may confer additional in utero effects, causing more anxiety for example.

 Trauma exposure during pregnancy directly affects the fetus and fetus germ cells, Yehuda shared.

How does trauma pass down? Yehuda explained that epigenetic changes could survive cell division associated with the formation of sperm and eggs; if the parent is exposed to trauma, their exposure could result in epigenetic changes that may affect their sperm or egg—meaning a single trauma could simultaneously affect multiple generations without direct exposure.

“This is inherited in our DNA,” said Yehuda. “Trauma is inherited.”

The biological remnants of parental experiences in our DNA can affect us in multiple ways, according to Yehuda. They can influence our response to stressors/challenges, make us better able to detect and respond to threats, increase vulnerability to mental health disorders, and increase our attunement to injustice. They are enduring, but not irreversible, Yehuda stressed.

1. Yehuda R, Daskalakis NP, Lehrner A, et al. 

Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring.

2. Yehuda R, Daskalakis NP, Bierer LM, et al. 

Holocaust exposure induced intergenerational effects on FKBP5 methylation.

Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy.

Can we inherit our parents’ trauma? Research points to yes. 

Trauma in Your DNA: Educator of the Year Lecture

Christopher Schneck, MD, gives a summary on his talk on bipolar disorder from the 

is the Division Head of Adult Psychiatry, the Chief of Service at CU Medicine Adult Outpatient Psychiatry, and Medical Director at the Helen and Arthur E. Johnson Depression Center Behavioral Health Director.

What is a mood disorder and what are the early warning signs? What treatments are available? 

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