“Sleep problems are understudied,” Ellen Lee, MD, told attendees at the 2021 American Psychiatric Association (APA) Annual Meeting. “They’re underdiagnosed and undertreated in people with mental illness.” Thus, Lee encouraged clinicians to screen for sleep problems, because sleep “is a modifiable and important target for intervention.” Lee, along with other colleagues, shared insights and preliminary research results on how sleep may impact mental health and psychiatric disorders.

Sleep problems affect between 30 and 80% of individuals with schizophrenia and are associated with lower quality of life and poorer cognitive and frontal lobe functioning, explained Lee, assistant professor in residence in the Department of Psychiatry at the University of California at 

 In as-yet unpublished research, Lee found that sleep apnea is associated with increased inflammation, while higher subjective reports of sleep quality are associated with lower levels of inflammation. Since inflammation is also associated with 

 treating sleep problems could also improve the symptoms of mental illnesses.

Beyond schizophrenia, sleep issues also appear in mood disorders like depression. Stephen Smagula, PhD, presented research on possible links between morning activation deficits and depression among family members caring for patients with dementia.

Older individuals with depression often report difficulty getting up and active in the 

 Morning activation deficits are sometimes thought to be immutable (some individuals are just not morning people), but in functional magnetic resonance imaging readings, dementia caregivers with depression showed higher resting-state amygdala-PCC connectivity, which is associated with stress, fear, and 

 “Although this is speculative,” Smagula cautioned, “it seems plausible that the non-morning type caregivers are doing behaviorally disengaged, emotion-focused coping. So put another way, some caregivers might wake up, feel overwhelmed, say ‘Expletive! I’m going back to bed.’”

This raises the possibility, according to Smagula, who is assistant professor of psychiatry and epidemiology at the University of Pittsburg, that “instead of treating the depression and hoping the morning activation deficit goes away, we could be targeting the morning activation deficit to treat the depression.” Clinicians could consider treatments such as activity scheduling, which would get the caregivers up and moving, increase their light exposure, decrease fragmented sleep, and limit the time they spend ruminating—all of which could improve their depressive symptoms.

Sleep also affects cognition, especially in older adults. Ruth O’Hara, PhD, presented initial data on the impacts of delta activity at sleep onset (DASO). Study participants with DASO demonstrated better affective function overall and over time, which led O’Hara to conclude that testing DASO or other variables may help clinicians predict patients’ cognitive futures. “We think that characterizing sleep dysregulation in older adults may in fact identify valuable biomarkers,” explained O’Hara, who is the Josephine Q. Berry Professor of Psychiatry and Behavioral Sciences at Stanford University. They could “help us predict cognitive decline and onset of dementia, as well as predicting affective dysfunction.”

1. Cohrs S. Sleep disturbances in patients with schizophrenia: impact and effect of antipsychotics. 

2. Keshavan MS, Montrose DM, Miewald JM, Jindal RD. Sleep correlates of cognition in early course psychotic disorders. 

3. Bromundt V, Köster M, Georgiev-Kill A, et al. Sleep-wake cycles and cognitive functioning in schizophrenia. 

4. Lee EE, Ancoli-Israel S, Eyler LT, et al. Sleep disturbances and inflammatory biomarkers in schizophrenia: focus on sex differences. 

5. Smagula SF, Capps CS, Krafty RT. Evaluating the timing of differences in activity related to depression symptoms across adulthood in the United States. 

6. Smagula SF, Karim HT, Ibrahim TS, et al. Resting-state function connectivity associated with being a "morning-type" dementia caregiver and having lower depression symptom severity. 

Articles

Sleep problems are understudied, underdiagnosed, and undertreated. 

Dreaming of New Treatments

 and traumas have the potential for long-term mental health implications, noted 

 National Institute of Mental Health (NIMH) Director, so it is no surprise that the simultaneous nationwide crises of 2020 posed significant threats to mental health. Fortunately, lessons learned from previous events and preliminary research point to a relatively positive outlook, he told attendees of the 

2021 American Psychiatric Association Annual Meeting

The past year presented a dangerous pandemic, with unprecedented morbidity and mortality numbers and mitigation strategies that resulted in isolation and economic strife. On top of that, the United States saw natural disasters and a reckoning around the systemic racial injustice that has plagued this country for years. Individually, each crisis had the possibility of a negative impact on mental health; together, they had the potential to be catastrophic.

Fortunately, lessons from previous traumas have found most individuals (90%) who are exposed to trauma improve within a year or so. However, there is a significant minority who may have long-term or chronic experiences with mental illness, Gordon explained. Specifically, studies have shown there are 

 The first group consists of individuals whose levels of symptomology following the trauma are low and remain low; they generally do not require clinical attention. The second and third groups have either immediate (within 1 to 3 months following trauma) or delayed (between 3 and 6 months post-trauma) increased symptomology, but usually recover. The final group has a sustained or chronic time course, and symptoms last beyond 6 months.

Although improvement is often due to treatment, Gordon noted other factors often predict recovery versus negative outcomes. Risk factors for long-term or chronic experiences include: few social supports, a history of trauma or mental illness, direct exposure to death or injuries, severe acute reactions to disaster, and ongoing stressors such occupational and financial strain. Having these risk factors does not equate to long-term issues, Gordon explained, but increases the risk of such. He added that having multiple factors further increases the risk of chronic symptoms.

Study after study has indicated that meeting immediate needs after a trauma helps to reduce the long-term impact, Gordon explained. For instance, after a hurricane, it is important to make sure victims have a safe place to stay and food. Similarly, treating new or worsening mental illness is very important, he said. After Hurricane Katrina, half the residents met criteria for a diagnosable DSM condition, Gordon shared, but only half received treatment and even less received evidence-based treatment. “We put people at risk when we don’t identify that they have symptoms, and don’t help them cope or get them treatment,” Gordon explained.

There is already data on the COVID-19 pandemic, Gordon reported. Building on previous traumas and risk factors, it was not a surprise that contracting COVID-19 increased the risk for long-term mental health issues. Individuals with 

, especially schizophrenia, were found at higher risk for developing trauma-related mental health issues.

 The same study found the likelihood of new onset psychiatric disorders following COVID-19 infection was 6%, which is 2 to 3 times the rate as that with the flu. The incidence of any psychiatric diagnosis within the first 3 months after infection rose to 18% when including those with previous psychiatric disorders. The majority of the new onset symptoms were mood or anxiety-related. Gordon said the NIMH is embarking on a multi-institute study to further explore these data.

Similarly, the pandemic affected individuals who did not contract the virus, Gordon added. Data from the 

Centers for Disease Control and Prevention

 indicated that most adults had some symptoms, including mood, substance use, and suicide ideation. Rates of suicidal ideation was disturbingly high among young adults, he said, with about 18% noting they seriously considered suicide in the previous 30 days, double the number than would be normally expected.

 Gordon cautioned, however, that this data is a result of self-reports of mental illness, not diagnosed illnesses. Still, he said he would not be surprised if future studies found an increased rate of psychiatric diagnoses during the pandemic.

Yet, the picture is not all bleak, Gordon said. He referred to unpublished data from the 

, which consists of a number of managed care organizations, that looked at electronic health records. In each system, the number of visits for self-harm diagnosis (including self-injurious behavior and suicide attempt) remained steady over time, even through the pandemic.

The pandemic also illuminated the inequities of health care in the United States, with certain minorities at increased risk of adverse events associated with COVID-19, Gordon said. Of great concern was the shift to telehealth in the early days of the pandemic, and the possibility of telehealth exacerbating access to care issues for vulnerable populations. 

The Mental Health Research Network looked at the number of mental health visits in person, via phone, and via video both before and during the pandemic, and the data revealed some promising news. The numbers of visits among White non-Hispanic patients, African-American patients, and Hispanic patients were similar, with a huge drop in in-person visits at the beginning of the pandemic, when a slow upward shift was found for voice and video visits, Gordon reported. Although there were fewer visits during the pandemic, the rates were similar among all groups. Gordon said more research is needed across wider swaths of populations to confirm these findings, but he believes the increased popularity and availability of smartphones helped forestall access issues.

Unfortunately, Gordon noted not all the news was good: There was a dramatic increase in suicide rates among Black youth. Blacks have been relatively protected against suicide when compared with Whites in the United States, he noted, although it is not quite certain why. For some reason, he added, that is changing in Black youth, especially males, and that is troubling.

Gordon added that the NIMH is addressing the growing awareness of broad systemic racism on 2 fronts: an increase in diversity in the workforce and an increase focus in disparity research. For instance, Gordon discussed the April 21, 2020, webinar cohosted with SAMHSA, “

Responding to the Alarm Addressing Black Youth Suicide

On a broader scale, the NIMH has taken the lead with a number of NIH organizations to further explore, measure, and address the social and economic impacts of COVID-19 on mental health, especially among vulnerable populations (eg, older adults, frontline workers, racial and ethnic minorities, etc). To date, the NIMH and working group members have funded 28 longitudinal studies, 15 digital health studies, and 9 community health studies looking at substance use and other mental health outcomes as well as public health mitigation impact and adherence. Gordon expects the information learned from these studies will not only help address issues from the pandemic, but also inform future disaster response.

In terms of the pandemic, there are still many uncertainties, which continues the risk of new and exacerbated mental health issues, Gordon warned. “We don’t know when it will end, there is increased exposure to morbidity and mortality (at this point we all know someone who has had COVID-19), there is continued social economic vulnerability, and preexisting mental health problems,” all of which are risk factors for poor outcomes, he explained.

Still, research shows there are ways to foster resiliency and prevent negative outcomes, and Gordon encouraged attendees to focus on those endeavors. Psychiatrists can help patients focus on the hope for the future and remind patients they have some control over their situations. They can encourage patients to find ways to meet their immediate needs. And, they can inspire healthy coping habits.

1. deRoon-Cassini TA, Mancini AD, Rusch MD, Bonanno GA. 

Psychopathology and resilience following traumatic injury: a latent growth mixture model analysis.

2. Taquet M, Luciano S, Geddes JR, Harrison PJ. 

Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA

3. Czeisler MÉ , Lane RI, Petrosky E, et al. 

Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020

Joshua A. Gordon, MD, PhD, National Institute of Mental Health Director, leverages lessons from past natural disasters and traumas to foster resiliency and inform future research endeavors.

Amidst Multiple Crises, NIMH Pursues Research to Improve Outcomes

“Globally, as of the 25th of April, there have been close to 150 million cases and over 3 million deaths,” 

2021 Annual Meeting of the American Psychiatric Association

 (APA). “In the United States, we now have over 32 million cases, and about 570,000 deaths, making this unquestionably the worst pandemic of infectious disease that the planet has experienced in over 100 years since the 

Fauci, who became the face of COVID-19 in the United States, providing a voice of reason and information from the onset of the pandemic, was invited to deliver the William C. Menninger Memorial Lecture. In introducing Fauci, APA President Jeffrey Geller, MD, MPH, commended Fauci for his “communication of science, the courage in the face of adversity, and the energy he brings to his work,” adding that this commitment “should inspire all of us.”

In his talk, “Lessons Learned and Remaining Challenges,” Fauci succinctly reviewed the epidemiology, clinical course, therapeutics, and vaccines associated with COVID-19, providing attendees with a clear picture of where we have been, where we are, and where we need to go.

Fauci acknowledged the progress we have made in the fight against the pandemic. However, he warned, “Even though we are now below the late fall extraordinary peak [of cases] that we saw that went into the early winter of January and early February [of more than 200,000 new cases per day], we are now stuck on plateau that is precarious, at around 60,000 new infections a day.”

The looming variants have become a particular concern. Currently, the B.1.1.7, originally found in the United Kingdom, has become the predominant variant in the United States, he said. Fortunately, the vaccines seem to do well against this variant, he added. Other variants include B.1.351, originally found in South Africa and problematic on multiple fronts; P.1, originally found in Brazil; B.1.427/B.1.429, originally found in California; and B.1.526 originally found in New York.

The unusual aspect of the virus is that at least a third, and as much as 40%, of the individuals who are infected never have symptoms, yet the virus has been deadly in so many individuals, Fauci noted. Because of this, about 35% of all transmissions were from presymptomatic individuals and 24% from those who never developed symptoms. This, he said, added to the complication of controlling the spread of the virus.

Currently, there are 3 types of test for SARS-CoV-2: molecular tests that detect genetic material from virus; antigen tests that detect proteins from the virus; and antibody tests that detect proteins in the blood made in response to the virus. Symptoms and affects include 

 (eg, bilateral cerebral infarcts), hyperinflammation, acute respiratory distress syndrome, cardiac function, hypercoagulability, acute kidney injury, and multisystem inflammatory syndrome in children.

In addition to the acute infection, there is a syndrome called “

” or “post-acute sequela of COVID,” which appears to affect between 10% and 30% of individuals, Fauci noted.

 In these cases, patients report persistent symptoms for as long as 9 months following acute illness, with fatigue being most common. Myalgias, temperature disruption, sleep disorders, and cognitive difficulties nicknamed “brain fog” have also been noted.

The pandemic’s effects, especially on mental health, have not been limited to patients infected with the virus. Fauci pointed to a new study of 5470 US adults that found 41% reported 

trauma or stressor-related disorder symptoms

 (26%), substance use issues (13%), and suicide ideation (11%) were most common among respondents.

Another concern, according to Fauci, is the continued 

, despite studies noting high safety and efficacy data worldwide, even against the more troublesome variants. “There are a number of reasons why people don’t want to take the vaccine, and we just have to address each of them,” he added.

, the top reason for not getting the vaccine was that it was too new/not enough information/unsure about long-term effects (17%).

 Other concerns included: don’t believe it is effective (8%), don’t need it (8%), concern over ingredients (8%), concern over side effects (7%), lack of trust of vaccines in general (6%), among others. As a result, there was a concerted effort to have well-known officials receive their vaccines in a public way, including leaders like Fauci, President Joe Biden, Vice President Kamala Harris, and Reverend Jesse Jackson. There also have been outreach programs to the Navajo Nation, and the US Department of Health and Human Services launched a National Network of Trusted Voices.

There have been “considerable challenges,” Fauci concluded, “but we are doing extraordinarily well. And we hope the next few weeks we see a dramatic remediation in the number of cases.”

1. Logue JK, Franko NM, McCulloch DJ et al. 

Sequelae in adults at 6 months after COVID-19 infection

2. Czeisler MÉ, Lane RI, Wiley JF, et al. 

Follow-up survey of US adult reports of mental health, substance use, and suicidal ideation during the COVID-19 pandemic, September 2020

3. Hamel L, Lopes L, Kearney A, Brodie M. 

. KFF. March 30, 2021. Accessed May 3, 2021. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-march-2021/

In his William C. Menninger Memorial Lecture, Anthony S. Fauci, MD, shared lessons learned and remaining challenges for the COVID-19 pandemic, especially in terms of mental health and behavioral issues. 

Fauci Addresses Attendees at APA Annual Meeting

There is universal confusion around excited delirium syndrome (ExDS): What is it and how should it be treated? The short answer is we do not know the answers, and there are no comprehensive treatment guidelines or formal criteria, according to a panel presenting at the 2021 

American Psychiatric Association (APA) Annual Meeting

Representing the fields ofemergency medicine, psychiatry, psychology, and emergency medical service (EMS), the expert panel consisted of Leslie Zun, MD, MBA; Thom Dunn, PhD; Julie Owen, MD, MBA; and Sarah E. Slocum, MD.

Events in the recent past bring to light the importance of clarifying the differential diagnosis, signs and symptoms, and universal treatment protocols of ExDS, which to date remain unclear.

 dying at the hands of a police officer. In 2019, Elijah McClain, a 23-year-old massage therapist, was placed in a chokehold by law enforcement and sedated by EMS with 500 mg of ketamine, a tactic that is legal in Colorado to control ExDS. By the time he arrived at the hospital, he was brain dead; he died 3 days later.

, but one thing is clear. These and countless other incidents in the public eye have brought to the forefront use of force by police and in emergency settings.

Dunn, a psychologist who is also experienced in EMS, shared a stark example of excited delirium in a hospital setting where an adult male Black patient demonstrated signs of the condition. The presence of police seemed to intensify the patient’s agitation: He sweat profusely, stripped naked, shouted incomprehensibly, and flailed his arms. After multiple attempts to restrain him; police tased him. Emergency staff then administered ketamine; he subsequently died.

 on the matter, stating: “DSM-5 recognizes Delirium, hyperactive type, but the symptoms of this condition differ in many ways from the symptoms typically attributed to excited delirium (eg, superhuman strength, impervious to pain, etc.).”

They further noted that ExDS itself “is too non-specific to meaningfully describe and convey information about a person.” They concluded that 

 should not be used until a clear set of diagnostic criteria are validated.”

The panel concurred: The American Medical Association, the APA, the National Association of Medical Examiners, and the 

s still diverge in their recognition of ExDS.

With all this confusion, the panelist concluded with Slocum’s call for action: “We really need to address this condition as a group and figure out what’s going to be best for that patient.”

1. Council on Psychiatry and the Law. Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts. American Psychiatric Association. December 2020. Accessed May 13, 2021. 

https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf

2. ACEP Excited Delirium Task Force: White Paper Report on Excited Delirium Syndrome. American College of Emergency Physicians. September 10, 2009. Accessed May 13, 2021. 

https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/ems-and-disaster-preparedness/ems-resources/acep-excited-delirium-white-paper-final-form.pdf

What is excited delirium syndrome and how should it be treated? The short answer is we do not know.

Agree to Disagree: Excited Delirium Syndrome as Volatile as the Term Itself

“You’re not simply a queer person; you are a multitude of selves, all trying to find a home that would you feel safe, secure, and that you will learn in and become the best psychiatrist that you can be,” said Marshall Forstein, MD, at the 2021 American Psychiatric Association Virtual Annual Meeting.

Forstein, who is an associate professor of psychiatry at Harvard Medical School, and Vice Chair for Education and Program Director of Adult Psychiatry Residency at Cambridge Health Alliance, led the session, “LGBTQ+ Medical Students and Applying to Psychiatry Residency.” He was joined by 4 students: Terrance W. Embry, MS; Allison Rhodes; Teddy G. Goetz, MS; and Matthew Abrams, all of whom discussed how to select and vet psychiatry residency programs as members of the LGBTQ+ community.

Their top tip? Finding a supportive environment that not just tolerated their identity, but celebrated it.

“It’s important that, across the US, no matter where you are, even if it’s a conservative area, that residency programs are actively thinking about how to support their students,” said Abrams.

“I thought that I needed to hide my identity in order to have professional advancement,” admitted Embry, in reference to applying to medical school. His policy has changed: He sought residencies that went beyond tolerating him.

Other tips and questions to keep in mind when applying for residency include:

-Find a program that openly shares their LGBTQ+ support. Do they ask for pronouns? Do they have an LGBTQ+ curriculum? Do they share their support on social media? Are there LGBTQ+ staff that serve as mentors?
-Make sure the program supports diversity of all kinds. If a program seems discriminatory to one group, what prevents them from discriminating against others?

-Find a location in which you feel safe. Is the community at large welcoming? Would you feel comfortable in that location of the United States?

-After interviews, film a 1-minute reaction clip. This will help remind you of your own excitement, neutrality, or disappointment about the experience.

-Coordinate health insurance. If a program’s health insurance does not cover LGBTQ+ needs, it might not be a good fit.

-Talk to previous or current residents, specifically LGBTQ+ residents. Have they experienced microaggressions in the program? Were they outed by staff, or called by the incorrect name?

Forstein also shared that he did not believe coming out is a necessary step in advancing a career in psychiatry.

“It’s about your authenticity with wherever you are on that continuum of coming out,” Forstein said, “which is a lifelong process.”

The panel expressed their hope that their own experiences and tips can help other members of the LGBTQ+ community find their homes in psychiatry.

Finding a program that is a good fit while LGBTQ+ may be more difficult than it seems…

Multitude of Selves: Applying to Residencies as an LGBTQ+ Medical Student

“The issues discussed today are really just the tip of the iceberg for women in academic psychiatry. There are a multitude of them: salary differences, harassment, parental leave policies, microaggressions, lack of mentorship, and these are just some of the challenges that young, female faculty face,” Marcia Unger, MD, MPH, a child psychiatrist at the University of California, Davis, said during a presentation at the 2021 Virtual American Psychiatric Association Annual Meeting.

In the presentation, “Triple Threat: Young, Female, Professional—the Experiences of Young Female Psychiatrists and Psychologists in Academic Medicine,” Unger and her colleagues shared some startling data: According to 2018-2019 data report, 17% of female faculty in academic psychiatry have experienced an instance of disrespect based on their gender, compared to only 1% of men.

Furthermore, according to their research, women were more likely to experience: diminished responsibility, decreased patient and provider trust, inappropriate verbal exchanges, and be asked to perform nonmedical tasks.

The panel covered 2 additional challenges based in gender discrimination against women in academic psychiatry: Impostor syndrome and motherhood. 

Imposter syndrome, a psychological phenomenon wherein people doubt their abilities and fear being exposed as a “fraud,” has a higher severity in female faculty. A 2016 report recorded 50% of female students were affected by impostor syndrome, compared to only 25% of their male counterparts.

“Men tend to own success, while women will state they were lucky,” said Anu Gupta, MD, a child psychiatrist at University of California, Davis.

A suggested solution for this issue lies in mentorship: female leaders or administrators overseeing and guiding younger women. Unfortunately, only 23% of psychiatry chairs are women, and only 6% of those chairs are Black, Indigenous, and people of color.

Academic psychiatry further fails women when it comes to motherhood and parenting. Institutional failure to support work-life integration can be a significant barrier to career advancement, according to Meera Ullal, PhD, a clinical psychologist at the University of California, Davis. 

“What’s interesting about pregnancy is that it’s kind of nonvolitional. We don’t get to decide whether to keep this from our patients or not—they will find out,” said Ullal on the difficulties of navigating work while pregnant.

Ullal stressed the need to eradicate the notion of parental leave as “vacation” and the importance of comprehensive maternity leave, as well as childcare policies. Parenthood should not be seen as an abandonment of work.

The panel closed with a plea to abolish the following myth of females in the academic workforce: “We cannot rely on the surge of women entering psychiatry to lessen this gap.”

“This idea that women work part-time or women don’t want to work full-time because of family obligations is simply not true,” Unger said with a shake of her head.

1. Association of American Medical Colleges. 2018-2019 The state of women in academic medicine: Exploring pathways to equity. 

https://www.aamc.org/data-reports/data/2018-2019-state-women-academic-medicine-exploring-pathways-equity

2. Borlik MF, Godoy SM, Wadell PM, et al. Women in academic psychiatry: Inequities, barriers, and promising solutions. 

Young, professional women in academic psychiatry are facing down the iceberg: gender discrimination. 

The Tip of the Iceberg for Women in Academic Psychiatry

Psychiatry may be lagging behind other branches of medicine in an important way.

“In the rest of medicine, as you increase the acuity you increase the number of treatments,” Nolan Williams, MD, told the attendees of the 2021 American Psychiatric Association (APA) Annual Meeting, but in psychiatry, “as we increase acuity we actually lose treatment options.”

Williams and his fellow presenters at a panel on rapidly acting medications

 all had the same question: How can psychiatrists design treatments to respond to sudden-onset conditions?

Williams, assistant professor of psychiatry and behavioral sciences at Stanford University Medical Center, described the situation as “emergency room purgatory.” Because of slow-acting treatments and limited hospital capacity, “the whole process of going through the inpatient unit can take several months,” he said. “The only treatment that we have available for these folks is ECT [electroconvulsive therapy.” But ECT is available in only 10% of US hospitals.

However, psychiatrists might have other options for fast-acting treatments. He shared 

showing that accelerated theta burst repetitive transcranial magnetic stimulation (r-TMS) had positive results for mood disorders, including MDD.

 R-TMS treatment works by stimulating the left dorsolateral prefrontal cortex (DLPFC). In MDD, the DLPFC may be failing to inhibit the subgenual cingulate, and the result of this network failure is cognitive impairment and inwardly directed negative thoughts,” Nolan explained. “By stimulating DLPFC, r-TMS corrects the mood imbalance and restores mood regulation.”

In initial numbers from his study of patients with a treatment-resistant mood disorder (TRD), Nolan found that after 5 days of sessions (10 hourly sessions at 1800 theta-burst pulses per hour), participants improved. On the Montgomery Asberg Depression Rating Scale (MADRS), he found an 80% average reduction of participants MADRS scores.

Another options for fast-acting treatment is ketamine. Charles DeBattista, MD, professor of psychiatry and behavioral sciences at Stanford University, presented evidence for its efficacy for TRD. He noted that ketamine is an anesthetic agent, a μ-opioid agonist, and while its effects on TRD are rapid, making it potentially helpful in psychiatric emergencies. “Often within a couple of hours to a day, patients experience a significant improvement, and the effects were sustained for a week or so,” he said. These effects did decrease after a week, but there is also evidence that repeated injections may lead to 

DeBattista also presented the option of esketamine, which has been fast tracked by the US Food and Drug Administration for treating TRD and acute suicidality in MDD. Multiple studies have found that it rapidly 

New mothers represent another population that might benefit from fast-acting medications. “Maternal mental health is something that’s been an enormous problem forever,” said Samantha Meltzer-Brody, MD, MPH. “Those of us that have the privilege of working with perinatal women are always struck by how debilitating PPD [postpartum depression] can be.” Rapidly acting medications could reduce mortality and morbidity, she said, and allow for more positive interactions between mothers and their newborns.

Although many selective serotonin reuptake inhibitors are approved to treat PPD, she pointed out that their initial effects may not be felt for weeks or even months, and many women’s symptoms do not respond to them. Meltzer-Brody, the Assad Meymandi Distinguished Professor and Chair in the University of North Carolina Department of Psychiatry, also considers an alternative to these medications: neurosteroids like brexanolone.

In a 2018 paper, Meltzer-Brody and her coauthors found brexanolone to be effective for

 Using the HDRS for measurement, the researchers found an average 8- to 10-point reduction in 12 hours, and around an 18-point reduction at 60 hours, the study’s primary endpoint. At day 30, participants average reduction remained, on average, 16 points down from baseline. The paper hypothesized that brexanolone works by increasing γ-aminobutyric acid (GABA) function, which appears to be inhibited during PPD.

With these new options, it seems psychiatry may not lag behind other branches of medicine for long. 

1. Williams N. Developing rapidly acting antidepressants: neurosteroids, dissociative agents (Ketamine Analogues and Psilocybin), and Accelerated Theta Burst r-TMS. Paper presented at: American Psychiatric Association Annual Meeting; May 1-3, 2021; virtual.

2. Nettekoven C, Volz LJ, Kutscha M, et al. Dose-dependent effects of theta burst rTMS on cortical excitability and resting-state connectivity of the human motor system. 

3. Li CT, Chen MH, Juan CH, et al. Efficacy of prefrontal theta-burst stimulation in refractory depression: a randomized sham-controlled study. 

4. Yip AG, George MS, Tendler A, et al. 61% of unmedicated treatment resistant depression patients who did not respond to acute TMS treatment responded after four weeks of twice weekly deep TMS in the Brainsway pivotal trial. 

5. Murrough JW, Perez AM, Pillemer S, et al. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. 

6. Canuso CM, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: results of a double-blind, randomized, placebo-controlled study. 

7. Fu DJ, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). 

8. Meltzer-Brody S, Colquhoun H, Riesenberg R, et al. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. 

What treatments could handle both psychiatric emergencies and long-standings mental health conditions—in a hurry?  

Fast-Acting Options for Mood Disorders and Psychiatric Emergencies

Too often, the medical issues associated with traumatic brain injury are mistaken as psychiatric disorders, and patients are referred to psychiatrists for treatment, Gregory J. O’Shanick, MD, DLFAPA, told attendees of the 2021 

American Psychiatric Association Virtual Annual Meeting

O’Shanick, who is the medical director of the 

in Richmond, Virginia, urged psychiatrists to leverage their medical knowledge when assessing patients to determine when the diagnosis is a psychiatric disorder and when patients are presenting with medical mimics associated with traumatic brain injury (TBI). He shared his frustration with psychiatry’s loss of medical identity, especially as it related to brain injury medicine. In his 40-year career, he found “all too often, physicians, both MDs and DOs, psychiatrists, [were] missing basic neurologic issues that we as physicians should catch. If we are to be vocal regarding the necessity of having a MD and DO to ultimately provide oversight of care for those with behavioral disorders and writing prescriptions for psychotropic medications, we must not relinquish the use of those tools and skills that were taught to us in medical school.”

The prevalence of TBI has increased over the last 10 or so years, O’Shanick explained, although he acknowledged that the increase may be partially due to increased awareness. According to 

 from the Centers for Disease Control and Prevention, there was a 53% increase from 2006 to 2014 in TBI-related emergency department visits, hospitalizations, and deaths. In older adults and the very young, falls account for the number 1 cause of TBI.

 A combination of motor vehicle accidents, sports, falls, and other activities were the cause for the “very active” and maybe not as cautious young adult population (aged 15 years to 24 years).

Meanwhile, research has found a link between psychiatric disorders and TBI, O’Shanick noted, with an increase of disorders following TBI.

 Jennie Ponsford, PhD, and colleagues explored this phenomenon and found that only about 23% and 21% of individuals had a pre-TBI history of a mood disorder or anxiety disorder, respectively. They found an increase in psychiatric symptomology within the first year after TBI, with a stabilization at the 5-year point. Mood and anxiety symptoms were most common in patients with TBI, with 17.2% to 62% presenting with mood symptoms and 10.3% to 34.2% with anxiety symptoms. Interestingly, he noted depression is 4 to 6 times more common in patients with TBI than the general population, and is the most common cause of depression in men (as opposed to women, for whom menopause is the number one cause).

It is possible, he explained, that some of these mood disturbances and anxiety symptoms may be better explained as a medical consequence of TBI—or a signal of homeostatic disruption. In such cases, providing psychopharmacological treatment might help the patient with the symptoms, but will not address the underlying cause.

O’Shanick provided an example of a phobia being misattributed. He pointed to an individual who is afraid of a jumping off a diving board. They go up the stairs, walk to the edge, realize they are frightened, and go back down. They have conditioned themselves to be afraid—there is a learned component.

Next, he presented the case of an individual who has unrecognized balance and visual issues as a result of TBI. The person goes into a crowd and feels a sense of anxiety, because they have trouble feeling and remaining stable, and the learned component may be inappropriately linked to an anxiety disorder.

“As a physician, we need to figure that out,” O’Shanick emphasized.

Fortunately, a toolkit to help decipher these TBI-related medical mimics is relatively inexpensive, O’Shanick shared. All you need is a pen, index card, blindfold (or ask your patient to close their eyes), a sofa cushion, a tuning fork (which can be procured online for about $6), and a few questions. For example, to determine if the issue is 

 or a vestibular in nature, ask your patient if they need to touch the wall when closing their eyes in the shower to prevent falling. Or, if they feel anxious in a crowded area like a store or mall, does pushing a cart or stroller or holding on to someone make them feel better? If so, there are a few simple follow-up tests (eg, the Balance Error Scoring System and Fukuda Stepping Test) to help confirm the medical mimic. A referral for vestibular physical therapy and a neuro-ENT may prove useful for such patients.

Similarly, to determine if there is social phobia or vergence, ask your patient if they are having trouble seeing/reading books at a normal distance. Then, check near point convergence and conduct a cover test. A referral to a neuro-optometrist should be considered.

Sometimes a central auditory processing disorder may be confused with 

. It is especially important to decipher the difference, O’Shanick explained, because stimulants will worsen the central auditory processing disorder. Ask your patient if they have better sustained attention for visual vs verbal interactions, or if they have trouble understanding what people say if they cannot see their faces or mouths. Weber and Rinne tests can also prove useful, and a referral to an audiologist is indicated.

, posttraumatic neuroendocrine (PTNE) disorders may be relatively common in patients with TBI,

 and mood symptoms are associated with PTNE, O’Shanick explained. Psychiatrists should inquire about changes in menses, sex drive, cold intolerance, and skin and hair dryness to elucidate if PTNE is a potential cause of the mood symptoms. Lab studies should be considered, including 

, TSH, FSH, LH, IG-1, estradiol/testosterone, and am/pm cortisol. In considering TBI in these cases, O’Shanick reminded attendees that they should not overlook 

Finally, O’Shanick illuminated inherent biases in the Minnesota Multiphasic Personality Inventory-2, which might lead to an incorrect diagnosis. For instance, stomach trouble and headaches score positively on the hypochondriasis scale, but both may be related to TBI and TBI treatments. Similarly, positive scores on the hysteria scale result from noting they are unable to work, feel sad, and have trouble sleeping, all of which are associated with TBI.

Ultimately, the psychiatrist is the ideal position to leverage their medical and behavioral knowledge to support these patients.

“Hopefully this will allow you to think a little bit differently when patients come into your office,” O’Shannick concluded. “Maybe ask some increased questions when it comes to injury related issues, concussion related issues… and to see if there is some other types of medical issues behind some of the anxieties that your patients have. At the end, you may just find that you’re practicing … much more successfully and ultimately helping your patients.”

1. CDC. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths. 2014. Accessed May 2, 2021. 

https://www.cdc.gov/traumaticbraininjury/pdf/TBI-Surveillance-Report-FINAL_508.pdf

2. Ponsford J, Always Y, Gould KR. Epidemiology and natural history of psychiatric disorders after TBI. 

3. Beyer C, Zaytsev J, Donegan D, et al. 

The effects of traumatic brain injury on pituitary function: a systematic review and meta-analysis

Too often, the medical issues associated with traumatic brain injury are mistakenly diagnosed as psychiatric disorders. A few simple questions and tests can elucidate the real culprit and lead to appropriate treatment.

Is It a Psychiatric Disorder or TBI Medical Mimic?

“There simply aren’t enough of us,” said Lori Raney, MD, in a scientific session, titled “

Unprecedented Access to Psychiatry: Expand Your Impact to Infinity and Beyond! Collaborative Care, eConsults, and ECHO Models

. The session addressed the vast shortage of psychiatrists and proposed alternative models of care to improve outcomes for more patients.

Speakers discussed the ever-widening gap between the shortage of psychiatrists and the overflowing flood of patients needing care. Shannon Kinnan, MD, a member of the APA Integrated Care Committee, spoke about the gravity of the problem of access to psychiatry. “The severity and the incidence of psychiatric illness continues to climb, which has only been magnified by the pandemic,” said Kinnan, assistant professor at Creighton University School of Medicine, Omaha, Nebraska. She worked in psychiatric services that had a wait list of 350 patients.

Moderated by Ron M. Winchel, MD, assistant clinical professor at Columbia University School of Medicine, Department of Psychiatry, presentations centered around 4 main themes: collaborative/integrated care, psychiatric consults, ECHO models, and eConsults.

Collaborative care, also known as integrated care, is ever evolving, informed by decades of research conducted by the APA, Academy of Psychosomatic Medicine, and other organizations. Kinnan directed participants to APA’s 

 to explore current evidence-base for the model, elements of implementation with detailed examples, lessons learned by those in the trenches, as well as recommendations on how to advance the use of the collaborative care model.

According to Kinnan, the collaborative care model is made up of a patient-centered team that targets the special needs of each patient, looks for solutions, and lays out piece by piece ways to educate primary care physicians (PCP). One core feature of the collaborative model includes encouraging PCPs to use measurement-based care with tools such as Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7).

“The patient’s main points of contact are their PCP and a care manager,” she explained. “The psychiatric consultant then reviews cases in a registry with a care manager and offer guidance to the team on the case.”

The integrated psychiatry model attends to the needs of patients with team-based care and systematic regular caseload reviews, which involves psychiatrists, case managers, PCPs, social workers, and other health care providers. It enables delivery of services to patients at most dire need of psychiatric services.

“It is better than traditional care in the primary care setting,” Kinnan told attendees. “Patients get better, faster. And there’s cost savings as well.”

Collaborative care guides care across disciplines, including psychology, psychiatry, and primary care. The goal is to change practice, build community, and identify health professionals needing the most assistance.

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