“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.

Articles

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

American Psychiatric Association (APA) Annual Meeting

. 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.”

A consult enables those involved in behavioral health to manage multiple cases and communicate with different allied health professionals, with the goal of extending psychiatric services.

According to Lori Raney, MD, a practicing psychiatrist in Colorado and principal consultant with Health Management Associates, curbside consultation educates PCPs about diagnostic dilemmas and medications, helping them with complex patients.

A consult is an opportunity for psychiatrists to educate and collaborate with the general practitioner, especially important since medical training often involves only 2 weeks of psychiatric training. The consult enables the PCP to understand specific needs of patients and provides diagnostic clarification.

“There are definite approaches you can take,” Raney told attendees. “You want to build the PCP’s confidence in prescribing psychotropic medications and diagnosing behavioral health conditions.”

Psychiatrists can get calls for consults on a variety of issues, Raney explained. “The most prevalent, most common behavioral health conditions we are getting called about often involve anxiety disorders, depression, and substance use disorders . . . And then you’ll see other things, patients with multiple somatic symptom personality disorder traits and pain that play out in the clinic,” said Raney.

Another item on the menu of integrated behavioral health is the electronic mental health consultation (eConsult).

Christopher T. Benetez, MD, associate medical director of the Los Angeles County Department of Mental Health and assistant clinical professor at UCLA David Geffen School of Medicine, has conducted more than 5000 eConsults in the LA County project over the past 5 years.

“An eConsult is an asynchronous consultative, provider-to-provider communication within a shared electronic health record [EHR] or web-based program,” Benetez explained.

The eConsult approach enables PCPs to have remote access to psychiatrists, entering questions into an EHR for quicker response than the bottleneck often found in traditional models of care.

As the second largest health system, LA County occupies more than 4000 square miles with 10.5 million residents, and it is both rural and urban. Psychiatrists are also involved in an array of community partnerships, jails, and courts.

The eConsult in LA County and other community health hubs are intended for the Safety Net population, defined by the Institute of Medicine (IOM) as “those providers that organize and deliver a significant level of health care and other needed services to uninsured, Medicaid and other vulnerable patients.”1

The eConsult system has optimized health equity by filtering psychiatric expertise to geographically challenged regions and a greater number of residents. “Our Safety Net takes care of over half a million patients a year with > 400 distinct sites; 4000 submitters; 500 specialty reviewers; and > 65 specialty portals,” said Benetez.

The advantages of the system set in place is centralized and coordinated systems and greater access to routine care, as well as patient-centered care and patient education. Limitations include measuring data, reimbursement, and concerns over liability.

Another way to improve access to psychiatric expertise has been through a learning community. Mark Duncan, MD, spoke about one alternative model at the University of Washington (UW).

Duncan is assistant professor at the Department of Psychiatry and director, UW Psychiatry and Addictions Case Conference (UW PACC), a 

 initiative. ECHO stands for Extension for Community Healthcare Outcomes.

 is made up of a didactic and case presentations. “The goal is to increase patient access across the state to effective and evidence based psychiatric, psychological, and addiction care through increasing the knowledge and self-efficacy of all interested health providers within an intentionally supportive virtual community,” said Duncan.

Using a collaborative/educational model, UW PACC is in a position to help guide care across disciplines, including psychology, psychiatry, and primary care. The net result has been to help change practice, build community, and identify providers needing the most assistance.

“It’s a great service because we’re interacting with the provider and asking for quick follow-up questions across many other specialties, so we can get a well-rounded summary of recommendations for people.”

America’s Health Care Safety Net: Intact But Endangered.

 Washington, DC: National Academy Press; 2000.

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.

Serving the Needs of the Many: Identifying Strategies for Better Care

“The current opioid crisis has been responsible for the largest increase in deaths associate with opioids that we have ever known,” said Nora D. Volkow, MD, at the 2021 Virtual American Psychiatric Association Annual Meeting.

Volkow, Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, discussed how the pandemic has exacerbated the opioid crisis in the session, “

Collision of the Opioid Crisis and the COVID-19 Pandemic.”

In March 2020 during the outset of the pandemic, the number of people reporting drug use rose significantly.

 The top 4 drugs were nonprescribed fentanyl, cocaine, heroin, and methamphetamine. Overdoses increased up to 42% per month during the pandemic.

 If an individual had SUD and were infected with SARS-CoV-2, the likelihood of dying increased, especially for black men.

As the amount of drug use increased, so did the problems. The pandemic presented a number of key challenges for individuals with substance use disorder (SUD), Volkow noted, including: stigma, isolation, and loss of work/homes. These challenges prevented individuals with SUD from getting proper care, or worsened their condition. Volkow gave an overview of these issues and their impacts.

“We know that people with opioid use disorder… are terribly stigmatized,” Volkow stated. “It’s very hard sometimes to convince people with an opioid use disorder to go to a hospital because they don’t like to be discriminated against or mistreated.”

Stigma and the belief they will not receive thoughtful care already kept some individuals with SUD from checking into a hospital; the pandemic worsened this likelihood. Both hospitals and prisons became hotbeds for the SARS-CoV-2 virus, places often with higher concentrations of individuals with SUD.

“In order to reverse an overdose, someone has to give them naloxone,” Volkow said. “But if you are isolated, and start shooting by yourself, the likelihood of getting naloxone is much less likely.”

According to Volkow, reports from the community suggest an increased number of overdose deaths in homes where the individual was alone.

“Economic challenges are some of the stress source that leads people to take more drugs to try to cope,” Volkow relayed.

Homelessness was also associated with an increased likelihood of contracting the SARS-CoV-2 virus, due to social distancing problems.

Volkow wants to increase research on topics like telemedicine and changes in the justice system, and how they can be furthered post-pandemic. Expanding access to treatment of comorbid conditions via telemedicine, and releasing nonviolent inmates with SUD, are just a few ideas she has.

Volkow posed the following question for the audience to ponder: “What is the structure we need to provide for these individuals to be successful in adjusting to their community and not be at risk for relapse?”

1. Millennium Health. Signals report COVID-19 special edition. July 8, 2020. 

https://www.millenniumhealth.com/news/signalsreportcovid/

2. Overdose Detection Mapping Application Program. 

3. Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. 

According to Nora D. Volkow, MD, Director of the National Institute on Drug Abuse, drug use and overdose deaths have significantly increased since the outset of the pandemic. What made it worse?  

A Tale of Two Crises: Fighting the Overdose Problem During the Pandemic 

“Ethical dilemmas arise when there are multiple ethical responsibilities that stand in tension with each other,” Charles Dike, FRCPsych, MBChB, MPH, told the attendees of the American Psychiatric Association (APA) Annual Meeting.

At a panel on “Ethical Dilemmas in Psychiatric Practice,” one dilemma stood out: the possible conflict between psychiatrists’ duties to their individual patients and their duties to promote the good of the public as a whole.

This conflict has become particularly pressing this past year due to the global pandemic, and the panelists considered the problem from several angles as they answered previously submitted questions.

One question concerned confidentiality: What should be done when a patient reports her parents are sending another child to school despite the child’s positive SARS-COV-2 virus results?

Daniel J. Anzia, MD, a member of the expert panel, explained “the participation in public health endeavors is a long-standing, recognized potential exception to the obligations of psychiatrists, and all physicians, maintaining confidentiality.” Past department chair for psychiatry at Advocate Lutheran General Hospital in Park Ridge, Illinois, Anzia said ideally the patient (who was no longer a minor) would make the report to the school, and then inform the family that public health officials might be contacting them. But, he added, if the patient refused, “it is permissible for the psychiatrist to make such a report.”

Another question asked what psychiatrists should do if patients insisted on being seen in person, even at the height of the pandemic. Panel member, Tia Patricia Powell, MD, Director of the 

, told attendees they are not required to put themselves at physical risk. “Among our many obligations as psychiatrists is to provide a safe space in which we can offer therapy for our patients. That includes keeping the patient and psychiatrist safe from each other in terms of communicating the virus,” she explained.

Powell noted that many psychiatrists have extended their own knowledge of telehealth, discharging their obligation to offer care in person by working with patients to make telehealth possible. If the patient refuses telehealth, protective gear, and vaccination, “it could be legitimate for a psychiatrist to say, ‘I’m not at this time able to continue working with you.’”

Along the lines of vaccinations, are psychiatrists obligated to get an available vaccine for SARS-COV-2? Although “a psychiatrist has a right to refuse the vaccine, the psychiatrist should consider their wider obligations of such a decision, including an unspoken statement—to the psychiatrist’s colleagues and patients—that the psychiatrist does not trust the vaccine,” said Dike, associate professor of psychiatry at Yale School of Medicine and associate program director of its 

. “This could discourage vulnerable patients from taking what could be a life-saving intervention.”

What are the obligations of a psychiatrist to a new patient who has yet to be seen? The panel was presented with a situation in which a patient fills in a reports suicidal thoughts on a new pre-visit questionnaire, and then does not come to the appointment or answer calls. Should the psychiatrist send someone to check on the patient?

Panelist Rebecca Brendel, MD, JD, detected a potential conflict between the psychiatrist’s duty to the individual patient and the public at large. “We’d hate to say we’re not going to screen patients for suicidality because it’s too hard to figure out what to do with the information,” said Brendel, assistant professor of psychiatry at Harvard Medical School and director of its Master in Bioethics program. However, she noted the need for a follow-up mechanism that does not overstep the bounds of a nascent doctor-patient relationship by violating the prospective patient’s rights to privacy and confidentiality.

One of the more controversial topics over the past few years has been what psychiatrists—or the APA as a whole—should say about the national psyche and potentially dangerous political leaders or movements. Brendel quickly reaffirmed the 

 but also insisted that “psychiatrists can participate in public life by adding insight and knowledge about mental health more generally.” For instance, psychiatrists might use their knowledge of history and psychology to “make some comment about what might lead groups of persons to become susceptible to certain beliefs, be prone to questioning authority in violent ways, and also to be thinking about how unrest or extremism or discriminatory views might affect certain members of our society, and in particular their mental health.”

Striking a balance between obligations to patients and society during a plague year might seem like an exceptional circumstance, but Philip Candilis, MD, reminded attendees that medical ethicists have previously faced similar situations. In fact, Candilis, professor of psychiatry and behavioral sciences at George Washington University School of Medicine and Health, noted that the field of medical ethics arguably began during a deadly outbreak. “When Thomas Percival wrote his 

, it was in response to the typhus epidemic in Manchester [UK],” Candilis said. During the plague, doctors fled the city, leaving many patients without care. In response the government demanded new professional guidance and ethical standards for physicians, 

Several decades later, the American Medical Association adopted Percival’s standards. The ethical dilemmas with which he grappled remain relevant today, and they will likely come up again. “How do you protect yourself as a doctor,” asked Candilis, “How do you protect your family, and how do you work for the public good at the same time? This is a difficult, difficult balance to strike.”

The panel reminded attendees that ethics resources and official APA opinions could be find on the APA’s Ethics webpage 

https://www.psychiatry.org/psychiatrists/practice/ethics

. Queries can be submitted to the APA’s Ethics Committee staff liaison for further guidance at apaethics@psych.org. Similarly, 

 readers can submit ethical dilemmas to our Ethics Editor via 

What’s a psychiatrist to do? An APA ethics panel at the Annual Meeting considered various dilemmas, including possible conflicts between physicians’ obligations to individual patients and their obligation to promote the public good. 

Expert Panel Ponders What It Takes To Be an Ethical Psychiatrist  

“The main message here is that depression is a family affair,” Myrna Weissman, PhD, professor at Columbia University and Chief of the Division of Translational Epidemiology at New York State Psychiatric Institute, told attendees of the 2021 Virtual American Psychiatric Association Annual Meeting. “Especially if you’re dealing with offspring.”

Weissman presented her research on the contributions to the understanding of depression during the session, “Depression in Families: Clinical Opportunities for Breaking the Cycle of Transmission.”

She discussed 3 major topics: studying 3 generations at high risk for depression over 38 years, how treatment has the potential to break the cycle of transmission, and how interpersonal psychotherapy for depression has expanded and been modified during the pandemic.

 She looked at parents with serious major depression (high-risk family) and followed their children and grandchildren, comparing them to those who did not have depression (low-risk family). “I was interested to see what happened to youth who became depressed and to follow them over time.”

She found that high risk families were more likely to pass mood disorders to their offspring, with a peak of onset at adolescence to young adulthood (usually before age 40). Grandchildren with 2 affected previous generations are at 3-fold risk for MDD and an increased risk of suicidal behavior. 

Another interesting find was the effect of religion: mothers for whom religion was very important were 81% less likely to have major depressive disorder (MDD) than mothers who did not find religion as important. Furthermore, religion and spirituality importance in parents was associated with lower risk of suicidal behavior in both boys and girls.

Can treatment prevent the cycle of transmission? Weissman said it is possible if the mothers are treated for depression. One study showed that children’s depression significantly improved after the mother received at least 3 months of treatment.

“The mother’s improvement, regardless of treatment type would help the child clinically. If you have a depressed child, find out about the mom,” Weissman advised.

Weissman’s decades of research concluded that depression is inheritable, but the cycle can be broken. However, the role of environment is still variable.

“Is it nature or nurture?” Weissman posed during the Q+A session. “We cannot at this time determine how much is genetic and how much is environmental because people who are depressed produce environments that can be toxic.”

When evaluating patients for depression, Weissman suggested asking them about key members of their family: their mother, father, and any biological children. Family, she stressed, is key to targeting treatment for depression.

1. van Dijk M, Murphy E, Posner JE, et al. Association of multigenerational family history of depression with lifetime depressive and other psychiatric disorders in children: results from the Adolescent Brain Cognitive Development (ABCD) study. JAMA Psychiatry. 2021.

2. Miller L, Warner V, Wickramaratne P, Weissman M. Religiosity and depression: ten-year follow-up of depressed mothers and offspring. 

3. Weissman M, Pilowsky DJ, Wickramaratne P, et al. Remissions in maternal depression and child psychopathology: a STAR*D-child report. 

Can depression be passed on to future generations, and if it can, how can treatment help? 

Depression: A Family Affair

2021 American Psychiatric Association Virtual Meeting

, Richard C. Shelton, MD, the Charles B. Ireland Professor in the Department of Psychiatry and Behavioral Neurobiology at the University of Alabama at Birmingham, and the Director of the UAB Depression and Suicide Center, discussed the functions and concerns of ketamine.

“This is not a simple treatment or a treatment to take lightly,” Shelton said during the Q+A portion of his presentation. “On the other hand, we’ve seen remarkable results.”

Shelton began with a discussion of ketamine’s functions in the brain, and how it restores the regulatory processes for patients with mood disorders, using a 

“Stressful experiences cause a reduction or retraction of spines and synapses. The brain is less able to control or regulate the emotional state,” Shelton explained.

With ketamine administration, there is an almost immediate increase in formation of critical spine and synaptic proteins.

“When you add ketamine to the system, you produce a rapid return and restoration of those spines and synapses. We see an effect within 24 hours,” Shelton continued. “Ketamine has the ability to restore the regulatory control to the brain and helps to theoretically normalize mood.”

Shelton shared data from 8 studies regarding ketamine, and how it produced a rapid, robust effect for patients with severe, resistant mood disorders,

 and further studies on how ketamine functioned for patients with suicidal ideation.

“The good news: ketamine really seemed to work in these highly treatment-resistant patients,” Shelton said. 

Shelton also addressed key concerns regarding ketamine, especially how it may be a challenge to prescribe. First, the US Food and Drug Administration requires a “somewhat cumbersome” risk evaluation and mitigation strategy program, in which the clinic, provider, and patient must all be registered in the program. There are prior authorization hurdles, as well as reimbursement issues. Nonetheless, Shelton finds ketamine more than worth it.

“When I treated my first patient with IV ketamine in 2012, it was just amazing to see the effect occur within 24 hours,” Shelton said.

1. Li N, Liu RJ, Dwyer JM, et al. Glutamate N-methyl-D-aspartate receptor antagonists rapidly reverse behavioral and synaptic deficits caused by chronic stress exposure. 

2. Berman RM, Narasimhan M, Sanacora G, et al. A randomized clinical trial of repetitive transcranial magnetic stimulation in the treatment of major depression. 

3. Zarate CA, Singh JB, Carlson PJ, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. 

One doctor at the APA Virtual meeting explains how ketamine can rebuild spine and synaptic proteins in the brain, but may be difficult to actually prescribe to patients. 

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