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In this Mental Health Minute video, Manny Garcia, MD, of the San Diego Psychiatric Society makes some recommendations for sites to see and activities to enjoy while you are in San Diego, California, for the upcoming 2022 Annual 

 is president of the San Diego Psychiatric Society.

2022 Annual Psychiatric Times™ World CME Conference

will take place August 11 to 13 in San Diego, California. 

Articles

Psychiatric Times World CME Conference

The president of the San Diego Psychiatric Society gives us a glimpse into the city for the upcoming 2022 Annual Psychiatric Times World CME Conference.

What To Do in San Diego

*A note from the authors: When we first presented our study at the APA annual meeting, we only had preliminary results. Now that our investigation is complete, the results are presented in this article.

Buprenorphine, along with methadone and extended-release naltrexone, is 1 of 3 medications currently approved by the US Food and Drug Administration (FDA) to treat opioid use disorder (OUD). Buprenorphine is considered the “gold standard” treatment for OUD and has been proven to reduce mortality and to improve treatment retention and remission. Buprenorphine has an advantage over methadone in that it has a lower overdose risk due to its ceiling effect and is less likely to cause QTc prolongation.

Opioid receptors have been extensively studied for the treatment of opioid addiction, but recent research has shifted to investigating opioid receptors in the treatment of psychiatric conditions. A significant proportion of patients with an OUD also have cooccurring psychiatric conditions. There is growing evidence from neurobiological research that the endogenous opioid system is involved in mood regulation and that disturbance of this system may lead to depression and anxiety, making it a potential therapeutic target for the treatment of these ailments.

Our study’s goal was to analyze clinical studies in order to determine the efficacy of buprenorphine in treating psychiatric conditions, in particular depression and suicidality (

 Buprenorphine and Its Therapeutic Potentials in Psychiatric Disorders, Presented at the American Psychiatric Association 2022 Annual Meeting

We conducted a literature search in 5 major databases, including PubMed, using inclusion and exclusion criteria. Of the 1347 identified studies, 6 clinical trials were included in this meta-analysis pooling in 417 adult participants. First, HAM-D inter-group assessment favored buprenorphine use compared to control (Cohen’s d=-0.34, 95% CI=-0.66, -0.02, P=0.04). Second, MADRS scores found endline (mean score changes compared to baseline) shifts of depression scores were in favor of buprenorphine (Cohen’s d=-0.31, 95% CI=-0.61, -0.01, P=0.04). Third, BSSI favored the use of buprenorphine (Cohen’s d=-1.4, 95% CI=-0.61, -0.01), and in the intra-group analysis, a single dose (64 mg) of sublingual buprenorphine was superior to 96 mg (Cohen’s d=0.19) and 32 mg (Cohen’s d=-0.22) single doses.

Several hypotheses have been proposed as to the mechanism of action of buprenorphine in the treatment of psychiatric disorders. The review of study shows that buprenorphine has an antidepressant effect at doses ranging from 2 to 8 mg/day, as well as an antisuicidal effect at relatively low doses (0.1 mg to 0.44 mg). According to several studies, buprenorphine's antisuicidal effect may be due to a partial agonist effect on the μ-opioid receptor and an antagonist effect on the delta and κ-opioid receptor. One plausible explanation for buprenorphine's antisuicidal effect is its potential to reduce the psychological or physical pain processing. Also, because of its agonism of nociceptive receptors, it may have anti-anxiety properties, too, and anxiety is an independent risk for suicidality.

A growing body of literature indicates that buprenorphine has therapeutic potential in treating psychiatric conditions, mainly via the endogenous opioid system. The findings of this study show that buprenorphine has a promising role in reducing depression and suicidality. Lower dosages appear to be more effective in producing favorable psychiatric outcomes in terms of decreasing suicidality.

Despite growing evidence in favor of buprenorphine in the treatment of psychiatric conditions, there are issues to consider before prescribing such as diversion and the potential for abuse. Larger and more rigorous studies are required to establish the efficacy of buprenorphine in psychiatric conditions or to widely use it in clinical practice.

 is an addiction psychiatrist; diplomate of the American Board of Psychiatry and Neurology; and medical director of the West Ridge Center for Addiction Recovery at Rutland Regional Medical Center in Rutland, Vermont. 

 is the chief resident at the St. Elizabeth Boston psychiatry residency program and a co-investigator for this study.

Researchers discuss new research on buprenorphine, the “gold standard” treatment for opioid use disorder at the APA Annual Meeting.

Buprenorphine and Its Therapeutic Potential in Psychiatric Disorders

In this Mental Health Minute video, M. Katherine Shear, MD, of Columbia University gives a preview of her presentation on bereavement-related depression at the upcoming 2022 Annual 

is Marion E. Kenworthy Professor of Psychiatry at Columbia University and director of the Center for Prolonged Grief at the Columbia University School of Social Work.

Grief or Bereavement-Related Depression?

In this Mental Health Minute video, Jonathan Meyer, MD, clinical professor of psychiatry at the University of California San Diego, gives a preview of his presentation on treatment-resistant schizophrenia, clozapine, and the importance of measuring antipsychotic plasma levels at the upcoming 2022 Annual 

is a clinical professor of psychiatry at the University of California San Diego and a psychopharmacology consultant.

Which treatment approaches are the state-of-the-art for helping this patient population?

Appropriate Treatment for Treatment-Resistant Schizophrenia

In this Mental Health Minute video, Rif El-Mallakh, MD, director of the Mood Disorders Research Program at the University of Louisville School of Medicine, gives a preview of his presentation on combination therapy in bipolar disorder at the upcoming 2022 Annual 

is the director of the Mood Disorders Research Program at the University of Louisville School of Medicine in Louisville, Kentucky.

 will take place August 11 to 13 in San Diego, California. 

How do you choose medications based on the biologic abnormalities that are known to occur in bipolar illness?

Combination Therapy in Bipolar Disorder

What to Expect at the 2022 Annual Psychiatric Times™ World CME Conference

Slideshows

“The amount of devastation that has occurred from this infection is unparalleled by any pandemic that we have faced on this continent or any war that we have faced.”

Avindra Nath, MD, a neurologist in Bethesda, Maryland, discussed the neurological and neuropsychiatric complications of COVID-19 at the 2022 American Psychiatric Association (APA) Annual Meeting, beginning with the recent statistics related to COVID-19. To date, there have been 100 million infections and 1 million deaths in the United States alone, with 500 million infections and 50 million deaths globally. 

The effects of long COVID—particularly on the brain—are also of concern. “The brain gets overlooked. But what is primary and most important at the end of any pandemic is what happens to the brain because those are the things that cause the long-term consequences,” said Nath, who is also senior investigator and clinical director in the Section of Infections of the Nervous System, Division of Neuroimmunology & Neurovirology, at the National Institute of Neurological Disorders and Stroke.

Nath explained that individuals who develop COVID-19 can be divided into 2 groups: (1) those who have very severe symptoms at the time of COVID-19 onset, but then gradually improve, and (2) those who have mild symptoms at onset or even improve for a while, but then develop new symptoms weeks or months later.

“If you look at patients acutely and they have lots of symptoms, over 3 to 5 months, many will get better, but some will not. And if they don’t get better by then, chances are they won’t,” Nath said.

Some of these symptoms that may occur in cases of long COVID—or the chronic stage of COVID-19—include exercise intolerance; mood, cognition, and sleep disorders; pain syndromes (eg, myalgia, neuropathic pain, paresthesia, headache, tinnitus); and dysautonomia (eg, palpitations, postural orthostatic tachycardia syndrome, hypotension, hypothermia, fever).

“First onset of major depressive illness, anxiety, or psychosis [with none] in the past history is directly related to this infection,” Nath added, also noting that some symptoms of long COVID overlap with symptoms of other diseases such as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), Gulf War illness, and post Lyme disease syndrome. “It’s quite possible that all of these are related to one another,” Nath said. “It’s just that the event that precipitated them may be somewhat different.”

In order to learn more about what happens to the brain during and following COVID-19 infection, Nath shared that he and colleagues analyzed the brains of individuals who had died of COVID-19 in MRIs. They found, in part, that perivascular fibrinogen leakage indicated vascular injury, and that platelets were activated and formed clots in small blood vessels. 

Based on this and additional neurological and neuropsychiatric research, Nath suggested that future directions should include more clinical trials involving immunomodulatory agents and more research involving biomarkers for neuronal injury (NfL, pNfH, GFAP, SNAP-25), vascular injury (sICAM, VEGF, P-selectin, E-selectin, MMP-3, antibodies to ACE2), and immune activation.

In terms of treatment, “there is symptomatic treatment—but can you affect the course of the disease?” Nath said. “…I think you need to tailor the treatment to the patient you’re seeing and depending on what you think is the major underlying pathophysiological mechanism. And now we have the tools to be able to refer to that.”

An expert discusses the effects of long COVID on the brain at the 2022 APA Annual Meeting.

Neurological and Neuropsychiatric Complications of COVID-19

“We do not live in a post-truth world. We live in the Age of Influence.”

A presentation at the 2022 American Psychiatric Association (APA) Annual Meeting focused on undue influence and the power of cults in the age of COVID-19. The panel of speakers—which included Cathleen Cerny-Suelzer, MD, of University Hospitals Cleveland Medical Center; Karen B. Rosenbaum, MD, a psychiatrist in private practice in Manhattan, New York; Ryan Hall, MD, a clinical and forensic psychiatrist and past president of the Florida Psychiatric Society; Susan Hatters-Friedman, MD, of the University Hospitals Cleveland Medical Center and Case Western Reserve University; and 

, of the Freedom of Mind Resource Center—discussed common deceptive and brainwashing techniques used by cult leaders, and some steps clinicians should take when they suspect that a patient may be under undue influence.

A major tool in gaining undue influence—which is classified as a dissociative disorder in DSM-5: Not Otherwise Specified 300.15 (F44.89)—is disinformation. Although disinformation, like misinformation, refers to false information that is spread, the difference is that disinformation is spread 

. Disinformation is a common tactic used by cult leaders to indoctrinate and control their followers.

“Information control is the critical variable,” said Hassan, who was recruited to the Unification Church cult, or the “Moonies,” at 19 years old, and has worked in the field of destructive authoritarian control (undue influence) in relationships, organizations, and belief systems for more than 45 years.

As explained by Hassan’s BITE (Behavior, Information, Thought, and Emotion) Model, cult leaders control information by lying and withholding information; installing irrational fears associated with leaving or questioning the group; extensively using cult-generated propaganda while minimizing access to noncult information sources; encouraging followers to spy on other members; and using past “sins” and memory distortion to manipulate followers and abolish identity boundaries. Between information control and other mind control tactics, “a lot of times, people don’t know they’re in a cult until they leave,” Rosenbaum said.

Also important to note is the distinction between delusions and other types of strongly held beliefs. Delusion is defined within the Schizophrenia Spectrum and Other Psychotic Disorders section of DSM-5 as “fixed beliefs that are not amenable to change in light of conflicting evidence.” There are many other types of ideas, but particularly notable are delusion-like beliefs, which superficially resemble delusions but are not delusions on closer consideration. Examples of delusion-like beliefs are conspiracy theories, which are very common in today’s political landscape.

“If you did a general population survey, about half the population would believe in at least 1 conspiracy theory,” Hatters-Friedman said.

To discern whether a patient is presenting with delusions or strongly held beliefs, Hatters-Friedman suggests learning the evidence for the patient’s beliefs, whether or not the beliefs are self-referential, and whether there is overlap, while noting that these 3 criteria are not mutually exclusive.

When speaking with patients about delusions or trying to identify whether they are under undue influence, “you want to be curious, not judgmental,” Cerny-Suelzer said. Some tips for clinicians include asking open-ended questions about important relationships and formative experiences; taking a good trauma history; helping patients with decision-making skills; focusing on harm reduction when deciding how directive to be with patients; and assessing and documenting the patients’ cognitive functioning, psychiatric symptoms, and behavioral functioning. “Also make sure that, for the protection of your patients, you know what a narcissist looks like so you can help them, should they be in a situation where they’re being manipulated by somebody in their life,” Cerny-Suelzer said.

A focus on education, destigmatization, and empowerment is also key in helping patients who are victims of undue influence, according to Hassan. “You have to go back to recover and connect with a person’s authentic self and then walk slowly, understanding the techniques of manipulation,” while empowering these individuals to speak up about their experiences, Hassan said. He recommends training everyone—especially mental health professionals—in how to cure phobias, and establishing a network of trained individuals (including friends, family, former members of the same cult, and therapists) to orchestrate an ethical influence program to empower the patient to let go of phobias and other indoctrinations and think for themselves.

Experts discuss appropriate interventions for patients who are victims of undue influence at the 2022 APA Annual Meeting.

Cults in the Age of Influence

“Artificial intelligence (AI) is here to stay, and it’s really very important for the psychiatric field to take a leading role in developing it.”

P. Murali Doraiswamy, MBBS, FRCP, of the Duke University School of Medicine discussed some of the latest developments in AI and its current and potential applications for psychiatry at the 2022 American Psychiatric Association (APA) Annual Meeting. He was joined in a panel discussion by Robert M. Califf, MD, MACC, commissioner of food and drugs for the US Food and Drug Administration (FDA), and moderator Samantha Boardman, MD, psychiatrist and author of 

Everyday Vitality: Turning Stress Into Strength

“If I was a computer programmer describing the unmet needs in the mental health field, I would use a formula that would go something like this: 40, 40, 30, 0. This means only 40% of people who need care get access to the care they want; of those, only 40% get optimal care; 

, only 30% achieve remission; and 0% of people get preventive care in terms of resilience,” Doraiswamy said. “That’s the problem in this field—and the hope and promise is that AI and technology can help with some of this.”

Doraiswamy noted that $4 billion has been invested in AI, which has been doubling every 3 months for the past few years and transforming multiple fields, including psychiatry. In psychiatry, digital health coaching, stigma reduction, triage and suicide prediction, clinical decision support, and therapeutic apps have already transformed the field, with therapeutic wearables, robots and virtual reality avatars, protocol standardization, QC and practice management, and population forecasting on the horizon.

Mental health and wellness apps are particularly lucrative, with more than 5000 such apps currently on the market and around 250 million individuals having accessed them in the past 2-and-a-half years. Although some are FDA-approved—such as Endeavor Rx for the treatment of pediatric attention-deficit/hyperactivity disorder (ADHD) and Somryst for the treatment of chronic insomnia—it is important to note that many are neither approved nor overseen by the FDA unless they make a disease claim. Many also provide inaccurate information, send data to third parties, and are based on “black box” algorithms rather than randomized controlled trials. However, recent data shows that 82% of individuals believe robots can support their mental health better than humans can, as robots are unbiased and judgment-free, and able to provide them with quick answers.

In addition to this, clinicians have cited a number of potential harms of AI, including diagnostic and treatment errors; a loss in creative clinical thinking; greater risks of dehumanization and the jeopardization of the therapeutic process due to a lack of empathy; and less privacy and more fatalism in general. Clinicians also worry that the process for the machine to reach a diagnosis could turn into a “black box” process, and that, if time saved is used by administrators to increase patient loads, it might lead to greater clinician burnout.

Another potential concern for clinicians is job security in light of the fully automated psychiatrist, which is another form of AI in development. Doraiswamy emphasized that a development like this should be regarded as an enhancement to psychiatric practice rather than as a replacement. “This is not going to replace you,” Doraiswamy said. “This is a personal assistant that’s going to be sitting in the waiting room doing the initial interview intake, get all the intake ready, and then summarize this information and have it ready for you so that you can make a diagnostic assessment.”

Clinicians have also cited a number of benefits of AI, including better outcomes through more standardized protocols and the elimination of human error; less bias due to race or gender; and scalability of treatment. They say AI can also encourage patients to answer truthfully and accept support more objectively; use big data more efficiently than humans; provide practical guidance for trainees; and help elucidate etiologies of diseases that are currently not well understood.

The evidence for the predictive benefits of AI for psychiatry is also growing. Recent research has found support that AI may be able to detect Alzheimer disease 5 years before diagnosis and predict future depressive episodes and risk of suicide, and that machine learning may be able to predict a mental health crisis using only data from electronic health records. “By and large, this shows you the promise,” Doraiswamy said. And, as DeepMind—which is owned by Google—recently released a general-purpose AI agent, “it’s probable that you could have 1 AI program that could help with all 159 diseases in the DSM-5,” Doraiswamy said.

In order to maximize the potential benefits of AI and ensure that psychiatry leads this revolution, Doraiswamy recommended that the field develop clinical practice guidelines; provide proper education and training; ensure that cases are relevant and human centered; advocate for equitable and accountable AI; implement QI methods into workflow; create benchmarks for “trusted and safe” apps; and work with payers to develop appropriate reimbursement.

“We need to step back and acknowledge that digitation in our society and broad access to the internet are having profound effects that we don’t yet understand, and that as we develop technologies with the plasticity that these technologies have, as opposed to traditional medical devices, you can change the software very quickly,” Califf said. “It’s a tremendous potential benefit, but it also carries very specific risks that we need to be aware of.”

“Some very reasonable people might argue that AI and psychiatry don’t belong even in the same sentence—that AI should play no role whatsoever in mental health care, and that the psychotherapeutic relationship is sacrosanct,” Boardman concluded. “But in a world where there are so many unmet mental health needs, I think there’s a very good argument that AI can not only improve care and diagnostics and increase access, but also reduce stigma and even flag potential issues and symptoms before they appear and reduce burnout among professionals.”

Experts discuss psychiatry’s role in the advancement of AI technologies at the 2022 APA Annual Meeting.

Leading the Artificial Intelligence Revolution

“We have clinical guidelines for the treatment of some disorders, and we have clinical guidelines that motivate the way we use certain treatments. But, for new and emerging treatments, we often don’t have guidelines on how best to use them, who to recommend for a particular intervention, and who not to do so,” said Eric Achtyes, MD, MS, in a presentation at the 2022 American Psychiatric Association (APA) Annual Meeting.

The presentation, chaired by Achtyes—a staff psychiatrist and researcher at Michigan State University with appointments at Pine Rest Christian Mental Health Services, Cherry Street Health Services, and Network180—focused on assessing current gaps and opportunities in the guidelines for electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and deep brain stimulation (DBS).

Although ECT has been used in the treatment of severe mental and medical conditions for more than 80 years, it is one of the few medical procedures that is regulated by state laws not based on medical guidelines, according to Georgios Petrides, MD, associate professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. “These laws are not based on medical guidelines—they’re mostly based on politics,” Petrides said. “Powerful antipsychiatry groups target ECT nationwide.” Today, 44 US states have specific ECT regulations, 21 states have specific regulations for ECT in minors, and 9 states mandate ECT reporting.

Petrides explained that, in 1975, the US Food and Drug Administration (FDA) gave ECT class III classification—for “unknown efficacy and risk”—with cleared indications for use in the treatment of unipolar and bipolar depression, schizophrenia, bipolar mania and mixed states, schizoaffective disorder, schizophreniform disorder, and catatonia. Although the FDA’s original aim was to reevaluate ECT and reclassify it as class II (“known efficacy”), reevaluation did not occur until 2018. In response to some scandals in the 2000s, the FDA reclassified ECT class II in 2018, but only for the treatment of severe depressive episodes and catatonia.

“This means that, according to the FDA, there is evidence of efficacy, but only for depression and catatonia,” Petrides said. “The rationale for these restrictions is a lack of double-blind, placebo-controlled trials in the other diagnoses. Scientific literature and the global clinical experience of more than 80 years has been completely disregarded.”

The ramifications of these restrictions are that treatment will remain off-label for a significant number of patients, and there is a need for investigational device exemption for research in diagnoses other than depression and catatonia. However, these restrictions have also drawn attention to informed consent processes, documentation, and database creation, presenting opportunities to reduce/eliminate the stigma associated with ECT; conduct efficacy and outcomes research in disorders considered “unproven”; and create comprehensive databases.

The most recent consensus guidelines for rTMS were developed by the APA Council on Research Task Force and the National Network of Depression Centers (NNDC) rTMS Task Force in 2018, according to Tracy Barbour, MD.

“These guidelines were based on literature published from 1990 to 2016. Given that TMS is a rapidly evolving field, and we have a lot of research in this field, these guidelines likely have some updating that needs to occur,” said Barbour, who is medical director of Massachusetts General Hospital, instructor at Harvard Medical School, and program director of the Interventional Neuropsychiatry and Neuromodulation Fellowship. These guidelines focus on rTMS as a treatment for patients with major depressive disorder (MDD), including patients who are medication-resistant and those who have significant comorbid anxiety. “Patients with significant comorbid psychotic disorders or acute suicidal ideation should consider other antidepressant treatments with established efficacy, such as ECT,” Barbour said.

Barbour discussed the 2018 consensus guideline recommendations for location and frequency, coil positioning, pulsing, motor threshold determination, treatment planning, and number of sessions, comparing the recommendations for each area to findings from more recent research. In regard to location and frequency, for example, most evidence supports high-frequency stimulation (10Hz) to the left DLPFC; however, there is also evidence that using the H1 coil is effective for bilateral PFC stimulation, and that right DLPFC low-frequency stimulation is also safe and effective for patients who are at risk of seizure, or who do not tolerate/respond to high-frequency left DLPFC stimulation. More recent studies have shown that theta burst stimulation (iTBS) can be applied for a shorter period of time, allow for more sessions per day, and have longer-lasting physiological and cognitive effects compared to high-frequency alternatives.

In 1 study, “the FDA-cleared protocol took 27 minutes, compared to iTBS, which took only 3 minutes,” Barbour said. “I think updated guidelines would definitely comment on iTBS.” And, when compared to a new type of rTMS called Stanford neuromodulation therapy (SNT), the FDA-cleared iTBS protocol involves 1 session per day for 36 days at 600 pulses iTBS per session, versus the SNT protocol of 10 sessions per day, with 50-minute intersession intervals for 5 days, at 1800 pulses iTBS per session. “If patients can get better that quickly and it has the efficacy,” Barbour said, “I think it is something to be excited about.”

Because DBS is not yet FDA-approved, it remains a thoroughly investigational, off-label treatment, and there are no official guidelines for its usage, according to Alik Widge, MD, PhD, assistant professor in the University of Minnesota Department of Psychiatry. However, some research has suggested its efficacy for the treatment of depression. “Open-label data showed an average of 50% loss of depressive symptom burden and then retention—back in 2009,” Widge said. “So, why is DBS still not FDA-approved and available at an academic medical center near you? Because we’ve had a devil of a time getting it through randomized clinical trials.” Widge explained that, because depression is heterogenous—and doubly so in patients who are treatment-resistant—this leads to difficulty passing the randomized controlled trials necessary for FDA approval.

Because there are some promising recent and ongoing clinical trials on the efficacy of DBS, Widge recommended that clinicians connect their patients who may be good candidates with clinical trials so those patients can receive advanced care while also helping develop the necessary data for FDA approval. A good candidate typically is at least 30 years old; has had multiple either bipolar or unilateral depressive episodes that are severe/disabling; has responded to treatment in prior episodes but experiences consistent/faster relapse; is resistant to evidence-based, guideline-adherent therapies; and is able to handle the burden of participating in a clinical trial. Widge also made some recommendations for how to get these patients involved, when and how to screen trials and their investigators, and how to warn patients of the study burden.

Widge emphasized that managing patients with DBS would not be an added burden on clinicians, as the device does not cause any cognitive impairment or prevent any specific medications and is stable for years once it is programmed. “A patient with a neurostimulator is just like anybody else who’s in your office for regular management, except they now tend to be more responsive to other interventions,” Widge said.

Achtyes closed the presentation by discussing some national surveys gauging perceptions and opinions of these treatment modalities and the most important ethical considerations relating to them. Among the 505 participating psychiatrists who have referred or administered these interventions to patients within the past 5 years, the top 3 most important ethical considerations when developing practical guidelines for these treatments were (1) providing evidence of the safety and efficacy of the interventions (nearly 50%); (2) selecting patients who would be good candidates for the interventions (20%); and (3) having a standard accreditation system to assure and improve the quality of administration of the interventions (around 12%).

The presentation was organized by Laura Y. Cabrera, PhD, associate professor of engineering science and mechanics and philosophy, and Dorothy Foehr Huck and J. Lloyd Huck Career Chair in Neuroethics at Penn State University.

The 2022 APA Annual Meeting highlights the latest guidelines for these treatments, plus recommendations for updates and improvements.

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