Conferences

The NCCHC Virtual Fall Conference on Correctional Health Care will offer education on health care, mental health, substance abuse disorder treatment, suicide prevention, and other critical topics virtually November 17-18.

The Fall Conference features highlights from the in-person National Conference on Correctional Health Care, taking place October 30-November 3 in Chicago, as well as online exclusive sessions.

“We have so many people who need education and information on best practices, treatment programs, and how to cope with the psychological and physical effects of the pandemic who are not able to travel. This virtual conference will help them catch up and keep up on critical topics,” says NCCHC CEO Deborah Ross, CCHP. Ross notes that “while many want to attend in-person, staffing levels are very tight in some locations.”

Topics of interest to the psychiatric community include compassion fatigue, sleep disorders, COVID-19, opioid withdrawal, trauma-informed treatment, ethics, deposition preparation, suicide prevention, and more.

Participants can log in live on November 17-18 or access sessions on demand through December 31. The conference offers up to 28.75 hours of continuing education credit.

For more information or to register, visit 

Articles

2021 NCCHC Conference

NCCHC Virtual Fall Conference on Correctional Health Care Highlights Mental Health and Medical Issues for Incarcerated People

There are 13 million adults with borderline personality disorder (BPD) in the United States and, of that number, 1.5 million are adolescents, Carl Fleisher, MD, told attendees of the 2021 Annual 

 World CME Conference. To best support them, there are 3 things you need to do, added Fleisher, assistant clinical professor of psychiatry at University of California Los Angeles Health.

To kick off the discussion, Fleisher shared the case example of “Hannah,” a 16 year old girl who presents wondering if she has BPD after Googling her experience. Specifically, she has rapid mood swings, feels numb more often than sad, and cuts herself superficially several times a week. She has 1 friend and spends all of her time with that friend in fear the friend will desert her. She is interested in boys, but she avoids them. Hannah does not voice her needs to parents, teachers, or friend; instead, she goes along with whatever they want or like.

The first thing to do, therefore, is to make the diagnosis, Fleischer said. To do so, there are 9 criteria to consider, and sometimes it feels like they are all over the map. As such, the patient might not see the connections, so it is important to help draw them for patients. One way to do that, he explained, is to use a model of interpersonal hypersensitivity. Since we all want and need to be in relationships, and we are hypersensitive, we may have a fear of abandonment. From there, you can talk about the other symptoms.

 for rapid assessment of patients. It helps patients think things through, he explained. It also provides an opportunity for further discussion, as the clinician may have a different perspective than the patient does on a particular item.

Most patients are relieved when they finally receive a diagnosis, Fleischer said. He shared the following patient perspective: “It explained a lot of things and I felt an enormous sense of relief that there was an explanation for the way I was.”

The second thing is to refer to helpful resources, including psychoeducation, support, and treatment strategies, Fleisher said. He recommended a number of resources both for patients and their clinicians: the National Education Alliance for Borderline Personality Disorder, Mentalizing Initiative, the Anne Freud National Centre for Children and Families, and McLean’s Borderline Personality Disorder center.

In terms of treatments, there are 4 evidence-based psychotherapy modalities, Fleisher said. They include dialectical behavioral therapy, transference-focused psychotherapy, mentalizing-based therapy, and good psychiatric management, which is not an orientation but more of framework for clinicians. “It is also possible also that a plain old talk therapy is an adequate treatment for borderline personality disorder, especially if you have nothing else,” he told attendees.

It is also important to consider psychoeducation and family support, Fleischer added. He shared the results of a study looking at the impact of 6 weeks of psychoeducation on patients. The investigators found that symptoms reduced greatly—by about half—and stayed low for 2 months after the intervention protocol.

 Similarly, since caregivers and family members are under a lot of stress and strain, it is important to broaden the treatment lens and provide support to them, too.

Unfortunately, Fleischer noted there are no medications approved by the US Food and Drug Administration to specifically treat BPD. Likewise, there is no medication that is uniformly helpful. Too often, patients find themselves on multiple medications, he said, and polypharmacy poses a significant danger because of adverse effects, like weight gain associated with antipsychotics.

“We can do a whole hour-long talk on just medication for BPD, but the short of it would be: If you're going to use medication to treat one of the comorbid illnesses that BPD presents with, as opposed to this BPD itself, then you can try that,” Fleisher told attendees. “But if we're going to try to treat the symptoms of BPD itself like lability, paranoia, that sort of thing, then it may be that we want to consider a brief trial of medication to get people through a crisis.” After using the medications in a way that is helpful, it is important to consider taking it away, because we do not expect them to be helpful in the long-term and do not want to cause a problem of polypharmacy, he added.

The third thing to do is to monitor the effectiveness of the treatment, Fleischer said. Start with baseline measurements on the areas you and the patient want to address, be it self-harm, work performance, risky behaviors, and quality of life and relationships.

With these 3 things in mind, Fleisher concluded, clinicians can best support their patients with BPD. As he told attendees, “Borderline personality disorder is worth treating, and people with BPD are very rewarding to work with.”

1. Lester R, Prescott L, McCormack M, Sampson M; North West Boroughs Healthcare, NHS Foundation Trust. 

Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review.

2. Ridolfi ME, Rossi R, Occhialini G, Gunderson JG. 

A Clinical Trial of a Psychoeducation Group Intervention for Patients With Borderline Personality Disorder

 2019;81(1):19m12753. Published 2019 Dec 31.

Psychiatric Times World CME Conference

These 3 essential steps best support patients with borderline personality disorder, according to Carl Fleisher, MD. 

Borderline Personality Disorder: 3 Things You Need To Do for Patients

As Larry Merkel, MD, PhD, professor of psychiatry and neurobehavioral sciences and Director of Outreach at the University of Virginia, told 2021 Annual 

 World CME Conference attendees, working with culturally different patients can be challenging and rewarding, but rarely avoided in current day psychiatry.

“Everyone’s backgrounds are very complicated, multi-layered, and dynamic,” said Merkel. “No person has influences these days from just 1 culture—we live in multiple cultures.”

Cultural distance is essentially qualitatively thinking about the difference between doctor and patient—how many things in your background are similar to their background, or not?

“There’s been research showing that the greater the cultural difference between the psychiatrist and the patient, the more likely there are to be mistakes of all sorts,” Merkel said.

Merkel also covered models for managing cultural differences, including the Cultural Formulation Interview (CFI) from DSM-5, which patients seem to value over traditional interactions.

 Field trials in a variety of locations (ie, United States, Canada, Netherlands, India, Kenya, and Peru) showed CFI is feasible, acceptable, useful, and sensitizes clinicians to cultural issues.

 An implementation study in an outpatient psychiatric clinic demonstrated CFI is an integral part of cultural competence training; there was a 50% reduction in discontinuation rate vs treatment as usual after one training session.

CFI does have some potential problems, Merkel noted. CFI can help with direction of therapy, but not diagnosis. Additionally, it is not able to be used with cognitive disability or with severe symptoms such as acute psychosis, suicidal behavior, or aggression.

We're fathers, mothers, children, physicians, barbers, Protestants, Catholics, Jews—all sorts of identities.

Further, the concept of identity may be difficult to translate work with, according to Merkel. “We all have multiple identities. We’re fathers, mothers, children, physicians, barbers, Protestants, Catholics, Jews—all sorts of identities. We use those identities in different ways at different times. Sometimes, if you ask a person what their identity is, they may have no idea what you’re talking about.”

Merkel has a few recommendations for physicians working with culturally different patients:

-Know something about the main populations with whom you are likely to work.

-Adapt to include more culturally relevant data.

-Take time and effort to work with interpreters.

-Be brief and succinct in your questions if you are using an interpreter.

-Understand that it may be difficult, and be patient.

Qualitative analysis of Cultural Formulation Interview: findings and complications for revising the outline for cultural formulation. 

2. Jarvis GE, Kirmayer LJ, Gómez-Carillo A, et al. 

Update on the Cultural Formulation Interview. 

3. Lewis-Fernández R, Aggarwal NK, Kirmayer LJ. 

The Cultural Formulation Interview: progress to date and future directions.

Cultural differences between patients and physician are hard to avoid. How can you best work with diverse patients? 

The Challenges and Rewards of Working With Culturally Different Patients

“You can imagine if you're regularly hearing in the media that trans people are risks to other people in bathrooms, that you're a risk to your peers on sports teams, that really you're just confused about your gender identity—over time, you may internalize these ideas and start to have self-hatred or low self-esteem,” said Jack L. Turban, MD, MHS, a Fellow in Child & Adolescent Psychiatry at Stanford University School of Medicine and 

In his session, “Evolving Treatment Paradigms for Transgender Youth,” Turban discussed the evolution of prepubertal transgender youth treatment over the past 2 decades, the current evidence base for pubertal suppression for transgender adolescents, and the rationale for gender-affirming hormone treatment for transgender adolescents.

Transgender youth, Turban explained, have an array of psychiatric morbidities, including mood disorders (12.4 to 64%), anxiety disorders (16.3 to 55%), and prior suicide attempts (9.3 to 30%). Additionally, about 80% have been a victim of bullying.

Another topic Turban found important to approach is the dangers of gender identity conversion therapy. In his research published in 

, Turban took a sample size of more than 27,000 American transgender adults who had spoken to a therapist about their gender identity, and compared those whose therapy involved trying to make them cisgender with those whose therapy did not have any conversion efforts.

 The results showed exposure to conversion efforts before age 10 led to increased suicidal ideation, increased lifetime cigarette use, increased lifetime illicit drug use, as well as more suicide attempts.

“We had a ton of data that trying to change sexual orientation was dangerous, but this is the first study to look at trying to change someone's gender identity and the mental health outcomes,” said Turban.

Furthermore, Turban noted it seems like childhood is particularly vulnerable time period for being exposed to conversion efforts. Conversion therapy is still legal in 29 states and 4 territories,

 and approximately 13.5% of transgender individuals report lifetime exposure to gender identity conversion efforts.

Instead, Turban believes a social transition might be a good idea for a prepubertal child. In a social transition, transgender children or adolescents adopt the name, pronouns, and gender expression (like clothing or haircuts) that match their gender identity.

“Banning social transition is likely dangerous and can send a message to a child that being transgender is bad. This can essentially instill shame and damage relationships between the child and the therapist, and the child in the family,” Turban said.

Research review: gender identity in youth: treatment paradigms and controversies.

2. Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. 

Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults.

3. Movement Advancement Project. Updated 2021. Accessed October 2, 2021. 

https://www.lgbtmap.org/equality-maps/conversion_therapy

4. Turban JL, King D, Reisner SL, Keuroghlian AS. 

Psychological attempts to change a person's gender identity from transgender to cisgender: estimated prevalence across US states, 2015.

Transgender youth are at increased risk for a number of psychiatric morbidities. Gender identity conversion therapy can make them worse. 

Treating Transgender Youth: The Danger of Gender Identity Conversion Therapy 

“There appears to be at least 3 types of major depressive disorder (MDD) based on pharmacology,”Sheldon Preskorn, MD, told attendees of the 2021 Annual 

TM World CME Conference. Preskorn, professor in the Department of Psychiatry and Behavioral Sciences at University of Kansas School of Medicine and Psychopharmacology Section Editor of 

, was also named Educator of the Year at the conference.

The first type of MDD responds to biogenic amine antidepressants. This group represents about 60% to 65% of patients, he added. The next group is nonresponsive to biogenic amine antidepressants, but responsive to glutaminergic (NMDA) antidepressants, and represents about 25% of patients. The third group is nonresponsive to both biogenic amine and glutaminergic antidepressants; this group represents about 15% of patients with MDD.

To get a clearer understanding of this philosophy, Preskorn turned to the Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study, which was funded by the National Institutes of Mental Health to determine the effectiveness of different treatments for MDD in cases in that failed to respond to initial treatment with an antidepressant. In the study, the initial treatment was citalopram. If MDD was not responsive to treatment, patients were switched to bupropion SR, sertraline, or venlafaxine XR, or treatment was augmented with bupropion SR or buspirone.

 In cases that remained unresponsive, participants were switched to mirtazapine or nortriptyline, or had augmentation with lithium of triiodothyronine. Finally, if treatment still failed, participants were switched to tranylcypromine or mirtazapine combined with venlafaxine SR.

What was noteworthy, Preskorn explained, was that acute outcomes worsened with increasing number of prior treatment failures. In the group with no or limited prior medications, 27.5% achieved remission, as measured by HAM-D 17. Those in the group with 1 prior failure saw remission rates drop to 21.1%. And those with 2 and 3 prior failures saw remission rates drop to 16.2% and 6.9%, respectively.

“If you're like me, you see these patients every day in the clinic, because we usually get patients after they have already been tried on an antidepressant in primary care.” 

“If you're like me, you see these patients every day in the clinic, because we usually get patients after they have already been tried on an antidepressant in primary care,” Preskorn said. “So we always are getting someone who has probably not benefited from treatment. And, not only did they not benefit, they also were much more likely to relapse.”

In looking at current treatment strategies, Preskorn said we know the vast majority of people initially receive a selective serotonin reuptake inhibitor. Next, most likely is either a serotonin-norepinephrine reuptake inhibitor or a norepinephrine dopamine reuptake inhibitor. If that does not work, he explained there is the likelihood of augmentation with atypical antipsychotics or other kinds of medications, or a new drug like esketamine. If you still are not seeing a proper response, you would move into monoamine oxidase inhibitors or various kinds of electrical treatments such as transcranial magnetic stimulation.

"There is no requirement that a new drug is superior to antidepressants, be it superior either in efficacy or tolerability… new, does not mean improved."

So, why is there so little benefit from switching among them the various antidepressants, Preskorn asked the audience. “First and foremost, you have to realize that the FDA only requires superiority over placebo for approval. There is no requirement that a new drug is superior to antidepressants, be it superior either in efficacy or tolerability… 

“The second thing is psychiatric drug development for antidepressants and antipsychotics has, for 60 years, mainly been reshuffling the relative receptor binding affinity of biogenic amine mechanisms of action,” he added. “So they all work on the same neurotransmitter system.”

To better help understand the situation, Preskorn gave the example of a patient with pneumonia. Out of the patients treated with penicillin 1, a certain percentage will get better. For those who do not, they receive penicillin 2, and a smaller percentage is likely to get better because you have the infectious agent causing the pneumonia does not respond to penicillin.

Although shuffling identical mechanisms has not necessarily improved efficacy, Preskorn noted it has improved safety and tolerability. “That's the reason why SSRIs, SNRIs, and other newer antidepressants have replaced tricyclic antidepressants—not because they are more efficacious, but because they are safer and better tolerated,” he explained. Preskorn added it is also why there is a meaningful subset of patients with seemingly treatment resistant depression, because they are not responding to biogenic amine antidepressants.

1. Rush AJ, Trivedi MH, Wisniewski SR, et al. 

Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression.

2. Trivedi MH, Rush AJ, Wisniewski SR, et al. 

Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice.

3. Fava M, Rush AJ, Wisniewski SR, et al.

 A comparison of mirtazapine and nortriptyline following two consecutive failed medication treatments for depressed outpatients: a STAR*D report.

4. McGrath PJ, Stewart JW, Fava M, et al. 

Tranylcypromine versus venlafaxine plus mirtazapine following three failed antidepressant medication trials for depression: a STAR*D report.

Sheldon Preskorn, MD, shares insights into drug mechanisms and delivery to better help patients with major depressive disorder. 

Understanding Major Depressive Disorder and Treatment Resistance

Rick Doblin, PhD, in his talk at the 2021 Annual 

 World CME Conference, gave an overview of the recent research on psychedelics in psychiatry. Doblin is the founder and executive director of Multidisciplinary Association for Psychedelic Studies (MAPS), which has raised more than $115 million in grants and donations for psychedelic therapy and medical marijuana research and education.

“MAPS has been practicing psychedelic science for 35 years,” shared Doblin.

According to Doblin, phase 3 trial results

 examining 3,4-methylenedioxy-methamphetamine (MDMA)-assisted therapy for posttraumatic stress disorder (PTSD) look promising, as echoed by a number of publications, including 

 By the study’s end, two-thirds of the MDMA group no longer qualified for a PTSD diagnosis after 3 MDMA sessions. There was a small p value (0.0001), a large effect size (0.91 and 2.1), no site-to-site variability, a good safety profile, and results were replicated from phase 2 trials. The 12-month follow up results will be available next year.

Doblin also believes psychedelics show promise in treating depression,

 and even demoralization in AIDS survivors.

“I really think psychedelics will play a major role in psychiatry in the future,” concluded Doblin.

1. Mitchell JM, Bogenschutz M, Lilienstein A, et al. 

MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study.

2. Jacobs A. The psychedelic revolution is coming. Psychiatry may never be the same. 

. May 9, 2021. Accessed October 2, 2021. 

https://www.nytimes.com/2021/05/09/health/psychedelics-mdma-psilocybin-molly-mental-health.html

3. Cormier Z. MDMA shows new promise for trauma, but the drug alone is not a cure. 

. May 12, 2021. Accessed October 2, 2021. 

https://www.scientificamerican.com/article/mdma-shows-new-promise-for-trauma-but-the-drug-alone-is-not-a-cure/

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

Trial of psilocybin versus escitalopram for depression.

5. Bogenschutz MP, Forcehimes AA, Pommy JA, et al. 

Psilocybin-assisted treatment for alcohol dependence: a proof-of-concept study.

A potential role for psilocybin in the treatment of obsessive-compulsive disorder. 

7. Anderson BT, Danforth A, Daroff PR, et al. 

Psilocybin-assisted group therapy for demoralized older long-term AIDS survivor men: an open-label safety and feasibility pilot study. 

Phase 3 results on MDMA-assisted therapy look promising for the treatment of PTSD. What other disorders can psychedelics help treat? 

Psychedelics: Psychiatry of the Future

“I think the DSM gives you one sense of depression,” Sidney Zisook, MD, told attendees of the 2021 Annual 

 World CME Conference. “But I think it's very, very one dimensional. A better way of really understanding what it is to be depressed and the diagnosis is getting firsthand accounts from those who have dealt with depression.”

Zisook, director of the University of California, San Diego (UCSD) Residency Training Program, Distinguished Professor of Psychiatry at UCSD, and last year’s Educator of the Year awardee, shared insights from several famous folks about their experiences with depression. Of depression, David Foster Wallace said:

It is a level of psychic pain wholly incompatible with human life as we know it. It is a sense of radical and thoroughgoing evil not just as a feature but as the essence of conscious existence. It is a sense of poisoning that pervades the self at the self’s most elementary levels. It is a nausea of the cells and soul.

This quote, and others like it, show a sense of hopelessness, even suicidality, more than other aspects of depression, including those recognized by the DSM 5, he noted.

To better understand the current state of diagnosis, Zisook took attendees back in time to discuss the various iterations of depression in the DSM, from being classified as psychoneurotic disorder in DSM I in 1952 through the psychoanalytic approaches through the specifiers in DSM IV. Changes continued into DSM 5, where we now have a variety of disorders: major depressive disorder, disruptive mood dysregulation disorder, persistent depressive disorders, substance- and medication-induced depressive disorder, premenstrual dysphoric disorder, depressive disorder due to another medical condition, and other specified (or unspecified) depressive disorder.

To help illustrate the problems associated with the current system, Zisook shared 2 case examples. Ms A is a 30 year old married woman complaining of stress. Upon further exploration, you learn she has been tearful and increasingly sad since her mother received a diagnosis of cancer. She has little motivation, is overeating and gaining weight, and sleeps about 12 hours a day. She has never felt like this before.

On the other hand, Mr B is a 60 year old man who is brought to you by the police after found wandering on the Coronado Bridge. He is unshaven, slovenly, and demonstrates psychomotor retardation. He shows no interest in answering questions, but an informant tells you he has not been eating or drinking for weeks. He has expressed feeling miserable and worthless. He had a similar episode 30 years prior; he achieved full recovery after responding to electroconvulsive therapy.

“What do they have in common?” Zisook asked rhetorically. “Definitely nothing except the diagnosis of major depressive disorder—without any overlap in functioning.”

In reviewing DSM 5 criteria, he posed a few questions for the authors of DSM 6 to consider. For instance, why must symptoms last 2 weeks? “This never made much sense to me,” he said. “Somebody is undergoing a horrible situation—they lost their job, they've lost their family, they've lost their money—they've never been depressed before, and the depression is relatively mild, moderate. You don't want to label them with a major depressive disorder in 2 weeks. Give me more time to see what happens. Let them take care of some of the situations.”

“On the other hand,” Zisook added, “if they had a history of severe major depressive disorder, and for the last 2 days they're despondent, hopeless, feeling worthless, feeling suicidal, you have got to wait another 12 days to make the diagnosis.”

To better understand the diagnosis, again Zisook looked to patients. He discussed studies conducted by Mark Zimmerman, MD, and colleagues looking at what was needed for patients with depression to consider themselves in remission.

 The top 3 features were: positive mental health, such as optimism and self-confidence; a return to one’s usual, normal self; and a return to a usual level of functioning. Interestingly, one-quarter of respondents who were mildly symptomatic and, per HAM-D scores, not in remission considered themselves remitters. As such, they reported better quality of life, less functional impairment due to depression, higher positive mental health scores, and better coping ability.

I diagnose depression not by counting the number of symptoms for a certain number of weeks. But is the low mood persistent, is it there most of the time, has it been there for a while? It is pervasive—affecting the way you work, the way you interact with other people, the way you function, the way you parent, etc. For me that's better than the screening questionnaire or the DSM 5 criteria.

So, how does Zisook define and diagnosis depression? “There are screening instruments, which is fine for looking at depression,” he told attendees. “But I think there's nothing to substitute for clinical inquiry. And I diagnose depression not by counting the number of symptoms for a certain number of weeks. But is the low mood persistent, is it there most of the time, has it been there for a while? It is pervasive—affecting the way you work, the way you interact with other people, the way you function, the way you parent, etc. For me that's better than the screening questionnaire or the DSM 5 criteria.”

He also reminded attendees that differential diagnosis is very important, adding “Always look for bipolar disorder or general medical conditions.” Bereavement and burnout also need special attention, he explained, since those are often misdiagnosed and/or confused with depression. A careful examination of the criteria and symptoms will help to distinguish the disorders.

Zisook concluded by saying, “I think our diagnostic concepts are a work in progress in terms of helping us communicate with each other, helping us take into account what patients are saying about what it feels like to be depressed, and helping us to prescribe very personalized medications.”

1. Zimmerman M, McGlinchey JB, Posternak MA, et al. 

How should remission from depression be defined? The depressed patient's perspective

2. Zimmerman M, Martinez J, Attiullah N, et al. 

Why do some depressed outpatients who are not in remission according to the hamilton depression rating scale nonetheless consider themselves to be in remission?

Sidney Zisook, MD, shares insights into defining depression diagnosis.

Defining and Diagnosing Depression: Clinical and Patient-Oriented Perspectives

“Adolescence is a critical period, with increased risk for cannabis and, in particular, high tetrahydrocannabinol (THC) potency cannabis use. This may represent a public health crisis,” Christopher J. Hammond, MD, PhD, shared with attendees of the 

In his presentation, “Impact of THC on Adolescents: Neurodevelopment,” Hammond shared that chronic adolescent THC exposure across animal and human studies is associated with disruptions or alterations in brain development. Furthermore, it is associated with adverse mental health outcomes, including depression and anxiety.

“Contrary to a lot of what the popular media messaging has communicated to us, data across studies of young people show that adolescents that use cannabis regularly and who cut down or stop using cannabis show reductions in depression and anxiety and improvements in cognition,” said Hammond.

Abstinence from cannabis for 3 to 4 weeks could reduce anxiety and depression, improve sleep, and boost cognition in adolescent regular cannabis users.

Cannabis is the most commonly used federally illicit drug by US youth, and it accounts for more than 75% of teen admissions to substance use treatment. About 1.4 million adolescents try cannabis for the first time each year.

Early onset of cannabis use, according to Hammond, could lead to a number of health issues, including major depressive disorder, alcohol use disorders, substance use disorders, suicidality, anxiety disorders, bipolar disorders, psychosis, and delinquent behaviors.

“There appears to be a relatively consistent pattern of findings showing that adolescent cannabis use is associated in a dose dependent manner with poor outcomes in academic and occupational functioning, cognition, and psychiatric and substance use outcomes, and that these may be worse for young people with mental health problems,” said Hammond.

Adolescent cannabis use could also lead to potential long-term brain effects, like dysfunction in white matter tracts, altered brain waves, and decreased brain blood flow. These effects are larger and more consistent with earlier age of onset and heavy use.

“As more data comes in, we can further update and inform this field, but using the data as it exists now is important,” concluded Hammond.

1. Jacobus J, Squeglia LM, Escobar S, et al. 

Changes in marijuana use symptoms and emotional functioning over 28-days of monitored abstinence in adolescent marijuana users. 

Reductions in cannabis use are associated with mood improvement in female emerging adults.

3. Hanson KL, Winward JL, Schweinsburg AD, et al. 

Longitudinal study of cognition among adolescent marijuana users over three weeks of abstinence.

4. Hammond CJ, Chaney A, Hendrickson B, Sharma P. 

Cannabis use among U.S. adolescents in the era of marijuana legalization: a review of changing use patterns, comorbidity, and health correlates.

5. Morgan CJ, Gardener C, Schafer G, et al. 

Sub-chronic impact of cannabinoids in street cannabis on cognition, psychotic-like symptoms and psychological well-being.

6. Arterberry BJ, Padovano HT, Foster KT, et al. 

Higher average potency across the United States is associated with progression to first cannabis use disorder symptom.

7. DiForti M, Quattrone D, Freeman TP, et al. 

The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study.

8. Hines LA, Freeman TP, Gage SH, et al. 

Association of high-potency cannabis use with mental health and substance use in adolescence.

Chronic adolescent exposure to THC and cannabis could lead to adverse mental health outcomes and impacted brain functioning. 

Chronic Adolescent THC Exposure: Mental Health Crisis? 

“For us to say that this has been a time of change, stress, and loss is an understatement,” 

. “Because the COVID pandemic has fundamentally taken the rug from underneath our feet, change the fabric of how we live our lives, how we work, and understandably, the amount of change and stress is very palpable and the amount of loss is even more.”

Iglewicz, assistant clinical professor of psychiatry at the University of California at San Diego, shared insights on the impact of COVID-19 on health care workers, specifically looking at burnout. In addition to the regular stressors, health care professionals faced many challenges during the height of the pandemic. Work-life balance was disrupted, there were longer shifts, and fears about personal risk and risk to family members abounded, she explained. There also were increased home-life demands associated with children’s virtual school, caregiver burdens, and a general sense of lack of control.

A recent study of COVID-19 and stressors looked at close to 21,000 health care professionals between May and October 2020 and found alarming rates of burnout and stress, Iglewicz reported.

 Investigators found that 61% feared exposure transmission, 38% reported anxiety or depression, 43% reported work overload, and 49% reported burnout. Not surprisingly, there were some gender and racial differences, she said. Higher rates of burnout were found among females and those from minoritized backgrounds.

Despite the pandemic’s impact on stress, Iglewicz reminded attendees that burnout has been an issue for years, and it has even garnered media attention due to its very real consequences. In health care, burnout can impact patients, the health care system, and the induvial, she explained. In patient care, burnout leads to worse patient outcomes and increased medical errors, Iglewicz said. On systems level, there is a drop in productivity as well as a great cost in replacing clinicians. On an individual level, burnout can lead to substance use and abuse, depression and suicidal ideation, and even an increase in motor vehicle accidents, she said.

Fortunately, there was some improvement in burnout found before the pandemic, Iglewicz explained. She shared details from a study by Tait D. Shanafelt, MD, and colleagues, that looked at rates of burnout in 2011, 2014, and 2017.

 There were a lot of interventions between 2014 and 2017, she noted, and, accordingly, Shanafelt et al found a slight decrease in burnout reports in the 2017 data. Interestingly, she said psychiatrists had some of the lowest reported rates of burnout. “But it's still unacceptable,” Iglewicz added, “as about 50% of psychiatrists are experiencing burnout.”

“Maybe we have gotten some of this wrong,” Iglewicz said of the attempts to address burnout. She used the analogy of the straw that broke the camels back. “We put our focus on trying to make that camel stronger. Tell the camel to meditate, teach that camel to be more mindful, tell that camel: You better sleep more, better eat healthier. Encourage that camel to exercise, and coach that camel to be more resilient.”

“We realized that there was a flaw,” she explained, “because we were essentially blaming the victim.”

Then the shift to address burnout fell on the habitat, Iglewicz said. Things like electronic health records, excessive workloads, and clerical burdens were addressed. Although these are important aspects, it still involved finger-pointing. She suggested it would be more productive to move to an understanding and self-introspective perspective.

Since words have meaning, Iglewicz entertained the idea of changing the term 

. She suggested “loss of meaning.” Essentially, folks enter medicine with idealistic notions, and now their work no longer matches those notions and they have a loss of meaning in their work

Similarly, she suggested considering burnout as unresolved grief. In other words, she said, there is so much to mourn in terms of why people entered the medical field. With this definition, it allows you to face the limitations and begin to accept it. 

Finally, burnout in the health care field may be code for depression, she suggested. There is no stigma associated with the term 

; it is tossed around casually in conversations, the media, and the like. There is still, however, stigma associated with depression. Looking at the issues associated with both, Iglewicz said there really is a very fine line between depression and burnout.

So, what can be done to address burnout, loss of meaning, and unresolved grief? The first step, she said, is that clinicians must become reformed perfectionists. “The same traits that helped us get into medical school comes with a price,” she said. She noted perfectionism, detail-oriented focus, desire for control, empathy, and competitiveness. Whenever possible, she said try to turn down the level perfectionism, even in your personal life. Let the struggles, hurdles, and adversities refine you, not define you, she explained.

It is also important to engage in system level change, she added. And, although it should not be a singular focus, self-care is indeed important, she said.

She then shared 5 antidotes to burnout: find a health relationship with anger, pick your battles, practice ordinary kindness and compassion, support one another and seek out support when needed, and live with contradictory truths.

Iglewicz took the opportunity to conclude her talk with a contradictory truth that rings very true on the subject of burnout: “We're all stronger than we know. Simultaneously, we are all more vulnerable than we'd like to acknowledge.”

1. Prasad K, McLoughlin C, Stillman M, et al. P

revalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: a national cross-sectional survey study

2. Shanafelt TD, West CP, Sinsky C, et al. 

Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017

Health care workers have always been prone to stress and burnout, and the COVID-19 pandemic exacerbated the issue. What do we know about burnout and how can we prevent and address it? 

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