Conferences

Brian Hurley, MD, MBA, DFASAM, gives a summary on his talk on motivational interviewing from the 

2022 Annual Psychiatric Times™ World CME Conference

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

Videos

Psychiatric Times World CME Conference

Here's how to listen to patients and offer selective reflections. 

Motivational Interviewing: Partnering With Patients

Michael E. Thase, MD, gives a summary of his exciting talk on difficult to treat depression from the 

is a professor of psychiatry at the Perelman School of Medicine University of Pennsylvania.

What are the latest treatments in difficult to treat depression? 

Exciting Developments for Difficult to Treat Depression

Hormonal changes are among a host of issues that can influence psychiatry and medical conditions in women, and being aware of the total picture can deeply impact these patient’s treatment, C. Neill Epperson, MD told attendees at the 2022 

 World CME Conference being held in San Diego this week.

Epperson, who is a professor and chair of the department of psychiatry at the University of Colorado in Aurora, Colorado, discussed the interaction between the endocrine system, early childhood influences, the brain, and the nervous system at the meeting.

Epperson noted that it is important for psychiatrists to consider the

when treating patients, particularly as it relates to women, since there are pronounced differences between genders in how hormones impact their mental health. The differences in how hormone treatments affect women begin in adolescence she said, with young girls twice as likely than male counterparts to be prescribed a steroid, often related to addressing unprotected sexual intercourse at sexual debut.

“Always think about what kind of steroid/contraception they are on, as they can profoundly affect the endocrine system,” Epperson explained. This is also true for women who are menopausal, as hormones have been shown to influence executive function, sexuality, cardiovascular disease, and mental health issues including major depressive disorder in women undergoing life transition. Postpartum, oxytocin has been shown to play a key role in milk letdown and uterine contraction, and it has a profound impact on maternal nurturing. 

“I’m not saying it’s all about the hormones, but I am saying if you don’t think about it you’re missing a big piece of the puzzle,” Epperson said.

Shifting gears to another “piece of the puzzle,” Epperson addressed how early life experience can impact hormones, which in turn can have an influence on a patient’s mental health. She discussed the work ofIda Haahr-Pedersen, PhD, from Trinity Center for Global Health in Dublin, Ireland, and colleagues in a study that looked at 1839 US household survey participants and assessed self-reported rates of 

The investigators found that women were twice as likely as their male counterparts to report ACE as well as social and emotional difficulties in childhood. 

In perimenopausal women, Epperson said, the most common ACEs associated with 4+ status for women included emotional abuse, domestic violence, emotional neglect, and physical neglect, and 15% of women in this age range are in the 4+ ACE group. There is also wide variability of ACE impact on women depending upon where they live, so taking that into account when considering how to interact with patients, and female patients in particular, is important as well, she said.

Looking at the total picture of the patient, including medication they may be taking, in addition to performing a thorough initial assessment that assesses past trauma, is key to helping address any mental health issues that may present, Epperson concluded.

1. Epperson N. Practical psychoneuroendocrinology: how the brain, nervous system, and endocrine system interact. Presented at: 

2022 Annual Psychiatric TimesTM World CME Conference

2. Haahr-Pedersen I, Perera C, Hyland P, et al. 

Females have more complex patterns of childhood adversity: Implications for mental, social, and emotional outcomes in childhood

Articles

The endocrine system is an important puzzle piece when addressing psychiatric disorders. 

Consider the Endocrine System When Addressing Mental Health

In his presentation, “How to Assess/Diagnose Childhood Trauma,” at the 

 in San Diego, Mark B. Hamner, MD pointed out that the Department of Health and Human Services data on child abuse underestimates traumatic exposure, given they only address abuse and not other traumas. “And abuse is often not reported,” he added.

Children can experience a number of traumatic experiences beyond physical, sexual, or psychological abuse and neglect, said Hamner, including: natural disasters or terrorism; family or community violence; the sudden or violent loss of a loved one; substance use disorder either personally or within their family; refugee and war experiences, including torture; serious accidents or life-threatening illness; military family related stressors, like deployment or parental loss, can all play a part in the child’s traumatic history.

Additionally, in the National Comorbidity Survey Replication Adolescent supplement, which looked at a national survey of adolescents aged 13 to 17, the lifetime prevalence of DSM-IV PTSD was 4.7% higher in girls.

Children and adolescents who identify as part of the LGBTQ+ community experience trauma at unique, higher rates. Common traumas include bullying, harassment, traumatic loss, intimate partner violence, physical and sexual abuse, stigma, and more.

“Somatization is a significant posttraumatic stress symptom,” said Hamner. “Some have argued this should be included in diagnostic criteria.”

An exemplifying study looked at the relationship between PTSD symptoms and somatization, and between intelligence and somatization in child sexual abuse victims to determine whether the type of abuse had an effect on the relationship between PTSD symptoms and somatization.

The study concluded that somatization in children who were sexually abused was influenced by the severity of PTSD symptoms and intelligence, and the effect of the PTSD symptoms on somatization was moderated by type of abuse.

When screening children and adolescents for trauma, Hamner shared a few tips that might help. 1. Make time in therapy sessions to complete screening measures with family members.

2. Allow the parent and child to choose the language in which the screen is completed.

3. Use developmentally appropriate strategies, like a chalk or dry erase board.

4. Let them decide the order in which they complete measures when possible.

6. If child is resistant, read aloud to them.

7. Offer to complete over 1 to 3 sessions.

8. Praise all children and parents for “hard work.”

9. Check endorsement of critical items like hurting oneself and develop safety plan.

10. Take time to explain what will happen next and clarify that you will readminister measures on an ongoing basis.

The National Child Traumatic Stress Network is an important resource, Hamner also noted. Specifically, he mentioned their Child and Adolescent Trauma Screen (CATS) instrument.

 It is downloadable and brief, taking only 5 to 10 minutes to complete. This could be a helpful tool in the screening arsenal, he said.

“There are the unique developmental considerations in this age range,” concluded Hamner. “It’s a vastly under researched area, not only in terms of epidemiology but also in terms of treatments.”

PTSD correlates with somatization in sexually abused children: type of abuse moderates the effect of PTSD on somatization.

2. Child and Adolescent Trauma Screen. International Society for Traumatic Stress Studies. Accessed August 12, 2022. 

https://istss.org/clinical-resources/child-trauma-assessments/child-and-adolescent-trauma-screen-(cats)

How do you screen for childhood trauma? One doctor at the 2022 Annual Psychiatric Times™ World CME Conference in San Diego, one doctor shared his most helpful tips.

Childhood Trauma: 10 Tips for Screening and More 

Although psychotherapy is first-line treatment for posttraumatic stress disorder (PTSD), there are a few psychopharmacological options that may be useful, Mark B. Hamner, MD, told attendees at the 

Antidepressants are currently considered the mainstay medication for 

, Hamner said, and sertraline and paroxetine are the 2 selective serotonin reuptake inhibitors approved by the FDA for this indication. Hamner is professor of psychiatry and behavioral sciences at the Medical University of South Carolina as well as the director of psychopharmacology research and medical director of the PTSD Clinical Team in the Department of Veterans Affairs Medical Center in Charleston.

Venlafaxine, a serotonin and noradrenaline reuptake inhibitor, has also shown efficacy in clinical trials, he reported. Specifically, in a 6-month placebo-controlled randomized trial (RCT) (N=329), venlafaxine (mean dose = 221.5 mg/day) has been shown to be helpful in reducing re-experiencing and avoidance/numbing; however, it did not seem to address hyperarousal. He also discussed a 12-week RCT of venlafaxine, placebo

 In addition to improvement as measured by Clinician-Administered PTSD Scale (CAPS), investigators found remission in 30.2% of patients on venlafaxine versus 24.3% on sertraline and 19.6% on placebo.

Hamner said other classes of the medications have been discussed for addressing PTSD. Although 

 have been considered, he noted they are not indicated per current treatment guidelines. Mixed data is the name of the game for other classes, according to Hamner. For antipsychotics, for instance, one VA cooperative study of risperidone was negative, while another RCT of quetiapine was positive, he said.

 A current study of hypnotics is in progress, he added. 

Antiadrenergic agents have also seen mixed data. The α1-adrenoreceptor antagonist 

 has also been of interest, Hamner reported, with some efficacy in alleviating nightmares associated with PTSD in military veterans. However, Hamner also reported results of a large RCT VA cooperative study (N=304, 13 sties) in which participants were randomly assigned to receive prazosin or placebo for 26 weeks.

 Investigators failed to find a significant differences between the prazosin group and the placebo group in the mean change from baseline in the CAPS item B2 score, in the mean change in Pittsburgh Sleep Quality Index (PSQI) score, or in the Clinical Global Impression of Change (CGIC) score, he said.

“More studies are needed of medications alone or in combination,” Hamner concluded. He further reminded attendees, “Psychotherapy is an essential, first line treatment for PTSD; evidence-based psychotherapies that are trauma-focused have larger treatment effect sizes than antidepressant medications.”

1. Davidson J, Baldwin D, Stein DJ, et al. Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled trial. 

2. Davidson J, Rothbaum BO, Tucker P, Asnis G, Benattia I, Musgnung JJ. Venlafaxine extended release in posttraumatic stress disorder: a sertraline- and placebo-controlled study [published correction appears in J Clin Psychopharmacol. 2006 Oct;26(5):473. Dosage error in article text]. 

3. VA/DoD Clinical Practice Guidelines: Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017. https://www.healthquality.va.gov/guidelines/MH/ptsd/ Accessed August 18, 2022.

4. Raskind MA, Peskind ER, Chow B, et al. Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans. 

Despite mixed data, there are some psychopharmacological options for treating PTSD.

Exploring Psychopharmacology for PTSD

Ben Greenberg, MD, PhD, shares some key takeaways from his presentation on methods of neuromodulation with Dhakshin Ramanathan, MD, PhD, of the University of California, San Diego, at the 

is director of COBRE Center for Neuromodulation at Butler Hospital.

What are some of the most exciting emerging and established methods?

An Update on Neuromodulation

Joseph F. Goldberg, MD, shares some key takeaways from “Medical Crossfire: Treatment Approaches to Mixed Features of Bipolar vs Unipolar Depression,” his discussion with Sanjai Rao, MD, of the University of California, San Diego, and Nassir Ghaemi, MD, of Tufts University School of Medicine, at the 

is a clinical professor of psychiatry at Mount Sinai School of Medicine.

Treatment Approaches to Mixed Features of Bipolar vs Unipolar Depression

 Editor in Chief John J. Miller, MD, discusses cannabis, its complex web of effects, and the importance of conducting more research at the 

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

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

Here's why more research is important to help us better understand the effects of cannabis on our patients.

Taking a Deeper Dive Into the Cannabis Story

Larry Culpepper, MD, MPH, discusses how clinicians can most effectively understand and address the effects of trauma on patients at the 

is professor of family medicine at Boston University School of Medicine.

How can we, as clinicians, understand how trauma has affected our patients and respond in the most effective way?

Trauma: Understanding How it Affects a Patient and How to Help

Delineating between major depressive disorder (MDD) and grief is essential to putting your patient on their path to healing, according to a speaker at the 

M. Katherine Shear, MD, who is professor of psychiatry with Columbia School of Social Work, discussed bereavement, grief, and depression in a special report on MDD held during the meeting.

She noted that it is important to note that “

,” and that a thorough initial assessment and differential diagnosis are both essential to best treat your patients.

Shear provided a framework for assessing grief severity to help delineate grief from depression, noting that the Inventory of Complicated Grief includes 19 items within a 5-point scale, which assesses emotional, cognitive, or behavioral symptoms. A score of more than 30 is considered “clinically significant” grief symptoms. Similarly, the Work and Social Adjustment Scale details 5 items to help identify grief, and a score of 10 or more can be deemed clinically significant impairment due to grief.

Commonly reported symptoms related to grief include: yearning for the person who has died, disbelief, pangs of intense emotion, avoidance or reminders of the loss, sense of confusion, feeling disconnected, being self-critical, and difficulty managing strong emotions, Shear explained. Those patients who report that they are experiencing yearning/longing and are preoccupied with the loss, and also report at least three of the mentioned grief symptoms for more than a year since the loss occurred may be dealing with prolonged grief disorder.

“When these symptoms are persistent and they don’t come and go, and they stay in a way that’s interfering with their lives, that’s when we have prolonged grief disorder,” Shear said.

There are some key distinguishing factors between grief and depression, Shear said, noting that patients who are experiencing grief often have happy, pleasant memories intermixed with emotional pain, loss of interest, guilt, and self-blame related and centered on longing for the deceased. Similarly, in patients experiencing grief, suicidality is related to longing for reunion and or not wanting to live without the decesased. In contrast, in patients with depression, emotional pain is often pervasive, as is loss of interest and pleasure.Guilt and self-blame in patients with depression are often related to feelings of worthlessness or being a “bad person,” and suicidality is related to feelings of hopelessness.

With those differences in mind, Shear noted, it is key to tailor the therapeutic approach for each patient using evidence-informed treatment.

“We do have good treatments for prolonged grief disorder therapy,” she said, with new treatments frequently emerging. Grief specific cognitive-behavioral therapy, interpersonal psychotherapy and complicated grief treatment are all options that have been explored patients, many with strong results.

Shear encouraged the psychiatric professionals in attendance at the meeting to facilitate the patient’s adaptation to the loss by helping them understand and accept their grief, manage their emotions, strengthening their relationships, and connect with their memories of the person who died, while also seeing a promising future for themselves.

Addressing impediments, including disbelief, protest, counterfactual thinking, caregiver self- blame, and avoidance of situations that remind them about the person who passed, in addition to avoiding closeness to others, can all help the patient reach healing milestones.

Shear encouraged health care providers seeking more information on grief to visit https:prolongedgrief.columbia.edu.

Shear KM. Bereavement and depression. Presented at: 2022 Annual 

 World CME Conference. Aug. 11-13, 2022. San Diego.

Is it prolonged grief or MDD? Expert shares insights at premiere annual meeting.  

Latest Conference Articles