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The history of psychiatry does not lack for great names. One of the greatest must be Helen Flanders Dunbar, MD, PhD. Widely recognized as the prime mover behind the psychosomatic medicine movement, she was a clinician, writer, the inaugural editor of 

 In addition, Dunbar’s work was essential to the development of consultation-liaison psychiatry. She also dedicated her professional life to promoting the role of clergy in medicine and exploring accident proneness. She lived a full, brilliant, and ultimately tragic life.

 Her father was a mathematician, engineer, and patent attorney; her mother a genealogist; and her brother, Francis, earned a master’s degree in botany at Stanford University. She, too, received a remarkable education. At Bryn Mawr College and Columbia Universityshe majored in mathematics and psychology. She then went on to earn 4 advanced degrees in 7 years. Dunbar attended 

 for medicine and obstetrics. She wrote a doctoral thesis on Dante at Columbia, while graduating magna cum laude from nearby Union Theological Seminary.

Her Episcopalian faith was a guiding light in her life, and she believed it should inform her medical practice. Dunbar worked closely with Anton Boisen, a clergyman inpatient at Westboro Mental Hospital who was convinced that religion and psychiatry needed to be connected on a professional level. Together they trained ministers to work in medical settings.

In 1929, Dunbar broadened her medical and spiritual horizons by traveling to Europe. She met the day’s leading figures in psychiatry and visited Lourdes, the world’s most famous healing shrine in France. This visit had a profound spiritual effect.

She legally changed her name to Flanders Dunbar in 1938. It is disappointing that such an accomplished woman had to change her name to overcome the prevailing misogyny.

From 1930 to 1942, Dunbar was the medical director of the Council for Clinical Training of Theological Students and director of the Joint Committee on Religion and Medicine. During this time, she earned the sobriquet of “mother of holistic medicine” with her 1935 publication of 

Emotions and Bodily Changes: A Survey of Literature on Psychosomatic Interrelationships: 1910-1933.

 In 1939, she became the first editor of the journal Psychosomatic Medicine.

American psychosomatic medicine was born in the 1930s. According to this school of thought, illnesses arose from the physiological effects of emotional stimuli. It was thought that certain psychodynamic patterns created typical illnesses, known as organ specificity. Repressed (and forgotten) emotions emerged from the unconscious to target certain organs, producing psychosomatic disorders. Somatic dysfunctions thus arose from patients’ emotional problems, which led practitioners of psychosomatic medicine to search for psychological profiles characteristic of specific syndromes. This expanded further to the belief that many diseases were psychogenic in origin and stressors, albeit undefined. Dunbar believed that having accidents was similar to the process by which other patients transformed psychological conflicts into somatic symptoms. Their personality styles and neuroses translated into accident proneness.

After 1939, Dunbar gave up academic commitments, drank heavily, alienated followers, and left the American Psychosomatic Society. On August 22, 1959, the publication day of her landmark book Psychiatry in the Medical Specialties,

Marcia Dunbar Soule, Dunbar’s daughter, referred to her mother as “a magnetic, charismatic woman with a disturbed and beautiful soul and an almost magical gift of insight and intuition.”

 It is difficult to put it any better, only to reflect that the passage of time may vindicate more of the views Dunbar held.

s clinical associate professor at the Graduate School of Medicine, University of Wollongong, Australia, and research fellow in the history department of Stellenbosch University, South Africa. He wrote about syphilis in the book 

The Exceptional Brain and How It Changed the World

, and is currently writing a biography of Helen Flanders Dunbar

1. Ozarin L. A psychiatric pioneer remembered. 

https://psychnews.psychiatryonline.org/doi/full/10.1176%2Fpn.41.5.0025

2. Kemp HV. Helen Flanders Dunbar (1902-1959). American Psychological Association Society for the Psychology of Women. 2010. Accessed February 16, 2021. 

https://www.apadivisions.org/division-35/about/heritage/helen-dunbar-biography

3. Powell RC. Emotionally, soulfully, spiritually ‘free to think and act’: the Helen Flanders Dunbar (1902–59) memorial lecture on psychosomatic medicine and pastoral care. 

5. Dunbar HF, Wolfe TP, Rioch JM. Psychiatric aspects of medical problems: the psychic component of the disease process (including convalescence), in cardiac, diabetic, and fracture patients. 

6. Dunbar HF, Wolfe TP, Tauber ES, Brush AL, Coffin M. The psychic component of the disease process (including convalescence), in cardiac, diabetic, and fracture patients. Part II. 

Widely recognized as the prime mover behind the psychosomatic medicine movement, Helen Flanders Dunbar, MD, PhD. was a clinician, writer, and founder of the American Psychosomatic Society.

A Pioneer of Psychosomatic Medicine

LGBTQ COMMITTEE OF THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

As the number of COVID-19 cases in the United States hits 30 million and continues to cause widespread pain in lives lost and economic devastation, sexual and gender minority youth face particular hardships threatening their lives, mental health, and social development.

In particular, social isolation may be especially challenging. These youths may be quarantining with rejecting family-members and losing contact with supportive social networks. The nature of quarantining means these problems are invisible to the public.

“Aiden,” a 16-year-old boy who is transgender, lives in a community particularly hard-hit by COVID-19. Aiden’s parents refuse to accept his gender identity or call him by his male name or use male pronouns. They frequently yell at Aiden to dress and act like a girl, assigning dishwashing and laundry chores to him alone, and not to his brother, to get him “used to doing girl stuff like you are supposed to.”

Serial COVID-19 outbreaks at Aiden’s school forced him into remote learning. His family has only 1 computer, shared by Aiden and his brother for schoolwork and Aiden’s mother for church meetings. Aiden’s parents banned him from using social media or communicating with friends because his parents believe “that’s where she picked up all this nonsense.” Aiden became completely disconnected from his friends. He was also cut off from affirming and supportive teachers. As tensions in Aiden’s family escalated, fighting became the only interaction between him and his parents.

One evening during a fierce argument, Aiden’s mother pushed him, and he pushed her back. As a result, she fell and had a small laceration on her shoulder. Aiden’s father became angry and punched Aiden in the face. Aiden’s brother called 911. The police arrested Aiden and his father. Aiden was released from jail to a Child Protective Services emergency residence. Because of COVID-19, he was required to spend 14 days isolated in his room, including mealtimes, and was unable to receive visitors. He also faced misdemeanor charges for assaulting his mother. His father also faced charges. Aiden was afraid of returning home because he was petrified of what his father might do to him.

Administration for Children’s Services (ACS) attempted to reunify Aiden with his parents, but over a period of several months, each attempt resulted in further physical altercations between Aiden and his father. Aiden moved into a group home where peers bullied him because of his gender identity. ACS was unable to address the problem because several staff members were hospitalized with COVID-19, and no other group homes were available for transfer. After a bully hit him, Aiden ran away from the group home, and the police could not locate him.

Even before COVID-19, lesbian, gay, bisexual, transgender, questioning (LGBTQ) youth were at 

 of depression, suicidality, and tobacco, alcohol, and other drug use.

 These increased risks stem from elevated rates of rejection, discrimination, and victimization. During the pandemic, risks were further compounded by the loss of relationships in schools, clubs, or other community venues where LGBTQ youth found support and affirmation. Laura Erickson-Schroth, MD, a psychiatrist at the Hetrick-Martin Institute, a New York City-based LGBTQ youth organization, reported that youth members of the institute are looking for more frequent counseling sessions. According to her, there were at least one-third more requests for initial psychiatry visits during 2020 than during the same period in 2019.

 found one-third of the city’s youth in foster care identifies as LGBTQ, an order of magnitude greater than the general population.

 Nearly three-quarters of these youth are Black, and one-third identify as Hispanic/Latino. LGBTQ youth are placed in group homes and other campus settings rather than foster families more often than their non-LGBTQ peers, and they are more likely to be dissatisfied with their placement. The study also found these youth experience a greater burden of depression.

According to Dylan Waguespack, director of public policy and external affairs of 

, 20% to 40% of homeless youth identify as LGBTQ. True Colors United is a national organization dedicated to ending LGBTQ youth homelessness. Although family conflict, involvement in the foster care system, and involvement in the criminal justice system are among the factors that contribute to homelessness among these youth, poverty is often the root cause. Not only are these youth at risk for adverse mental health outcomes because of rejection and discriminatory behaviors, they often face traumatic experiences through conflict with their families, involvement in overwhelmed and poorly informed state programs.

Agencies that previously made efforts to address racial, social, gender, or sexuality based inequities before the pandemic have become even more overwhelmed with the increase in housing and food insecurity, increased unemployment, instability in the agency’s own staff, and the need to rapidly implement physical distancing and other public health measures in routine work. Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications.

Even as the pandemic ends, there may be continual struggles and support needs. Fortunately, there are ways psychiatrists and other mental health care professions can help.

Some of these methods include the following:

Financially donate to organizations that support or serve LGBTQ youth.

Advocate for programs that decrease income inequality and promote housing and food security.

Enable rapid interventions to prevent LGBTQ youth from entering the foster care and criminal justice systems.

Use clinical, teaching, institutional, and forensic roles to speak out and advocate for this vulnerable group of young people.

Share resources and references for supportive organizations with patients who are LGBTQ (

LGBTQ youth have long experienced marginalization and significantly increased risk of poor mental health outcomes. The COVID-19 pandemic sharpened the crisis and brought clarity to the precariousness of social service agencies that address those needs. Strengthening the support system for these youth and their allies and making agencies more inclusive of their voices is critical to help these young people achieve a healthy and fulfilling life.

is the director of the Youth Equity Science/YES Project and senior visiting fellow at Yale Law School. He is also an assistant clinical professor at Columbia University and an adjunct clinical assistant professor at Cornell Weill Medical College.

the medical director emeritus at Weill Cornell Center for Human Rights. Dr Barberis the past president and journal editor for the Association of LGBTQ Psychiatrists and is an MDiv candidate at Union Theological Seminary.

is a community and public psychiatrist in New York City.Dr Drescher is a clinical professor of psychiatry at Columbia University and an adjunct professor at New York University. He is also a distinguished life fellow of the American Psychological Association and the past president of the Group for Advancement of Psychiatry

is an assistant professor of psychiatry at Columbia University Medical Center and a consulting psychiatrist at Hetrick-Martin Institute for LGBTQ youth.

. 2020;18(3):268-276. doi:10.1176.appi.focus.20200018
2. Sandfort TGM. Experiences and well-being of sexual and gender diverse youth in foster care in New York City: disproportionality and disparities. November 2020. Accessed January 5, 2020. 

https://www1.nyc.gov/assets/acs/pdf/about/2020/WellBeingStudyLGBTQ.pdf

Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications. There are 5 ways psychiatrists can help.

Helping LGBTQ Youth During the Pandemic

Treating depression in the context of any other medical disorders can challenge our usual approaches and frustrate our efforts to reach good outcomes. Not surprisingly, this is especially true for patients with depression and 

 (CHD). For example, how should we screen for CHD risks in our patients with recurrent depression? Does it matter which came first, the depression or the heart disease? What is next for patients who do not respond to the second or third antidepressant trial? How does relapse prevention for depression in patients with CHD differ from relapse prevention in those with depression alone?

Psychiatric epidemiology over the past 10 years has given us some useful guideposts for approaching patients with comorbid depression and CHD.

Psychosocial factors, especially recurrent depressive symptoms, severe mental illness, and high numbers of adverse childhood experiences, contribute substantially to both the onset and progression of CHD.

 is as strong as that of the traditional CHD risk factors, such as 

 Since there is no single cause of CHD, it is helpful to consider psychosocial risk factors among the many contributing influences that determine the course of CHD. The more effectively these psychosocial factors are managed, the fewer hurdles patients will face.

 for CHD represent the many faces of autonomic imbalance, hypothalamic-pituitary-adrenal axis dysregulation, and/or low grade inflammation.

 Each of these pathways reflects chronic dysregulation of the stress response system.

 High risk health behaviors common in depression, such as smoking, physical inactivity, and high-carbohydrate diets, add to this dysregulation process.

 Effective treatment of depression in patients at risk for CHD includes reducing these early indicators of metabolic syndrome.

Patients with depression and elevated cardiac risk factors can often be identified in their 30s and 40s, a prime opportunity for 

 in the context of depression treatment and relapse prevention.

 For patients with recurrent depression, psychiatrists can play an essential role, offering both 

 of CHD risks and behavioral interventions for CHD risk reduction.

The most robust psychosocial interventions for CHD are intensive lifestyle medicine programs.

 Psychiatrists can motivate patients with depression to engage in and sustain these behavior changes.

 summarizes the pathways by which depression leads to adverse cardiac outcomes, and it suggests a framework for approaching common dilemmas in assessment and treatment.

“Norma,” a 34-year-old single Black woman comes to see you after her third panic attack on the job as a high school history teacher. She is most concerned about the cat calls and notes passed around by 3 senior athletes insinuating she is gay, which she finds threatening and humiliating. She scores 18 on the Patient Health Questionnaire-9 (PHQ 9). Her history reveals at least 2 other episodes of depression lasting several months at ages 18 and 23, both of which resolved without treatment.

Psychiatrists should consider these important questions as they move forward with such a case (

 More digging may illuminate underlying and complicating issues that need to be considered to develop a successful treatment plan.

 The interrelationship and how one disorder impacts the other is an important consideration in understanding the issues at hand and implementing a treatment plan.

 The preceding questions should lead to this important query. Based on the issues uncovered, it should become obvious which cardiac and depressive symptoms should be monitored to ensure a successful outcome.

Do we keep treatment simple, ie, treat her with sertraline, and see what happens? Or do we dig and look for potential complications? Norma’s blood pressure is 135/90, and her resting heart rate is 88, both of which she attributes to her being nervous about the appointment. Further probing reveals she has had high blood pressure readings at 2 gynecology visits for birth control pills in the past 2 years, but it has never been addressed. Her BMI is 29, and her mother developed 

 at age 46. A metabolic panel ordered at your first visit confirms she has high low-density lipoprotein and, therefore, metabolic syndrome (3 of 5 risk factors for CHD).

On her second visit, you press Norma to return to her gynecologist or establish a relationship with a primary care clinician. In addition to a trial of sertraline, you devote some of each monthly appointment to helping her understand how untreated depression accelerates the development of common risk factors for heart disease. At first, she is alarmed. But eventually Norma is motivated to walk to work instead of riding the bus and give up sweetened drinks, 2 behavior changes that are good for her limbic system as well as her heart.

In most individuals the age of onset for 

 appears to precede the age of onset for CHD by about 30 years. But Norma’s case reminds us that the underlying processes for each illness may begin much closer in time for many individuals. These 2 illnesses, recurrent depression and CHD, may be driven by shared genetic vulnerabilities to stress.

 The bidirectional relationship between depression and CHD—each illness raises the risks for the other—means that we should always suspect that in a given patient the occurrence of 1 illness may accelerate the development of the other. It is also safe to assume that effective treatment of either illness facilitates the treatment or prevention of the other illness. For psychiatrists, this translates into the necessity of effective collaborations with primary care clinicians and cardiologists. It is easier to reverse the course of cardiac risk factors when 

, compared to reversing them after the first heart attack.

Systematic symptom monitoring for depression is especially helpful in the context of physical illnesses symptoms that overlap with depressive symptoms. Serial assessments of depressive symptoms with a PHQ-9 or similar measure improves the efficiency of antidepressant treatment trials. It also charts the relationship between depressive symptoms and the target physical measures of CHD. For example, effective treatment of Norma’s panic attacks and depression may reduce her resting heart rate and her need for antihypertensive medication, or it may not. Serial monitoring of both targets is the most efficient way to establish the relationship between these dimensions of the 2 illnesses.

Choosing a treatment option can be guided by a few considerations, such as previous responses, side effects, and genetic drug metabolism profiles. In the absence of any evidence pointing to or from a specific strategy, the serotonin reuptake inhibitors (SSRIs) sertraline and citalopram have the broadest

from clinical trials of antidepressants in patients with CHD, are well tolerated, and have the fewest clinically relevant drug interactions.

 There is also some evidence that SSRIs may provide a protective anti-inflammatory effect in patients with 

 Serotonin-norepinephrine reuptake inhibitors (SNRIs) are second tier choices only because of their smaller research base. The atypical antidepressant mirtazapine carries a heavier risk for metabolic burden, while bupropion may be a first choice for patients who smoke or those who need to avoid potential sexual side effects. Tricyclic antidepressants, because of their lethality in overdose, should be reserved for patients with malabsorption, since blood levels in tricyclics follow a linear dose-response relationship. Their use requires attention to the 

 of arrhythmias and postural hypotension.

Two areas of drug interactions between antidepressants and CHD medications deserve consideration for special monitoring: anticoagulation and arrhythmias. In some patients, SSRIs may augment the effects of anticoagulants in a clinically significant way. International Normalized Ratio (INR) monitoring provides the best way to adjust the proper doses of both sets of medications. In a similar way, SSRIs may prolong the QT-interval (QTc) in a clinically significant way for some patients on antiarrhythmic medications. Citalopram carries a black box warning about its potential for QTc prolongation. Regular electrocardiogram monitoring provides the standard measure for adjusting these doses or determining when a medication switch is necessary.

Studies of response rates to standard antidepressant treatment trials of both medications and psychotherapies have shown mixed results.

 Psychiatrists can expect to see a disproportionate number of nonresponders and partial responders referred by primary care physicians and cardiologists. Here is where a familiarity with standard approaches to treatment-resistant depression can serve us well. After revisiting the accuracy of our 2 primary diagnoses (major depression and CHD), it helps to scour the terrain for any missed comorbid diagnoses, medical or psychiatric, that could undermine the current treatment efforts. On the psychiatric side of the street, the most commonly missed comorbid conditions include attention-deficit/hyperactivity disorder, anxiety disorders, and substance use disorders. On the medical side, unrecognized or inadequately managed chronic pain and sleep disorders are common disrupters of treatment efforts. Effective management of these comorbid conditions often turns a partial responder into a full responder to antidepressant treatments.

The role of daily self-management plans in the treatment of complex comorbid disorders is often overlooked by psychiatrists. For example, exercise has been shown to be as 

 for the treatment of major depression as cognitive beahvioral therapy and pharmacotherapy,

 yet formal exercise regimens are not a common element of treatment plans for patients with depression. Careful attention to structured, daily self-management plans that address both the depression and the CHD can often turn a partial responder into a responder within months. The intensity of the self-management plan needed to achieve a remission of the depression may require a care manager or a health coach in the early stages of exploring what works and sustaining the habit of practicing the plan.

For almost all patients with complex comorbid chronic disorders, many of whom only partially respond to initial treatments, combined treatment plans that include a course of psychotherapy, care management, and stepped care focused on achieving remission from depression is an investment that brings returns for many years.

The relief and sense of emancipation that comes with recovery from depression invites patient and psychiatrist alike to count our victories and overlook the risks for relapse. Although we have achieved our primary goal of relieving suffering, it is also important to prevent future suffering, and there is no better time to prevent relapse than in the wake of a depressive episode. Given that the risks of recurrence for depression are magnified by CHD, and the consequences of a recurrence are more severe when the management of CHD is undermined by a depressive episode, the stakes are high to prevent a relapse in the months and years that follow a recovery from depression. Relapse prevention plans are essential, not extra, especially for patients with comorbid CHD.

Effective relapse prevention plans should include a list of maintenance treatment plans, early warning signs, a monitoring measure, and predetermined early steps to respond to warning signs. This information should be shared in writing with the patient and relevant clinicians, and documented in the patient’s chart. Periodic check-ins, if only through brief phone appointments at 6- or 12-month intervals, can verify which plans are working, and which are not.

Treating depression in people with CHD can be tricky and pose complicated dilemmas. It is reassuring to remember that, in spite of all the dilemmas, guidelines to treat these patients boil down to a simple maxim: what is good for the brain is good for the heart.

is professor emeritus of psychiatry and family medicine in the Department of Psychiatry and Behavioral Neuroscience and Department of Family and Community Medicine at the University of Cincinnati.

is a research fellow in psychiatry in the Department of Psychiatry at Massachusetts General Hospital.

1. Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study. 

2. Galatzer-Levy IR, Bonanno GA. Optimism and death: predicting the course and consequences of depression trajectories in response to heart attack. 

3. Thayer JF, Yamamoto SS, Brosschot JF. The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors. 

4. Wulsin L, Herman J, Thayer JF. Stress, autonomic imbalance, and the prediction of metabolic risk: a model and a proposal for research. 

5. Huffman JC, Celano CM, Beach SR, et al. Depression and cardiac disease: epidemiology, mechanisms, and diagnosis. 

6. Dong M, Giles WH, Felitti VJ, et al. Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. 

7. Brown DW, Balluz LS, Heath GW, et al. Associations between recommended levels of physical activity and health-related quality of life. Findings from the 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey. 

8. Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al. Remissions in maternal depression and child psychopathology: a STAR*D-child report. 

9. Jagannathan R, Patel SA, Ali MK, Narayan KMV. Global updates on cardiovascular disease mortality trends and attribution of traditional risk factors. 

10. Silberman A, Banthia R, Estay IS, et al. The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. 

11. Razavi M, Fournier S, Shepard DS, et al. Effects of lifestyle modification programs on cardiac risk factors. 

12. McCaffery JM, Frasure-Smith N, Dubé MP, et al. Common genetic vulnerability to depressive symptoms and coronary artery disease: a review and development of candidate genes related to inflammation and serotonin. 

13. Sun Q, Townsend MK, Okereke OI, et al. Physical activity at midlife in relation to successful survival in women at age 70 years or older. 

14. Lachman ME, Teshale S, Agrigoroaei S. Midlife as a pivotal period in the life course: balancing growth and decline at the crossroads of youth and old age. 

15. Zambrano J, Celano CM, Januzzi JL, et al. Psychiatric and psychological interventions for depression in patients with heart disease: a scoping review. 

16. Wang L, Wang R, Liu L, et al. Effects of SSRIs on peripheral inflammatory markers in patients with major depressive disorder: a systematic review and meta-analysis. 

17. Marshall JB, Forker AD. Cardiovascular effects of tricyclic antidepressant drugs: therapeutic usage, overdose, and management of complications. 

18. Blumenthal JA, Smith PJ, Hoffman BM. Is exercise a viable treatment for depression? 

Does it matter which came first, the depression or the heart disease?

Clinical Dilemmas: What’s Good for the Brain Is Good for the Heart

“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

Obesity is a prevalent global problem that affects patients with major mental illness disproportionately.

 It is associated with cardiovascular risk factors, including hypertension, dyslipidemia, and impaired glucose tolerance. Not surprisingly, the prevalence of these conditions is also high in patients with major mental illness. In fact, patients with major mental illness have a lifespan 

 than the general population, with cardiovascular mortality largely accounts for this difference.

Several biological, psychological, behavioral, and social factors predispose patients with major mental illness to obesity. One well-established risk factor is the weight gain-inducing side effect of antipsychotic drugs.

 Two features of this risk factor make it stand out: It is modifiable, and it is under the control of the prescriber.

Weight Gain-Inducing Risk of Antipsychotic Drugs

Most early antipsychotic drugs caused acute and chronic motor side effects. Clozapine was different because it was not haloperidol-like or a high-potency dopamine-2 full antagonist, but its routine use was prevented by the risk of agranulocytosis. Several safer atypical antipsychotic drugs have become available, and they are now standard treatment for schizophrenia and other approved indications. Despite this progress, an important side effect of clozapine—weight gain—has remained an issue with later-generation antipsychotics.

Researchers use 2 measures to determine the weight gain-inducing side effects of psychotropic drugs

: how many patients exposed to a given drug gain weight and how much weight is gained by patients. The latter can be measured as a crude number, or it can be standardized as a proportion of weight gain from baseline. Generally, weight gain greater than 7% from baseline is considered significant.

We now have extensive research on the weight gain-inducing and metabolic risks of antipsychotic drugs, including meta-analyses of the data.

 If we leave subtle differences and academic discussions aside, the common antipsychotic drugs can be grouped into 3 categories of weight gain-inducing potential (

There are a few important things to remember when contending with weight gain-inducing risk. First, weight gain is an individual-specific phenomenon; therefore, each patient must be monitored individually. Second, young patients who were not previously exposed to an antipsychotic drug (ie, drug-naive patients) are at a much higher risk of weight gain than older individuals who are not drug-naïve.

 Third, there is some evidence that metabolic complications (dyslipidemia and/or glucose intolerance) may result from these drugs independent of significant weight gain.

 Lastly, antipsychotic drug use is associated with weight gain irrespective of the diagnosis.

Limiting and Managing Drug-Induced Weight Gain

A preventive approach. Losing excess weight is tough for anyone and even tougher for individuals with major mental illness.

 Obesity might not receive much clinical attention because it is not acutely distressing or life-threatening. In the long term, however, it contributes to morbidity and mortality. In addition, young, nonobese, drug-naive patients can gain significant weight within a matter of months when exposed to antipsychotic drugs with a high risk of weight gain.

 Once they have gained that weight, many of them will never be able to lose it.

Differences in the efficacy of commonly used antipsychotics are marginal, but differences in their weight gain-inducing potential are huge.

 There is little justification for prescribing an antipsychotic drug that has a high potential to induce weight gain when there are safer alternatives. A more reasonable approach would be to start with a low-risk medication and switch to another medication in case of inefficacy or intolerance.

Despite limited evidence, second-generation antipsychotics are used for several off-label conditions.

 Psychiatric conditions generally have a high placebo response, which may be what off-label antipsychotic use offers, but at a much higher side-effect burden than placebo. It is quite concerning that off-label antipsychotic use is prevalent in children and adolescents, who are particularly prone to these weight gain-inducing and metabolic side effects. The Choosing Wisely 

Baseline assessment and ongoing monitoring. In 2004, the APA along with other associations issued a consensus statement on baseline assessment and monitoring of patients who are prescribed an antipsychotic drug for any indication (

 Measurement of waist circumference may not be practical in some cases, but tracking body mass index should not be a problem. Inquiring about family history of antipsychotic drug use, including response and side effects, could also provide useful information.

According to the guidelines, several factors contribute to nonadherence. These include clinicians’ lack of knowledge, psychiatrists’ limited training in monitoring patients’ physical health, limited resources, time constraints, diffusion of roles, and patient nonadherence.

 If an abnormality is detected that warrants further assessment or treatment, it should be communicated to the patient’s general physician with clarity about role designation for further assessment and management. Poor physical health care of patients with major mental illness is a systemic problem. Psychiatrists should use their social influence to shift health care culture, clinical prompts, and monitoring tools to 

 an integrated or coordinated health care approach.

Prioritizing discussions of weight gain, its complications, and healthy lifestyle. Clinical encounters are often too brief to tackle all important matters. In the hierarchy of priorities, discussion of weight and healthy lifestyle are often at the bottom of the list. However, patients with major mental illness are prone to obesity even without an iatrogenic contribution. Furthermore, personal and socioeconomic factors often make it more difficult for individuals with mental illness to adopt healthy lifestyles.

 Obesity is associated with stigma and poor self-esteem; presenting weight issues as a medical problem can help destigmatize it. Discussions about obesity and its complications would automatically become a focus of clinical attention if the aforementioned APA guidance (

 were incorporated into clinical practice.

Involvement of other experts for healthy lifestyle interventions.

 Healthy lifestyle interventions are most effective in helping obese patients lose weight and offer the best long-term outcome.

 They should be offered to all suitable patients irrespective of other offered interventions.

For a healthy lifestyle intervention to be effective, it should include individualized counseling on diet and exercise, cognitive and behavioral interventions, setting well-defined, attainable goals, objective monitoring of progress, and expertise to plan and implement the interventions.

 Most psychiatrists do not have the time or expertise to take on these tasks, so involving relevant professionals (eg, dieticians, psychologists, occupational therapists, and case managers for obese patients) is a good idea. Patients who are already obese or who are gaining unhealthy amounts of weight should be referred to these professionals after appropriate counseling. In addition to monitoring measures of obesity, the 

 can be used to monitor general physical fitness.

Antipsychotic-induced weight gain evolves over time, leads to chronic complications, and is very difficult to reverse. Pharmacologic interventions used to tackle weight gain are modestly effective and worth considering in certain cases.

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