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Highlights From Past Events

2017 Current Psychiatry/AACP Conference Wrap Up

Psychiatry Update: Solving Clinical Challenges, Improving Patient Care
Hilton Chicago
March 30 - April 1, 2017

PSYCHIATRY UPDATE 2017

Thursday, March 30, 2017

Essentials of Malingering Assessment
Douglas Mossman, MD, University of Cincinnati

Malingering is intentional lying with an external incentive, such as avoiding work or obtaining drugs. Dr. Mossman gave 2 examples of malingered posttraumatic stress disorder and psychosis. Although lying cannot be detected by careful examination of facial expressions or gestures, a detailed evaluation can reveal malingering. An individual who is malingering psychosis may describe symptoms, such as “I talk to voices all the time,” but clinicians never observe such behavior. Signs of malingering include using “textbook” terms for symptoms; inconsistencies in their history or symptoms; sudden onset of delusions; exaggerating; and being unpleasant, dishonest, or demanding.

Beyond Efficacy and Effectiveness: Neurotoxicity vs Neuroprotection are the REAL Differences Between Typical and Atypical Antipsychotics
Henry A. Nasrallah, MD, Saint Louis University School of Medicine

Dr. Nasrallah discussed the difference between typical vs atypical antipsychotics—the former is neurotoxic, the latter is neuroprotective. Because patients with schizophrenia experience a loss of brain volume and cerebral grey matter and increased lateral ventricle volume, consider atypical antipsychotics for their neuroprotective properties.

In several studies typical antipsychotics, such as haloperidol, have been found to be neurotoxic, causing apoptosis and decreased cell viability. Atypical antipsychotics may be beneficial for patients with schizophrenia because they:

  • stimulate production of new brain cells and increase neurotropic factors
  • reverse PCP-induced changes in gene expression and loss of dendritic spines in the frontal cortex
  • are neuroprotective against ischemic stroke damage
  • prevent oligodendrocyte damage caused by interferon gamma-stimulated microglia.

Medicolegal Hazards in the Information Age: Malpractice and More
Douglas Mossman, MD, University of Cincinnati

Dr. Mossman began by answering the question, “What should I do if a patient ‘friended’ me on Facebook?” Such online relationships can blur boundaries or risk breaching confidentiality, therefore medical organizations recommend ignoring a friend request. Telemedicine via Skype is cost effective and enhances outreach to patients in rural areas or who cannot travel to the office, but online clinical encounters lack multidimensional aspects of the interpersonal encounter and might not be HIPAA compliant. E-mail carries some of the same concerns, such as confidentially of personal information, although the practice—when employed appropriately—is supported by some medical associations, including the American Psychiatric Association.

Friday, March 31, 2017

Treatment-Resistance and Suicidality in Schizophrenia: 2 Major Management Challenges

Henry A. Nasrallah, MD, Saint Louis University School of Medicine

Patients can seem treatment-resistant because of inadequate antipsychotic dosing, smoking, substance-induced relapse, nonadherence, or a general medical condition. Dr. Nasrallah discussed how to recognize true treatment-resistant schizophrenia and rule of spurious treatment resistance. If your patient is truly treatment-resistant, what do you do when everything else fails?

Risk factors for suicide include male sex, depressed mood, substance use, and social isolation. Clozapine, the only drug FDA-approved for refractory schizophrenia and suicidality, is underutilized for such patients. Dr. Nasrallah also presented evidence for the use of adjunctive modalities, such as lamotrigine, steroids, omega-3 fatty acids, NSAIDs, antidepressants, glutamatergic agents, and rTMS, as well as psychotherapy.

New and Old Treatments for Opioid Abuse and Dependence
Mark S. Gold, MD, Washington University

Each day more than 1,000 people are treated in emergency departments for improper use of prescription opioids. But is naloxone saving lives or is overdose reversal nothing more than CPR? Dr. Gold spoke about the need for psychiatric assessment after a patient has been revived. Historically, treatment has stopped at abstinence or overdose treatment, but patients need ongoing treatment. Family therapy, vocational assistance, and psychotherapy are essential.

Dr. Gold reviewed established and newer treatments, including naloxone and naltrexone. Methadone and buprenorphine-naloxone can be effective for adherent patients who abuse only one drug. Naltrexone gives patients time to get their lives on track. Probuphine has comparable efficacy with buprenorphine-naloxone and methadone.

Impact of a Personality Disorder in Management of Comorbid Disorder
Donald W. Black, MD, University of Iowa

Personality disorder (PD) indicates patterns of long-term functioning and are not limited to episodes of illness. Abnormal personality traits are common among the general population, but are not considered a personality disorder unless they are inflexible, maladaptive, persisting, and cause distress either for the patient or the family. There are few cases of “pure” PDs without a comorbid psychiatric disorder. Personality disorders are not as stable as once understood; they wax and wane in response to stressors or depressed mood or anxiety. When a PD is comorbid with another disorder, patients are less likely to respond to medication and to experience remission from the comorbid psychiatric disorder.

Evaluation and Treatment of Patients Who Abuse Methamphetamine or Cocaine

Mark S. Gold, MD, Washington University

There are no FDA-approved medications or advancement in treatment for cocaine overdose—primary treatment is still ice baths. When assessing cocaine use, consider the route of ingestion and duration of use, which influence severity. Stimulants, whether methamphetamine or cocaine, cause changes in dopamine that are difficult to reverse. Substitute stimulants, such as modafinil, or vaccines have been proposed for cocaine abuse, but the evidence is not robust. Methamphetamine produces a schizophrenia-like illness, but antipsychotics are not effective. Naltrexone and bupropion showed some efficacy but was not statistically significant. There are no effective treatments for overdose or relapse prevention other than traditional group and residential treatment approaches.

Risks in Using Cannabis
Kevin Hill, MD, MHS, McLean Hospital

Although only 9% of Cannabis users become dependent, Dr. Hill recommended talking to all patients who use Cannabis about the risks, such as problems with work, school, and relationships. When treating patients with Cannabis use disorder, explore reasons that the individual would want to stop using Cannabis, take a careful history, and most importantly, build a good therapeutic alliance.

The most robust data for medical Cannabis is for chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis; however, there are more than 70 indications among the 28 states that allow its use. Dr. Hill suggests having a written policy, engage in conversation about why the patient wants medical Cannabis, be open to evaluating such a patient, and consider treating the patient’s symptoms with traditional modalities.

How Providers can Help Women During Pregnancy
Marlene P. Freeman, MD, Massachusetts General Hospital

Dr. Freeman discussed the important role mental health providers play in helping women during pregnancy decrease medical and obstetrical risks, such as nutrition and maintaining a healthy weight. Because one-half of pregnancies in the United States are unplanned, consider medications that are compatible with pregnancy, and recommend omega-3 fatty acids and lifestyle changes such as diet.

To diagnose premenstrual dysphoric disorder, Dr. Freeman recommends asking your patient to document and rate daily moods using a mobile app or calendar. In perimenopause, the risk of depression increases because estrogen has antidepressant effects. Although, there are no guidelines for treating depression in women in perimenopause, consider serotonergic antidepressants, supplements such as omega-3 fatty acids, isoflavones, and black cohosh, and sleep aids for patients with insomnia—a common feature of menopause.

ADHD, Bipolar Disorder, and Depression in Children
Jeffrey R. Strawn, MD, FAACP, University of Cincinnati

Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) may share an underlying biological etiology, Dr. Strawn explained. Shared risk factors include in utero events, dietary factors, and genetics. Differentiating ADHD from BD depends on the developmental stage of the patient. Symptoms overlap, which could lead to overdiagnosis of ADHD in youths with BD.

Dr. Strawn discussed how children with depression might display mood lability and irritability, rather than verbalizing feelings because they do not use language effectively until age 7. Children may have somatic symptoms early and irritability might decrease into adolescence. Anxiety disorder in children emerges early—usually as a phobia—around age 12 to 14, with an increase in onset of depressive disorders. Dr. Strawn reviewed screening tools to diagnose and track anxiety symptoms, as well as the pros and cons of pharmacological treatments.

Find Underyling Problems in Patients with Psychotic Disorders
George T. Grossberg, MD, Saint Louis University

Psychotic symptoms could be common in older adults; therefore it is important to evaluate whether these symptoms cause emotional suffering or impairment in daily function. Dr. Grossberg recommended that when treating psychotic disorders in geriatric patients to first evaluate and treat underlying medical problems and identify offending medications or environmental or psychosocial triggers, then consider psychosocial or environmental interventions. Consider antipsychotics for patients who are experiencing severe emotional distress or those who pose a high safety risk. If antipsychotics are necessary, pick an agent based on side effects, “start low, go slow,” and discuss the risks and benefits with the family.

Role of Psychiatrists in Long-term Care Facilities
George T. Grossberg, MD, Saint Louis University

In his presentation on the role of psychiatrists in long-term care facilities, Dr. Grossberg described common disorders including the behavioral and psychiatric symptoms of dementia, as well as risk for depression. Overprescribing is common in long-term care facilities; therefore when considering a patient’s medication regimen, often less is more. Dr. Grossberg also discussed common undertreated or undercorrected physical health problems, including hearing or vision deficits, obstructive sleep apnea, and malnutrition.

Saturday, April 1, 2017

Treating Somatizing Patients
Alexander W. Thompson, MD, MBA, MPH, University of Iowa Carver College of Medicine

Somatizing patients experience symptoms all of the time, whether a headache or nausea, but most symptoms do not have an organic cause, and they might seek treatment for any or all symptoms. The goal of treating somatizing patients is to not harm them with unneeded workup and treatment. Dr. Thomspon recommends providing a letter to the patient’s primary care physician with your recommendations, which can reduce medical costs and improve physical function. Although there are no clear pharmacotherapies, cognitive-behavioral therapy focused on health and anxiety can help.

Fatigue
Alexander W. Thompson, MD, MBA, MPH, University of Iowa Carver College of Medicine
Fatigue experienced by patients with chronic fatigue syndrome is unrelenting, is not the result of ongoing exertion, and is unrelieved by rest. When approaching a patient with extreme fatigue, start with a thorough evaluation in collaboration with a primary care physician, Dr. Thompson said. Establish a rapport with the patient, limit iatrogenic harm, and treat chronic fatigue as you would any chronic condition. Rintatolimod and valganciclovir have showed some evidence of benefit, and graded exercise therapy has shown success.

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