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Misguided fear is keeping benzodiazepines from elderly
SAN FRANCISCO – Used appropriately, the benefits of benzodiazepines far outweigh the risks in elderly people, according to Carl Salzman, MD, a psychiatry professor at Harvard Medical School, Boston.
Appropriate use means very low doses – 0.5 mg or less every day or b.i.d. – of short-acting benzodiazepines, either lorazepam, oxazepam, or temazepam. There’s no worry of dose escalation or addiction in the elderly, and since the drugs are not metabolized by the cytochrome P450 system, the risk of drug interactions is very small, except for a compounding effect with alcohol and other sedative hypnotics, such as zolpidem (Ambien). The fall risk is lower than it is with antidepressants and antipsychotics (Psychiatr Serv. 2003 Jul;54[7]:1006-1); (Arch Intern Med. 2009 Nov 23;169[21]:1952-60).
In short, the drugs are “wonderful” for geriatric anxiety and anxiety-related insomnia, Dr. Salzman said at the American Psychiatric Association annual meeting.
Even so, it’s “very hard to get doctors and residents to prescribe them.” It’s like the benzodiazepine scare in the 1980s, about valium. “Newspapers were filled with stories about addicts. I’m having a little bit of déjà vu all over again,” he said.
This time around, the problem is a concern that benzodiazepines cause Alzheimer’s disease, plus collateral damage from the opioid crisis. People with addiction to opioids like benzodiazepines, because they boost the high, so they have significant street value, and drug seekers demand them in the clinic. Some clinicians would rather not deal with the drugs at all.
The Alzheimer’s worry stems largely from a widely reported review that found an association between Alzheimer’s disease and previous benzodiazepine use. The finding was based on public health insurance data from Quebec; no patients were seen (BMJ. 2014 Sep 9;349:g5205).
Among many “very large questions” about the study’s validity, people “may have been on benzos because they already had memory impairment and were anxious about it,” a common occurrence. In that case, “it’s not that benzos caused dementia; it was the other way around.” Also, there was no control for substance and alcohol use, Dr. Salzman said (J Clin Psychopharmacol. 2015 Feb;35[1]:1-3).
A more robust study followed patients 65 years and older for a mean of 7.3 years, comparing benzodiazepine users to nonusers. The team found a slightly higher risk of dementia in people with minimal exposure to benzodiazepines but not with the highest level of exposure, and concluded that the finding did “not support a causal association between benzodiazepine use and dementia” (BMJ. 2016 Feb 2;352:i90).
Meanwhile, a recent review of more than a million patients found either no or a minor increased risk of mortality, another concern with benzodiazepines in the elderly. “If a detrimental effect exists, it is likely to be much smaller than previously stated and to have uncertain clinical relevance. Residual confounding likely explains at least part of” it, the investigators concluded (BMJ. 2017 Jul 6;358:j294).
in an upscale nursing home in Boston. A “dramatic” rebound was reported in short-term recall 2 weeks after volunteers tapered off benzodiazepines, mostly lorazepam, compared with those who stayed on them.
“I sat down to have lunch with the discontinuers, and I said to them, ‘Aren’t you glad that you are not taking these horrible drugs anymore, and your memory is so much better? They said, ‘No, what’s to remember? It was true that when we were taking those drugs, we might not have remembered what we watched on television the night before, but if you give a choice between feeling calm in the days, sleeping at night, and remembering what we watch on television, we’ll take the calm and the sleep every time,’ ” Dr. Salzman said.
He had no disclosures.
SAN FRANCISCO – Used appropriately, the benefits of benzodiazepines far outweigh the risks in elderly people, according to Carl Salzman, MD, a psychiatry professor at Harvard Medical School, Boston.
Appropriate use means very low doses – 0.5 mg or less every day or b.i.d. – of short-acting benzodiazepines, either lorazepam, oxazepam, or temazepam. There’s no worry of dose escalation or addiction in the elderly, and since the drugs are not metabolized by the cytochrome P450 system, the risk of drug interactions is very small, except for a compounding effect with alcohol and other sedative hypnotics, such as zolpidem (Ambien). The fall risk is lower than it is with antidepressants and antipsychotics (Psychiatr Serv. 2003 Jul;54[7]:1006-1); (Arch Intern Med. 2009 Nov 23;169[21]:1952-60).
In short, the drugs are “wonderful” for geriatric anxiety and anxiety-related insomnia, Dr. Salzman said at the American Psychiatric Association annual meeting.
Even so, it’s “very hard to get doctors and residents to prescribe them.” It’s like the benzodiazepine scare in the 1980s, about valium. “Newspapers were filled with stories about addicts. I’m having a little bit of déjà vu all over again,” he said.
This time around, the problem is a concern that benzodiazepines cause Alzheimer’s disease, plus collateral damage from the opioid crisis. People with addiction to opioids like benzodiazepines, because they boost the high, so they have significant street value, and drug seekers demand them in the clinic. Some clinicians would rather not deal with the drugs at all.
The Alzheimer’s worry stems largely from a widely reported review that found an association between Alzheimer’s disease and previous benzodiazepine use. The finding was based on public health insurance data from Quebec; no patients were seen (BMJ. 2014 Sep 9;349:g5205).
Among many “very large questions” about the study’s validity, people “may have been on benzos because they already had memory impairment and were anxious about it,” a common occurrence. In that case, “it’s not that benzos caused dementia; it was the other way around.” Also, there was no control for substance and alcohol use, Dr. Salzman said (J Clin Psychopharmacol. 2015 Feb;35[1]:1-3).
A more robust study followed patients 65 years and older for a mean of 7.3 years, comparing benzodiazepine users to nonusers. The team found a slightly higher risk of dementia in people with minimal exposure to benzodiazepines but not with the highest level of exposure, and concluded that the finding did “not support a causal association between benzodiazepine use and dementia” (BMJ. 2016 Feb 2;352:i90).
Meanwhile, a recent review of more than a million patients found either no or a minor increased risk of mortality, another concern with benzodiazepines in the elderly. “If a detrimental effect exists, it is likely to be much smaller than previously stated and to have uncertain clinical relevance. Residual confounding likely explains at least part of” it, the investigators concluded (BMJ. 2017 Jul 6;358:j294).
in an upscale nursing home in Boston. A “dramatic” rebound was reported in short-term recall 2 weeks after volunteers tapered off benzodiazepines, mostly lorazepam, compared with those who stayed on them.
“I sat down to have lunch with the discontinuers, and I said to them, ‘Aren’t you glad that you are not taking these horrible drugs anymore, and your memory is so much better? They said, ‘No, what’s to remember? It was true that when we were taking those drugs, we might not have remembered what we watched on television the night before, but if you give a choice between feeling calm in the days, sleeping at night, and remembering what we watch on television, we’ll take the calm and the sleep every time,’ ” Dr. Salzman said.
He had no disclosures.
SAN FRANCISCO – Used appropriately, the benefits of benzodiazepines far outweigh the risks in elderly people, according to Carl Salzman, MD, a psychiatry professor at Harvard Medical School, Boston.
Appropriate use means very low doses – 0.5 mg or less every day or b.i.d. – of short-acting benzodiazepines, either lorazepam, oxazepam, or temazepam. There’s no worry of dose escalation or addiction in the elderly, and since the drugs are not metabolized by the cytochrome P450 system, the risk of drug interactions is very small, except for a compounding effect with alcohol and other sedative hypnotics, such as zolpidem (Ambien). The fall risk is lower than it is with antidepressants and antipsychotics (Psychiatr Serv. 2003 Jul;54[7]:1006-1); (Arch Intern Med. 2009 Nov 23;169[21]:1952-60).
In short, the drugs are “wonderful” for geriatric anxiety and anxiety-related insomnia, Dr. Salzman said at the American Psychiatric Association annual meeting.
Even so, it’s “very hard to get doctors and residents to prescribe them.” It’s like the benzodiazepine scare in the 1980s, about valium. “Newspapers were filled with stories about addicts. I’m having a little bit of déjà vu all over again,” he said.
This time around, the problem is a concern that benzodiazepines cause Alzheimer’s disease, plus collateral damage from the opioid crisis. People with addiction to opioids like benzodiazepines, because they boost the high, so they have significant street value, and drug seekers demand them in the clinic. Some clinicians would rather not deal with the drugs at all.
The Alzheimer’s worry stems largely from a widely reported review that found an association between Alzheimer’s disease and previous benzodiazepine use. The finding was based on public health insurance data from Quebec; no patients were seen (BMJ. 2014 Sep 9;349:g5205).
Among many “very large questions” about the study’s validity, people “may have been on benzos because they already had memory impairment and were anxious about it,” a common occurrence. In that case, “it’s not that benzos caused dementia; it was the other way around.” Also, there was no control for substance and alcohol use, Dr. Salzman said (J Clin Psychopharmacol. 2015 Feb;35[1]:1-3).
A more robust study followed patients 65 years and older for a mean of 7.3 years, comparing benzodiazepine users to nonusers. The team found a slightly higher risk of dementia in people with minimal exposure to benzodiazepines but not with the highest level of exposure, and concluded that the finding did “not support a causal association between benzodiazepine use and dementia” (BMJ. 2016 Feb 2;352:i90).
Meanwhile, a recent review of more than a million patients found either no or a minor increased risk of mortality, another concern with benzodiazepines in the elderly. “If a detrimental effect exists, it is likely to be much smaller than previously stated and to have uncertain clinical relevance. Residual confounding likely explains at least part of” it, the investigators concluded (BMJ. 2017 Jul 6;358:j294).
in an upscale nursing home in Boston. A “dramatic” rebound was reported in short-term recall 2 weeks after volunteers tapered off benzodiazepines, mostly lorazepam, compared with those who stayed on them.
“I sat down to have lunch with the discontinuers, and I said to them, ‘Aren’t you glad that you are not taking these horrible drugs anymore, and your memory is so much better? They said, ‘No, what’s to remember? It was true that when we were taking those drugs, we might not have remembered what we watched on television the night before, but if you give a choice between feeling calm in the days, sleeping at night, and remembering what we watch on television, we’ll take the calm and the sleep every time,’ ” Dr. Salzman said.
He had no disclosures.
REPORTING FROM APA 2019
Ketamine edges out ECT for refractory depression in small study
SAN FRANCISCO – Electroconvulsive therapy and ketamine both work well for refractory depression, but ketamine had the edge in a small, open label trial at the University of California, Los Angeles.
“Over the short term,” even a single ketamine infusion may “be as effective as ... ECT for reducing overall depression, apathy, anhedonia, and suicidal ideation,” but ECT may be more durable, said investigator Katherine Narr, PhD, an associate professor of neurology, psychiatry, and biobehavioral sciences at the school.
The study begins to address an issue that’s probably on the minds of many these days: ECT or ketamine for refractory depression? ELEKT-D (Clinicaltrials.gov NCT03113968), a large randomized, trial is underway to answer the question, but results aren’t expected for a couple of years.
In the meantime, although there was no randomization or blinding, Dr. Narr’s results are informative.
Twenty-six adults received one ketamine infusion, 0.5 mg/kg over 40 minutes, while 36 had four over about 2 weeks. Ketamine patients were allowed to stay on antidepressants. Forty-seven subjects, meanwhile, had 11 ECT treatments over 3 weeks, before which all psychiatric medications were stopped. The Hamilton Depression Rating Scale (HDRS) was used to assess outcomes.
Suicidal ideation probability dropped from 86% to 51% in the ECT group, but from 75% to 37% after one ketamine infusion, and to 11% after four (P less than .0001). A single “ketamine infusion showed similar probability of suicidal ideation reduction as a full course of ECT,” Dr. Narr said at the American Psychiatric Association annual meeting.
Improvements in overall HDRS scores were also greater after both single and serial ketamine (P less than .001).
However, HDRS scores – particularly for suicidal ideation – were beginning to creep up in the ketamine arm after just 5 weeks, but remained largely stable in the ECT group even at 3 months. In both groups, “therapeutic benefits for apathy and anhedonia last longer than for suicidal ideation,” Dr. Narr said.
At the moment, “you can’t predict who’s going to respond” better to one option or the other, “but I’m sure” biomarkers for that “are coming,” she said. Patients were 40 years old, on average, with depression first diagnosed in their early 20s. ECT subjects were equally split between the sexes, while there were more men than women in the ketamine arm, and current episodes were longer (average 6.6 years ketamine versus 3.7 years ECT). Baseline apathy scores were slightly higher in the ketamine group.
The work was funded by the National Institutes of Health. Dr. Narr didn’t have any disclosures.
SOURCE: Narr K et al., Presented at APA 2019
SAN FRANCISCO – Electroconvulsive therapy and ketamine both work well for refractory depression, but ketamine had the edge in a small, open label trial at the University of California, Los Angeles.
“Over the short term,” even a single ketamine infusion may “be as effective as ... ECT for reducing overall depression, apathy, anhedonia, and suicidal ideation,” but ECT may be more durable, said investigator Katherine Narr, PhD, an associate professor of neurology, psychiatry, and biobehavioral sciences at the school.
The study begins to address an issue that’s probably on the minds of many these days: ECT or ketamine for refractory depression? ELEKT-D (Clinicaltrials.gov NCT03113968), a large randomized, trial is underway to answer the question, but results aren’t expected for a couple of years.
In the meantime, although there was no randomization or blinding, Dr. Narr’s results are informative.
Twenty-six adults received one ketamine infusion, 0.5 mg/kg over 40 minutes, while 36 had four over about 2 weeks. Ketamine patients were allowed to stay on antidepressants. Forty-seven subjects, meanwhile, had 11 ECT treatments over 3 weeks, before which all psychiatric medications were stopped. The Hamilton Depression Rating Scale (HDRS) was used to assess outcomes.
Suicidal ideation probability dropped from 86% to 51% in the ECT group, but from 75% to 37% after one ketamine infusion, and to 11% after four (P less than .0001). A single “ketamine infusion showed similar probability of suicidal ideation reduction as a full course of ECT,” Dr. Narr said at the American Psychiatric Association annual meeting.
Improvements in overall HDRS scores were also greater after both single and serial ketamine (P less than .001).
However, HDRS scores – particularly for suicidal ideation – were beginning to creep up in the ketamine arm after just 5 weeks, but remained largely stable in the ECT group even at 3 months. In both groups, “therapeutic benefits for apathy and anhedonia last longer than for suicidal ideation,” Dr. Narr said.
At the moment, “you can’t predict who’s going to respond” better to one option or the other, “but I’m sure” biomarkers for that “are coming,” she said. Patients were 40 years old, on average, with depression first diagnosed in their early 20s. ECT subjects were equally split between the sexes, while there were more men than women in the ketamine arm, and current episodes were longer (average 6.6 years ketamine versus 3.7 years ECT). Baseline apathy scores were slightly higher in the ketamine group.
The work was funded by the National Institutes of Health. Dr. Narr didn’t have any disclosures.
SOURCE: Narr K et al., Presented at APA 2019
SAN FRANCISCO – Electroconvulsive therapy and ketamine both work well for refractory depression, but ketamine had the edge in a small, open label trial at the University of California, Los Angeles.
“Over the short term,” even a single ketamine infusion may “be as effective as ... ECT for reducing overall depression, apathy, anhedonia, and suicidal ideation,” but ECT may be more durable, said investigator Katherine Narr, PhD, an associate professor of neurology, psychiatry, and biobehavioral sciences at the school.
The study begins to address an issue that’s probably on the minds of many these days: ECT or ketamine for refractory depression? ELEKT-D (Clinicaltrials.gov NCT03113968), a large randomized, trial is underway to answer the question, but results aren’t expected for a couple of years.
In the meantime, although there was no randomization or blinding, Dr. Narr’s results are informative.
Twenty-six adults received one ketamine infusion, 0.5 mg/kg over 40 minutes, while 36 had four over about 2 weeks. Ketamine patients were allowed to stay on antidepressants. Forty-seven subjects, meanwhile, had 11 ECT treatments over 3 weeks, before which all psychiatric medications were stopped. The Hamilton Depression Rating Scale (HDRS) was used to assess outcomes.
Suicidal ideation probability dropped from 86% to 51% in the ECT group, but from 75% to 37% after one ketamine infusion, and to 11% after four (P less than .0001). A single “ketamine infusion showed similar probability of suicidal ideation reduction as a full course of ECT,” Dr. Narr said at the American Psychiatric Association annual meeting.
Improvements in overall HDRS scores were also greater after both single and serial ketamine (P less than .001).
However, HDRS scores – particularly for suicidal ideation – were beginning to creep up in the ketamine arm after just 5 weeks, but remained largely stable in the ECT group even at 3 months. In both groups, “therapeutic benefits for apathy and anhedonia last longer than for suicidal ideation,” Dr. Narr said.
At the moment, “you can’t predict who’s going to respond” better to one option or the other, “but I’m sure” biomarkers for that “are coming,” she said. Patients were 40 years old, on average, with depression first diagnosed in their early 20s. ECT subjects were equally split between the sexes, while there were more men than women in the ketamine arm, and current episodes were longer (average 6.6 years ketamine versus 3.7 years ECT). Baseline apathy scores were slightly higher in the ketamine group.
The work was funded by the National Institutes of Health. Dr. Narr didn’t have any disclosures.
SOURCE: Narr K et al., Presented at APA 2019
REPORTING FROM APA 2019
Medical cannabis legalization outpacing evidence
For now, CBD is better option than whole-plant cannabis for psychiatric disorders
SAN FRANCISCO – Outside of prescription products for chemotherapy nausea/vomiting, AIDS anorexia, and rare pediatric epilepsies, medical cannabis has the strongest evidence for chronic pain, neuropathic pain, and multiple sclerosis spasticity, according to Kevin P. Hill, MD, director of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston.
“We are talking about multiple, positive RCTs [randomized, controlled trials]. I think you can’t ignore that. For people who are staunchly opposed to medical cannabis, [it’s becoming] harder and harder to take that tack. I do think we need to come to an understanding that there is some evidence,” Dr. Hill said at the American Psychiatric Association annual meeting.
However, “there’s incredible interest in using cannabinoids for a whole host of [other] conditions for which the level of evidence isn’t where we’d like it to be. In many ways,” legalization has “far outpaced the evidence.
Perhaps that’s most true for psychiatric disorders. Although many patients swear by cannabis, what little evidence there is comes from observational studies, and those have mostly been disappointing.
Whole-plant cannabis, for instance, has been associated with an increased risk of depression in a dose-dependent fashion, and increased depression and anxiety symptoms, including panic attacks, among inexperienced users. Cutting back has been associated with symptom relief.
No placebo-controlled trials have been conducted to address cause and effect, so it’s unknown whether people use because they have worse disease or have worse disease because they use.
For now, “whole-plant cannabis to treat anxiety is probably not a good idea. We may ultimately find that cannabidiol” – CBD, the nonpsychoactive component of cannabis – “may have utility. If patients are already using, CBD is a better bet; it has no abuse potential,” Dr. Hill said.
He sometimes recommends CBD when patients fail traditional options, but over-the-counter or online products rather than the “exorbitantly expensive” Food and Drug Administration–approved version Epidiolex, indicated for the rare pediatric epilepsies Lennox-Gastaut and Dravet syndromes.
He asks patients to “tell me what you’re going to buy and we’ll go from there, and try to dose it.” Dr. Hill has confidence in only a few CBD brands to be accurately labeled, one of which is Charlotte’s Web.
There’s been a lot of excitement over cannabis for PTSD, but at this point, positive findings are mostly anecdotal, and use was associated with worse symptoms, increased violence, more alcohol and drug use, and worse therapy outcomes in a longitudinal study of 2,276 veterans. At least one ongoing RCT is underway that should address cause-and-effect (J Clin Psychiatry. 2015 Sep;76[9]:1174-80).
Like anxiety, CBD “would probably have more promise than whole-plant cannabis” for PTSD, Dr. Hill said.
That also might be the case for bipolar disorder. Whole-plant use is particularly common among patients, and it, again, seems to make symptoms worse.
The data for insomnia are much like that seen with alcohol: quicker asleep but worse sleep quality. “One of the myths about CBD is that it improves sleep; I don’t think that’s really been shown to be the case. A lot of it has to do with other chemicals included in the CBD preparation,” he said.
Dr. Hill is the author of Marijuana: The Unbiased Truth about the World’s Most Popular Weed (Center City, Minn.: Hazelden Publishing, 2015). He had no industry disclosures.
For now, CBD is better option than whole-plant cannabis for psychiatric disorders
For now, CBD is better option than whole-plant cannabis for psychiatric disorders
SAN FRANCISCO – Outside of prescription products for chemotherapy nausea/vomiting, AIDS anorexia, and rare pediatric epilepsies, medical cannabis has the strongest evidence for chronic pain, neuropathic pain, and multiple sclerosis spasticity, according to Kevin P. Hill, MD, director of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston.
“We are talking about multiple, positive RCTs [randomized, controlled trials]. I think you can’t ignore that. For people who are staunchly opposed to medical cannabis, [it’s becoming] harder and harder to take that tack. I do think we need to come to an understanding that there is some evidence,” Dr. Hill said at the American Psychiatric Association annual meeting.
However, “there’s incredible interest in using cannabinoids for a whole host of [other] conditions for which the level of evidence isn’t where we’d like it to be. In many ways,” legalization has “far outpaced the evidence.
Perhaps that’s most true for psychiatric disorders. Although many patients swear by cannabis, what little evidence there is comes from observational studies, and those have mostly been disappointing.
Whole-plant cannabis, for instance, has been associated with an increased risk of depression in a dose-dependent fashion, and increased depression and anxiety symptoms, including panic attacks, among inexperienced users. Cutting back has been associated with symptom relief.
No placebo-controlled trials have been conducted to address cause and effect, so it’s unknown whether people use because they have worse disease or have worse disease because they use.
For now, “whole-plant cannabis to treat anxiety is probably not a good idea. We may ultimately find that cannabidiol” – CBD, the nonpsychoactive component of cannabis – “may have utility. If patients are already using, CBD is a better bet; it has no abuse potential,” Dr. Hill said.
He sometimes recommends CBD when patients fail traditional options, but over-the-counter or online products rather than the “exorbitantly expensive” Food and Drug Administration–approved version Epidiolex, indicated for the rare pediatric epilepsies Lennox-Gastaut and Dravet syndromes.
He asks patients to “tell me what you’re going to buy and we’ll go from there, and try to dose it.” Dr. Hill has confidence in only a few CBD brands to be accurately labeled, one of which is Charlotte’s Web.
There’s been a lot of excitement over cannabis for PTSD, but at this point, positive findings are mostly anecdotal, and use was associated with worse symptoms, increased violence, more alcohol and drug use, and worse therapy outcomes in a longitudinal study of 2,276 veterans. At least one ongoing RCT is underway that should address cause-and-effect (J Clin Psychiatry. 2015 Sep;76[9]:1174-80).
Like anxiety, CBD “would probably have more promise than whole-plant cannabis” for PTSD, Dr. Hill said.
That also might be the case for bipolar disorder. Whole-plant use is particularly common among patients, and it, again, seems to make symptoms worse.
The data for insomnia are much like that seen with alcohol: quicker asleep but worse sleep quality. “One of the myths about CBD is that it improves sleep; I don’t think that’s really been shown to be the case. A lot of it has to do with other chemicals included in the CBD preparation,” he said.
Dr. Hill is the author of Marijuana: The Unbiased Truth about the World’s Most Popular Weed (Center City, Minn.: Hazelden Publishing, 2015). He had no industry disclosures.
SAN FRANCISCO – Outside of prescription products for chemotherapy nausea/vomiting, AIDS anorexia, and rare pediatric epilepsies, medical cannabis has the strongest evidence for chronic pain, neuropathic pain, and multiple sclerosis spasticity, according to Kevin P. Hill, MD, director of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston.
“We are talking about multiple, positive RCTs [randomized, controlled trials]. I think you can’t ignore that. For people who are staunchly opposed to medical cannabis, [it’s becoming] harder and harder to take that tack. I do think we need to come to an understanding that there is some evidence,” Dr. Hill said at the American Psychiatric Association annual meeting.
However, “there’s incredible interest in using cannabinoids for a whole host of [other] conditions for which the level of evidence isn’t where we’d like it to be. In many ways,” legalization has “far outpaced the evidence.
Perhaps that’s most true for psychiatric disorders. Although many patients swear by cannabis, what little evidence there is comes from observational studies, and those have mostly been disappointing.
Whole-plant cannabis, for instance, has been associated with an increased risk of depression in a dose-dependent fashion, and increased depression and anxiety symptoms, including panic attacks, among inexperienced users. Cutting back has been associated with symptom relief.
No placebo-controlled trials have been conducted to address cause and effect, so it’s unknown whether people use because they have worse disease or have worse disease because they use.
For now, “whole-plant cannabis to treat anxiety is probably not a good idea. We may ultimately find that cannabidiol” – CBD, the nonpsychoactive component of cannabis – “may have utility. If patients are already using, CBD is a better bet; it has no abuse potential,” Dr. Hill said.
He sometimes recommends CBD when patients fail traditional options, but over-the-counter or online products rather than the “exorbitantly expensive” Food and Drug Administration–approved version Epidiolex, indicated for the rare pediatric epilepsies Lennox-Gastaut and Dravet syndromes.
He asks patients to “tell me what you’re going to buy and we’ll go from there, and try to dose it.” Dr. Hill has confidence in only a few CBD brands to be accurately labeled, one of which is Charlotte’s Web.
There’s been a lot of excitement over cannabis for PTSD, but at this point, positive findings are mostly anecdotal, and use was associated with worse symptoms, increased violence, more alcohol and drug use, and worse therapy outcomes in a longitudinal study of 2,276 veterans. At least one ongoing RCT is underway that should address cause-and-effect (J Clin Psychiatry. 2015 Sep;76[9]:1174-80).
Like anxiety, CBD “would probably have more promise than whole-plant cannabis” for PTSD, Dr. Hill said.
That also might be the case for bipolar disorder. Whole-plant use is particularly common among patients, and it, again, seems to make symptoms worse.
The data for insomnia are much like that seen with alcohol: quicker asleep but worse sleep quality. “One of the myths about CBD is that it improves sleep; I don’t think that’s really been shown to be the case. A lot of it has to do with other chemicals included in the CBD preparation,” he said.
Dr. Hill is the author of Marijuana: The Unbiased Truth about the World’s Most Popular Weed (Center City, Minn.: Hazelden Publishing, 2015). He had no industry disclosures.
REPORTING FROM APA 2019
Case shows power of collaborative care for depression
Remission rate for Boeing employees climbed from 10% to 35%
SAN FRANCISCO – Under an accountable care contract with airplane maker Boeing, the University of Washington, Seattle, increased the rate of depression remission from about 10% to 35%, and the number of people in remission improved, based on Patient Health Questionnaire (PHQ-9) scores, from 20% to 70% – both in less than a year.
Boeing was particularly concerned about depression among its roughly 27,000 Puget Sound–area employees when it entered a contract with the University of Washington (UW) a few years ago for health services. Workers with depression are less likely to show up to work, and when they do, they are more likely to make mistakes and cause safety problems. To ensure that the university addressed the problem, Boeing tied payments to improved depression scores.
It didn’t take UW long to meet the PHQ-9 targets for improvement and remission, meaning a score below 5 points. Boeing also wanted its employees to be screened annually for depression and repeated testing of patients with depression to track how well they were doing. The university increased the number of patients rescreened within 8 weeks of their first PHQ-9 from about 45% to 75% – also in less than a year.
It simply scaled up the approach to meet Boeing’s targets.
“This has been an interesting journey,” said Jürgen Unützer, MD, MPH, who has been key to the efforts. “It’s required quite a bit of work, but it can be done. We’ve made a lot of progress,” he said at the American Psychiatric Association annual meeting.
Key components, besides the primary care provider, include evidence-based treatment, a mental health case manager, a system to track outcomes, and a psychiatrist to consult when patients do not improve. It’s a team approach.
Dr. Unützer and his colleagues have proved that it can work among older adults with depression and, in the end, save money (Am J Manag Care. 2008 Feb;14[2]:95-100). They’ve even published a how-to book, “Integrated Care: Creating Effective Mental and Primary Health Care Teams” (John Wiley & Sons, 2016).
A key challenge with Boeing was making sure that depressed patients returned for follow-up care and repeat PHQ-9s, and that they did not languish on ineffective treatments.
“We explain [to them that] this is not just a one-time thing,” said Dr. Unützer, chair of psychiatry and behavioral sciences at UW. “We [will] keep with them until they are well.”
Patients are enrolled in the patient portal on UW’s Epic records system to facilitate communication. The system sends out follow-up reminders, and sometimes it is used to send PHQ-9s directly to patients.
“We have automated this as much as possible.” When there’s no response, patients often are sent text messages or called by phone to make sure that they are doing OK and taking their medicine, he said.
Chart reviews are used to identify patients who are not improving. “We reach out to primary care and say, ‘We think you could use some help.’ It’s not always ”a comfortable conversation. “A lot of us like to assume our patients are getting better,” Dr. Unützer said.
Overall, “this notion of population-based care – the idea that ... you have a whole bucket of patients out there you might have seen at some point” but are still responsible for – “is a total change for most of us who are practicing clinicians,” he said.
Dr. Unützer did not report any disclosures.
Remission rate for Boeing employees climbed from 10% to 35%
Remission rate for Boeing employees climbed from 10% to 35%
SAN FRANCISCO – Under an accountable care contract with airplane maker Boeing, the University of Washington, Seattle, increased the rate of depression remission from about 10% to 35%, and the number of people in remission improved, based on Patient Health Questionnaire (PHQ-9) scores, from 20% to 70% – both in less than a year.
Boeing was particularly concerned about depression among its roughly 27,000 Puget Sound–area employees when it entered a contract with the University of Washington (UW) a few years ago for health services. Workers with depression are less likely to show up to work, and when they do, they are more likely to make mistakes and cause safety problems. To ensure that the university addressed the problem, Boeing tied payments to improved depression scores.
It didn’t take UW long to meet the PHQ-9 targets for improvement and remission, meaning a score below 5 points. Boeing also wanted its employees to be screened annually for depression and repeated testing of patients with depression to track how well they were doing. The university increased the number of patients rescreened within 8 weeks of their first PHQ-9 from about 45% to 75% – also in less than a year.
It simply scaled up the approach to meet Boeing’s targets.
“This has been an interesting journey,” said Jürgen Unützer, MD, MPH, who has been key to the efforts. “It’s required quite a bit of work, but it can be done. We’ve made a lot of progress,” he said at the American Psychiatric Association annual meeting.
Key components, besides the primary care provider, include evidence-based treatment, a mental health case manager, a system to track outcomes, and a psychiatrist to consult when patients do not improve. It’s a team approach.
Dr. Unützer and his colleagues have proved that it can work among older adults with depression and, in the end, save money (Am J Manag Care. 2008 Feb;14[2]:95-100). They’ve even published a how-to book, “Integrated Care: Creating Effective Mental and Primary Health Care Teams” (John Wiley & Sons, 2016).
A key challenge with Boeing was making sure that depressed patients returned for follow-up care and repeat PHQ-9s, and that they did not languish on ineffective treatments.
“We explain [to them that] this is not just a one-time thing,” said Dr. Unützer, chair of psychiatry and behavioral sciences at UW. “We [will] keep with them until they are well.”
Patients are enrolled in the patient portal on UW’s Epic records system to facilitate communication. The system sends out follow-up reminders, and sometimes it is used to send PHQ-9s directly to patients.
“We have automated this as much as possible.” When there’s no response, patients often are sent text messages or called by phone to make sure that they are doing OK and taking their medicine, he said.
Chart reviews are used to identify patients who are not improving. “We reach out to primary care and say, ‘We think you could use some help.’ It’s not always ”a comfortable conversation. “A lot of us like to assume our patients are getting better,” Dr. Unützer said.
Overall, “this notion of population-based care – the idea that ... you have a whole bucket of patients out there you might have seen at some point” but are still responsible for – “is a total change for most of us who are practicing clinicians,” he said.
Dr. Unützer did not report any disclosures.
SAN FRANCISCO – Under an accountable care contract with airplane maker Boeing, the University of Washington, Seattle, increased the rate of depression remission from about 10% to 35%, and the number of people in remission improved, based on Patient Health Questionnaire (PHQ-9) scores, from 20% to 70% – both in less than a year.
Boeing was particularly concerned about depression among its roughly 27,000 Puget Sound–area employees when it entered a contract with the University of Washington (UW) a few years ago for health services. Workers with depression are less likely to show up to work, and when they do, they are more likely to make mistakes and cause safety problems. To ensure that the university addressed the problem, Boeing tied payments to improved depression scores.
It didn’t take UW long to meet the PHQ-9 targets for improvement and remission, meaning a score below 5 points. Boeing also wanted its employees to be screened annually for depression and repeated testing of patients with depression to track how well they were doing. The university increased the number of patients rescreened within 8 weeks of their first PHQ-9 from about 45% to 75% – also in less than a year.
It simply scaled up the approach to meet Boeing’s targets.
“This has been an interesting journey,” said Jürgen Unützer, MD, MPH, who has been key to the efforts. “It’s required quite a bit of work, but it can be done. We’ve made a lot of progress,” he said at the American Psychiatric Association annual meeting.
Key components, besides the primary care provider, include evidence-based treatment, a mental health case manager, a system to track outcomes, and a psychiatrist to consult when patients do not improve. It’s a team approach.
Dr. Unützer and his colleagues have proved that it can work among older adults with depression and, in the end, save money (Am J Manag Care. 2008 Feb;14[2]:95-100). They’ve even published a how-to book, “Integrated Care: Creating Effective Mental and Primary Health Care Teams” (John Wiley & Sons, 2016).
A key challenge with Boeing was making sure that depressed patients returned for follow-up care and repeat PHQ-9s, and that they did not languish on ineffective treatments.
“We explain [to them that] this is not just a one-time thing,” said Dr. Unützer, chair of psychiatry and behavioral sciences at UW. “We [will] keep with them until they are well.”
Patients are enrolled in the patient portal on UW’s Epic records system to facilitate communication. The system sends out follow-up reminders, and sometimes it is used to send PHQ-9s directly to patients.
“We have automated this as much as possible.” When there’s no response, patients often are sent text messages or called by phone to make sure that they are doing OK and taking their medicine, he said.
Chart reviews are used to identify patients who are not improving. “We reach out to primary care and say, ‘We think you could use some help.’ It’s not always ”a comfortable conversation. “A lot of us like to assume our patients are getting better,” Dr. Unützer said.
Overall, “this notion of population-based care – the idea that ... you have a whole bucket of patients out there you might have seen at some point” but are still responsible for – “is a total change for most of us who are practicing clinicians,” he said.
Dr. Unützer did not report any disclosures.
REPORTING FROM APA 2019
Cannabis withdrawal syndrome real but underrecognized
SAN FRANCISCO – Marijuana withdrawal syndrome is real, and physicians and patients should recognize the phenomenon and take it seriously as legalization rolls out across the United States, an investigation from Columbia University in New York suggests,
“Most clinicians don’t really believe there is a withdrawal syndrome, but there definitely is. The prevalence we found was 12% among frequent cannabis users,” meaning three or more times a week, said psychiatrist and lead investigator Ofir Livne, MD, who until recently was a research fellow at Columbia but now is affiliated with Tel Aviv University in Israel (Drug Alcohol Depend. 2019 Feb 1;195:170-7).
“Usually what happens is a cannabis user will feel a bit agitated, and they’ll take another joint without even realizing they are just perpetuating the addiction.”
Dr. Livne said the syndrome is seen with other substances but is underrecognized with cannabis. “The word needs to get out more,” he said at the annual meeting of the American Psychiatric Association.
The symptoms can last for several days – or longer.
To get an idea of the extent of the problem, he and his team analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions-III. The survey collected data on more than 36,000 adults about drug use, associated effects, and other issues in 2012-13.
The investigators focused on the 1,527 people who reported frequent use in the preceding 12 months, and looked to see whether the symptoms they reported when they stopped or cut back would qualify them for cannabis withdrawal syndrome (CWS) in the DSM-5, the first edition of the manual to include the diagnosis.
Overall, 12.1% made the cut. The most common symptoms were nervousness/anxiety (76%), irritability (72%), sleep difficulty (68%), and depressed mood (59%). CWS patients also had lower health-related quality of life scores than peers without CWS.
Physical symptoms associated with CWS included headache, tremors, and sweating, among others. Overall, 70% of people reported some sort of physical discomfort associated with withdrawal.
“We also saw that frequent cannabis users who experience withdrawal are a lot more prone to other psychiatric disorders,” Dr. Livne said, including mood disorders (adjusted odds ratio, 1.9-2.6), anxiety disorders (aOR, 2.4-2.5), and personality disorders (aOR, 1.7-2.2). They more often had a family history of depression (aOR, 2.5).
“This study provides the first nationally representative large-scale report on the DSM-5 cannabis withdrawal syndrome. ... Its shared symptoms with depressive and anxiety disorders call for clinician awareness of CWS and the factors associated with it,” Dr. Livne and his colleagues concluded.
The work was adjusted for social demographics and other confounders, including tobacco withdrawal, which has overlapping symptoms.
It’s possible that in some cases, the survey simply caught a return of the anxiety and other issues that caused people to use in the first place, instead of true withdrawal, but Dr. Livne didn’t think so. “Some of them might have been prone to anxiety, but we controlled for that as much as we could,” he said.
The work was funded by the National Institute on Drug Abuse. Dr. Livne had no disclosures.
SAN FRANCISCO – Marijuana withdrawal syndrome is real, and physicians and patients should recognize the phenomenon and take it seriously as legalization rolls out across the United States, an investigation from Columbia University in New York suggests,
“Most clinicians don’t really believe there is a withdrawal syndrome, but there definitely is. The prevalence we found was 12% among frequent cannabis users,” meaning three or more times a week, said psychiatrist and lead investigator Ofir Livne, MD, who until recently was a research fellow at Columbia but now is affiliated with Tel Aviv University in Israel (Drug Alcohol Depend. 2019 Feb 1;195:170-7).
“Usually what happens is a cannabis user will feel a bit agitated, and they’ll take another joint without even realizing they are just perpetuating the addiction.”
Dr. Livne said the syndrome is seen with other substances but is underrecognized with cannabis. “The word needs to get out more,” he said at the annual meeting of the American Psychiatric Association.
The symptoms can last for several days – or longer.
To get an idea of the extent of the problem, he and his team analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions-III. The survey collected data on more than 36,000 adults about drug use, associated effects, and other issues in 2012-13.
The investigators focused on the 1,527 people who reported frequent use in the preceding 12 months, and looked to see whether the symptoms they reported when they stopped or cut back would qualify them for cannabis withdrawal syndrome (CWS) in the DSM-5, the first edition of the manual to include the diagnosis.
Overall, 12.1% made the cut. The most common symptoms were nervousness/anxiety (76%), irritability (72%), sleep difficulty (68%), and depressed mood (59%). CWS patients also had lower health-related quality of life scores than peers without CWS.
Physical symptoms associated with CWS included headache, tremors, and sweating, among others. Overall, 70% of people reported some sort of physical discomfort associated with withdrawal.
“We also saw that frequent cannabis users who experience withdrawal are a lot more prone to other psychiatric disorders,” Dr. Livne said, including mood disorders (adjusted odds ratio, 1.9-2.6), anxiety disorders (aOR, 2.4-2.5), and personality disorders (aOR, 1.7-2.2). They more often had a family history of depression (aOR, 2.5).
“This study provides the first nationally representative large-scale report on the DSM-5 cannabis withdrawal syndrome. ... Its shared symptoms with depressive and anxiety disorders call for clinician awareness of CWS and the factors associated with it,” Dr. Livne and his colleagues concluded.
The work was adjusted for social demographics and other confounders, including tobacco withdrawal, which has overlapping symptoms.
It’s possible that in some cases, the survey simply caught a return of the anxiety and other issues that caused people to use in the first place, instead of true withdrawal, but Dr. Livne didn’t think so. “Some of them might have been prone to anxiety, but we controlled for that as much as we could,” he said.
The work was funded by the National Institute on Drug Abuse. Dr. Livne had no disclosures.
SAN FRANCISCO – Marijuana withdrawal syndrome is real, and physicians and patients should recognize the phenomenon and take it seriously as legalization rolls out across the United States, an investigation from Columbia University in New York suggests,
“Most clinicians don’t really believe there is a withdrawal syndrome, but there definitely is. The prevalence we found was 12% among frequent cannabis users,” meaning three or more times a week, said psychiatrist and lead investigator Ofir Livne, MD, who until recently was a research fellow at Columbia but now is affiliated with Tel Aviv University in Israel (Drug Alcohol Depend. 2019 Feb 1;195:170-7).
“Usually what happens is a cannabis user will feel a bit agitated, and they’ll take another joint without even realizing they are just perpetuating the addiction.”
Dr. Livne said the syndrome is seen with other substances but is underrecognized with cannabis. “The word needs to get out more,” he said at the annual meeting of the American Psychiatric Association.
The symptoms can last for several days – or longer.
To get an idea of the extent of the problem, he and his team analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions-III. The survey collected data on more than 36,000 adults about drug use, associated effects, and other issues in 2012-13.
The investigators focused on the 1,527 people who reported frequent use in the preceding 12 months, and looked to see whether the symptoms they reported when they stopped or cut back would qualify them for cannabis withdrawal syndrome (CWS) in the DSM-5, the first edition of the manual to include the diagnosis.
Overall, 12.1% made the cut. The most common symptoms were nervousness/anxiety (76%), irritability (72%), sleep difficulty (68%), and depressed mood (59%). CWS patients also had lower health-related quality of life scores than peers without CWS.
Physical symptoms associated with CWS included headache, tremors, and sweating, among others. Overall, 70% of people reported some sort of physical discomfort associated with withdrawal.
“We also saw that frequent cannabis users who experience withdrawal are a lot more prone to other psychiatric disorders,” Dr. Livne said, including mood disorders (adjusted odds ratio, 1.9-2.6), anxiety disorders (aOR, 2.4-2.5), and personality disorders (aOR, 1.7-2.2). They more often had a family history of depression (aOR, 2.5).
“This study provides the first nationally representative large-scale report on the DSM-5 cannabis withdrawal syndrome. ... Its shared symptoms with depressive and anxiety disorders call for clinician awareness of CWS and the factors associated with it,” Dr. Livne and his colleagues concluded.
The work was adjusted for social demographics and other confounders, including tobacco withdrawal, which has overlapping symptoms.
It’s possible that in some cases, the survey simply caught a return of the anxiety and other issues that caused people to use in the first place, instead of true withdrawal, but Dr. Livne didn’t think so. “Some of them might have been prone to anxiety, but we controlled for that as much as we could,” he said.
The work was funded by the National Institute on Drug Abuse. Dr. Livne had no disclosures.
REPORTING FROM APA 2019
Psychiatry residents not getting training in treating chronic pain
SAN FRANCISCO –
Given the unique role of psychiatrists in helping chronic pain patients with coping strategies and managing comorbid psychiatric illness, this void is concerning, said Ali Ahsan Ali, MD, a resident psychiatrist at the Micah School of Medicine at Mount Sinai/Elmhurst Hospital Center in New York, in an interview at the annual meeting of the American Psychiatric Association.
In a video interview, Dr. Ali spoke with Ahmar M. Butt, MD, about how and why Dr. Ali and his colleagues conducted the survey of all 221 U.S. psychiatry residency programs in January 2019. They also discuss the implications of these trends for patients, particularly in light of the country’s opioid crisis.
Dr. Ali had no disclosures. Dr. Butt is board certified in general psychiatry, child and adolescent psychiatry, and preventive medicine, with a subspecialty in addiction medicine. Dr. Butt is interim program director of the psychiatry residency program at Broadlawns UnityPointe Health, Des Moines, Iowa. He had no disclosures.
SAN FRANCISCO –
Given the unique role of psychiatrists in helping chronic pain patients with coping strategies and managing comorbid psychiatric illness, this void is concerning, said Ali Ahsan Ali, MD, a resident psychiatrist at the Micah School of Medicine at Mount Sinai/Elmhurst Hospital Center in New York, in an interview at the annual meeting of the American Psychiatric Association.
In a video interview, Dr. Ali spoke with Ahmar M. Butt, MD, about how and why Dr. Ali and his colleagues conducted the survey of all 221 U.S. psychiatry residency programs in January 2019. They also discuss the implications of these trends for patients, particularly in light of the country’s opioid crisis.
Dr. Ali had no disclosures. Dr. Butt is board certified in general psychiatry, child and adolescent psychiatry, and preventive medicine, with a subspecialty in addiction medicine. Dr. Butt is interim program director of the psychiatry residency program at Broadlawns UnityPointe Health, Des Moines, Iowa. He had no disclosures.
SAN FRANCISCO –
Given the unique role of psychiatrists in helping chronic pain patients with coping strategies and managing comorbid psychiatric illness, this void is concerning, said Ali Ahsan Ali, MD, a resident psychiatrist at the Micah School of Medicine at Mount Sinai/Elmhurst Hospital Center in New York, in an interview at the annual meeting of the American Psychiatric Association.
In a video interview, Dr. Ali spoke with Ahmar M. Butt, MD, about how and why Dr. Ali and his colleagues conducted the survey of all 221 U.S. psychiatry residency programs in January 2019. They also discuss the implications of these trends for patients, particularly in light of the country’s opioid crisis.
Dr. Ali had no disclosures. Dr. Butt is board certified in general psychiatry, child and adolescent psychiatry, and preventive medicine, with a subspecialty in addiction medicine. Dr. Butt is interim program director of the psychiatry residency program at Broadlawns UnityPointe Health, Des Moines, Iowa. He had no disclosures.
REPORTING FROM APA 2019
Psychiatrists discuss work on climate change
SAN FRANCISCO –
“We can find reasons to hope even in dark times,” Dr. Van Susteren said. “We understand science. We have all the tools ... this is what we do for a living. We warn about behaviors that are going hurt us now and are going to be even worse down the road.”
In a video discussion, Dr. Van Susteren spoke with David A. Pollack, MD, about the accomplishments of the Climate Psychiatry Alliance, an organization they helped launch more than 2 years ago that warns the medical profession and the public about risks of climate change and the impact of climate disruption on mental health. One victory, for example, was getting the APA to vote to divest from fossil fuels.
Dr. Van Susteren and Dr. Pollack also discuss steps psychiatrists can take as individuals to provide care for patients suffering from the effects of climate change – such as prescribing “park therapy.” In their offices, physicians can look toward emerging solutions such as My Green Doctor and Health Care Without Harm, Dr. Pollack said.
Dr. Van Susteren has a private psychiatry private practice in Washington and has no disclosures. Dr. Pollack is affiliated with Oregon Health & Science University in Portland. He has no disclosures.
SAN FRANCISCO –
“We can find reasons to hope even in dark times,” Dr. Van Susteren said. “We understand science. We have all the tools ... this is what we do for a living. We warn about behaviors that are going hurt us now and are going to be even worse down the road.”
In a video discussion, Dr. Van Susteren spoke with David A. Pollack, MD, about the accomplishments of the Climate Psychiatry Alliance, an organization they helped launch more than 2 years ago that warns the medical profession and the public about risks of climate change and the impact of climate disruption on mental health. One victory, for example, was getting the APA to vote to divest from fossil fuels.
Dr. Van Susteren and Dr. Pollack also discuss steps psychiatrists can take as individuals to provide care for patients suffering from the effects of climate change – such as prescribing “park therapy.” In their offices, physicians can look toward emerging solutions such as My Green Doctor and Health Care Without Harm, Dr. Pollack said.
Dr. Van Susteren has a private psychiatry private practice in Washington and has no disclosures. Dr. Pollack is affiliated with Oregon Health & Science University in Portland. He has no disclosures.
SAN FRANCISCO –
“We can find reasons to hope even in dark times,” Dr. Van Susteren said. “We understand science. We have all the tools ... this is what we do for a living. We warn about behaviors that are going hurt us now and are going to be even worse down the road.”
In a video discussion, Dr. Van Susteren spoke with David A. Pollack, MD, about the accomplishments of the Climate Psychiatry Alliance, an organization they helped launch more than 2 years ago that warns the medical profession and the public about risks of climate change and the impact of climate disruption on mental health. One victory, for example, was getting the APA to vote to divest from fossil fuels.
Dr. Van Susteren and Dr. Pollack also discuss steps psychiatrists can take as individuals to provide care for patients suffering from the effects of climate change – such as prescribing “park therapy.” In their offices, physicians can look toward emerging solutions such as My Green Doctor and Health Care Without Harm, Dr. Pollack said.
Dr. Van Susteren has a private psychiatry private practice in Washington and has no disclosures. Dr. Pollack is affiliated with Oregon Health & Science University in Portland. He has no disclosures.
REPORTING FROM APA 2019
Psilocybin promising for alcohol use disorder
SAN FRANCISCO – Patients with alcohol use disorder reported a substantial decrease in drinking days, drinks per drinking day, and cravings in an ongoing trial of psilocybin at New York University.
“If this keeps going the way it looks like it’s going, I think it will lead to a large phase 3 trial that could be part of getting psilocybin rescheduled” from a schedule I drug, said NYU psychiatrist and lead investigator Kelley O’Donnell, MD, PhD.
The work builds on positive results from the 1950s and 1960s of LSD for alcoholism, before LSD research was largely abandoned. Researchers such as Dr. O’Donnell are revisiting the approach, but with psilocybin because, among other reasons, it has less stigma and a shorter duration that allows for outpatient use (J Psychopharmacol. 2012 Jul;26[7]:994-1002). The Drug Enforcement Administration currently classifies psilocybin, the psychoactive ingredient in hallucinogenic, or “magic” mushrooms, as schedule I. The results found by Dr. O’Donnell’s team and other factors, such as the low risk of abuse tied to the use of psilocybin, are leading some researchers to suggest that the drug should be reclassified to “no more restrictively than schedule IV” (Neuropsychopharm. 2018 Nov;142:143-66).
Dr. O’Donnell’s presentation was part of a recurring theme at the annual meeting of the American Psychiatric Association – the transformation of what were once considered street drugs into therapeutic tools. Favorable results also were reported for 3,4-Methylenedioxymethamphetamine (MDMA), commonly known as ecstasy, for posttraumatic stress disorder; ketamine for depression and suicidality; and marijuana for pain and other problems.
Concerning psilocybin for alcohol use disorder (AUD), Dr. O’Donnell said: “Some people have really profound psychological experiences that shift the way they think about themselves and the way alcohol is affecting their relationships. Therapy can work with that shift in meaning [to create] lasting change.”
Many people “say that they get exactly what they needed.” Sometimes, patients revisit a past trauma but with a greater openness and flexibility – and a growing sense of peace. “They access affective states they just don’t have access to normally,” she said.
In another case, a woman hallucinated that she was sitting on a throne ascending through the universe, surrounded by the faces and voices of people she knew telling her she is a valuable and worthwhile person, and could take her place within the center of her universe without the sense of defectiveness and shame that often triggered her drinking. Happy little beer bottles told her: “We don’t need to be the enemy. We don’t need to be a part of your life,” Dr. O’Donnell said.
She and her team are pitting psilocybin against diphenhydramine as a control in the NYU AUD trial.
People are randomized, then undergo therapy focused equally on their alcohol use and preparing them for the drug experience. At week 4, they take their study medication – either 25 mg per 70 kg psilocybin or 50 mg diphenhydramine – in a relaxed living room–like setting, with classical or world music in the background. The study team avoids music with words in English. Two therapists, usually a man and a woman, are there as guides. The experience lasts a few hours; patients are debriefed afterward.
Patients undergo another round of counseling to understand the meaning of the experience, followed by a second dose, either 40 mg per 70 kg psilocybin or 100 mg diphenhydramine, at week 8. Patients are debriefed again and undergo a third month of counseling.
The results have not yet been unblinded, but Dr. O’Donnell and her team did find that, among their first 56 subjects, more intense mystical experiences, as gauged by the self-reported Mystical Experience Questionnaire (MEQ), correlated with greater treatment success.
Patients fill out the MEQ 8 hours after their dose, rating dimensions such as ego dissolution, oceanic boundlessness, joy, compassion, and openness. The maximum score is 1, the lowest 0, meaning no mystical effects. The median score among the 56 subjects was 0.26. The 30 or so patients who scored at or above that mark after their first medication session – as a group, their mean first MEQ score was 0.65 – reported a smaller percentage of drinking days at week 12 than those who scored below 0.26 (19% vs. 40%; P less than .05), with fewer drinks per drinking day (2.63 vs. 7.01; P less than .01); and lower craving (8.43 vs. 13.86 points on 30-point Penn Alcohol Craving Scale, P less than .01).
The groups were evenly matched at baseline. Both reported drinking an average of 3 out of 4 days, with an mean of 7.5 drinks per drinking day and a craving score of about 18. No differences were found in anxiety and depression scores, which were minimal in both groups.
More than half the subjects were men; the mean age was 46; and subjects were fairly well educated, reporting an average of 17 school years.
Dr. O’Donnell said she’s seen a range of experiences on psilocybin, but that bad trips are rare. Benzodiazepines are kept on hand, however, to help people who get too anxious, and an atypical antipsychotic is on hand to reverse hallucinatory effects.
Her team hopes to enroll 100 subjects and plans for follow-up past 12 weeks. Both Denver and Oakland, Calif., recently decriminalized psilocybin.
The work is being funded by the Heffter Research Institute. Dr. O’Donnell had no disclosures.
SAN FRANCISCO – Patients with alcohol use disorder reported a substantial decrease in drinking days, drinks per drinking day, and cravings in an ongoing trial of psilocybin at New York University.
“If this keeps going the way it looks like it’s going, I think it will lead to a large phase 3 trial that could be part of getting psilocybin rescheduled” from a schedule I drug, said NYU psychiatrist and lead investigator Kelley O’Donnell, MD, PhD.
The work builds on positive results from the 1950s and 1960s of LSD for alcoholism, before LSD research was largely abandoned. Researchers such as Dr. O’Donnell are revisiting the approach, but with psilocybin because, among other reasons, it has less stigma and a shorter duration that allows for outpatient use (J Psychopharmacol. 2012 Jul;26[7]:994-1002). The Drug Enforcement Administration currently classifies psilocybin, the psychoactive ingredient in hallucinogenic, or “magic” mushrooms, as schedule I. The results found by Dr. O’Donnell’s team and other factors, such as the low risk of abuse tied to the use of psilocybin, are leading some researchers to suggest that the drug should be reclassified to “no more restrictively than schedule IV” (Neuropsychopharm. 2018 Nov;142:143-66).
Dr. O’Donnell’s presentation was part of a recurring theme at the annual meeting of the American Psychiatric Association – the transformation of what were once considered street drugs into therapeutic tools. Favorable results also were reported for 3,4-Methylenedioxymethamphetamine (MDMA), commonly known as ecstasy, for posttraumatic stress disorder; ketamine for depression and suicidality; and marijuana for pain and other problems.
Concerning psilocybin for alcohol use disorder (AUD), Dr. O’Donnell said: “Some people have really profound psychological experiences that shift the way they think about themselves and the way alcohol is affecting their relationships. Therapy can work with that shift in meaning [to create] lasting change.”
Many people “say that they get exactly what they needed.” Sometimes, patients revisit a past trauma but with a greater openness and flexibility – and a growing sense of peace. “They access affective states they just don’t have access to normally,” she said.
In another case, a woman hallucinated that she was sitting on a throne ascending through the universe, surrounded by the faces and voices of people she knew telling her she is a valuable and worthwhile person, and could take her place within the center of her universe without the sense of defectiveness and shame that often triggered her drinking. Happy little beer bottles told her: “We don’t need to be the enemy. We don’t need to be a part of your life,” Dr. O’Donnell said.
She and her team are pitting psilocybin against diphenhydramine as a control in the NYU AUD trial.
People are randomized, then undergo therapy focused equally on their alcohol use and preparing them for the drug experience. At week 4, they take their study medication – either 25 mg per 70 kg psilocybin or 50 mg diphenhydramine – in a relaxed living room–like setting, with classical or world music in the background. The study team avoids music with words in English. Two therapists, usually a man and a woman, are there as guides. The experience lasts a few hours; patients are debriefed afterward.
Patients undergo another round of counseling to understand the meaning of the experience, followed by a second dose, either 40 mg per 70 kg psilocybin or 100 mg diphenhydramine, at week 8. Patients are debriefed again and undergo a third month of counseling.
The results have not yet been unblinded, but Dr. O’Donnell and her team did find that, among their first 56 subjects, more intense mystical experiences, as gauged by the self-reported Mystical Experience Questionnaire (MEQ), correlated with greater treatment success.
Patients fill out the MEQ 8 hours after their dose, rating dimensions such as ego dissolution, oceanic boundlessness, joy, compassion, and openness. The maximum score is 1, the lowest 0, meaning no mystical effects. The median score among the 56 subjects was 0.26. The 30 or so patients who scored at or above that mark after their first medication session – as a group, their mean first MEQ score was 0.65 – reported a smaller percentage of drinking days at week 12 than those who scored below 0.26 (19% vs. 40%; P less than .05), with fewer drinks per drinking day (2.63 vs. 7.01; P less than .01); and lower craving (8.43 vs. 13.86 points on 30-point Penn Alcohol Craving Scale, P less than .01).
The groups were evenly matched at baseline. Both reported drinking an average of 3 out of 4 days, with an mean of 7.5 drinks per drinking day and a craving score of about 18. No differences were found in anxiety and depression scores, which were minimal in both groups.
More than half the subjects were men; the mean age was 46; and subjects were fairly well educated, reporting an average of 17 school years.
Dr. O’Donnell said she’s seen a range of experiences on psilocybin, but that bad trips are rare. Benzodiazepines are kept on hand, however, to help people who get too anxious, and an atypical antipsychotic is on hand to reverse hallucinatory effects.
Her team hopes to enroll 100 subjects and plans for follow-up past 12 weeks. Both Denver and Oakland, Calif., recently decriminalized psilocybin.
The work is being funded by the Heffter Research Institute. Dr. O’Donnell had no disclosures.
SAN FRANCISCO – Patients with alcohol use disorder reported a substantial decrease in drinking days, drinks per drinking day, and cravings in an ongoing trial of psilocybin at New York University.
“If this keeps going the way it looks like it’s going, I think it will lead to a large phase 3 trial that could be part of getting psilocybin rescheduled” from a schedule I drug, said NYU psychiatrist and lead investigator Kelley O’Donnell, MD, PhD.
The work builds on positive results from the 1950s and 1960s of LSD for alcoholism, before LSD research was largely abandoned. Researchers such as Dr. O’Donnell are revisiting the approach, but with psilocybin because, among other reasons, it has less stigma and a shorter duration that allows for outpatient use (J Psychopharmacol. 2012 Jul;26[7]:994-1002). The Drug Enforcement Administration currently classifies psilocybin, the psychoactive ingredient in hallucinogenic, or “magic” mushrooms, as schedule I. The results found by Dr. O’Donnell’s team and other factors, such as the low risk of abuse tied to the use of psilocybin, are leading some researchers to suggest that the drug should be reclassified to “no more restrictively than schedule IV” (Neuropsychopharm. 2018 Nov;142:143-66).
Dr. O’Donnell’s presentation was part of a recurring theme at the annual meeting of the American Psychiatric Association – the transformation of what were once considered street drugs into therapeutic tools. Favorable results also were reported for 3,4-Methylenedioxymethamphetamine (MDMA), commonly known as ecstasy, for posttraumatic stress disorder; ketamine for depression and suicidality; and marijuana for pain and other problems.
Concerning psilocybin for alcohol use disorder (AUD), Dr. O’Donnell said: “Some people have really profound psychological experiences that shift the way they think about themselves and the way alcohol is affecting their relationships. Therapy can work with that shift in meaning [to create] lasting change.”
Many people “say that they get exactly what they needed.” Sometimes, patients revisit a past trauma but with a greater openness and flexibility – and a growing sense of peace. “They access affective states they just don’t have access to normally,” she said.
In another case, a woman hallucinated that she was sitting on a throne ascending through the universe, surrounded by the faces and voices of people she knew telling her she is a valuable and worthwhile person, and could take her place within the center of her universe without the sense of defectiveness and shame that often triggered her drinking. Happy little beer bottles told her: “We don’t need to be the enemy. We don’t need to be a part of your life,” Dr. O’Donnell said.
She and her team are pitting psilocybin against diphenhydramine as a control in the NYU AUD trial.
People are randomized, then undergo therapy focused equally on their alcohol use and preparing them for the drug experience. At week 4, they take their study medication – either 25 mg per 70 kg psilocybin or 50 mg diphenhydramine – in a relaxed living room–like setting, with classical or world music in the background. The study team avoids music with words in English. Two therapists, usually a man and a woman, are there as guides. The experience lasts a few hours; patients are debriefed afterward.
Patients undergo another round of counseling to understand the meaning of the experience, followed by a second dose, either 40 mg per 70 kg psilocybin or 100 mg diphenhydramine, at week 8. Patients are debriefed again and undergo a third month of counseling.
The results have not yet been unblinded, but Dr. O’Donnell and her team did find that, among their first 56 subjects, more intense mystical experiences, as gauged by the self-reported Mystical Experience Questionnaire (MEQ), correlated with greater treatment success.
Patients fill out the MEQ 8 hours after their dose, rating dimensions such as ego dissolution, oceanic boundlessness, joy, compassion, and openness. The maximum score is 1, the lowest 0, meaning no mystical effects. The median score among the 56 subjects was 0.26. The 30 or so patients who scored at or above that mark after their first medication session – as a group, their mean first MEQ score was 0.65 – reported a smaller percentage of drinking days at week 12 than those who scored below 0.26 (19% vs. 40%; P less than .05), with fewer drinks per drinking day (2.63 vs. 7.01; P less than .01); and lower craving (8.43 vs. 13.86 points on 30-point Penn Alcohol Craving Scale, P less than .01).
The groups were evenly matched at baseline. Both reported drinking an average of 3 out of 4 days, with an mean of 7.5 drinks per drinking day and a craving score of about 18. No differences were found in anxiety and depression scores, which were minimal in both groups.
More than half the subjects were men; the mean age was 46; and subjects were fairly well educated, reporting an average of 17 school years.
Dr. O’Donnell said she’s seen a range of experiences on psilocybin, but that bad trips are rare. Benzodiazepines are kept on hand, however, to help people who get too anxious, and an atypical antipsychotic is on hand to reverse hallucinatory effects.
Her team hopes to enroll 100 subjects and plans for follow-up past 12 weeks. Both Denver and Oakland, Calif., recently decriminalized psilocybin.
The work is being funded by the Heffter Research Institute. Dr. O’Donnell had no disclosures.
REPORTING FROM APA 2019
Mismatch and repair technique adapted for autism
SAN FRANCISCO – Children with autism often struggle with repairing “messy” interactions with others, and this can impair their ability to communicate and develop properly. The interactive mismatch and repair technique, developed by Ed Tronick, PhD, when he was a researcher at Harvard Medical School and Children’s Hospital, Boston, may be able to guide communication development between an adult and a child with autism.
At the annual meeting of the American Psychiatric Association, Alexandra Harrison, MD, assistant professor of psychiatry at Harvard Medical School, described her experiences applying the technique to her work with autism patients, and showed a video of an awkward interaction she had with a 3-year-old boy with autism. By working to synchronize body movements with “Hal,” as well as inserting 1-second gaps between her statements, she helped him resolve an awkward moment, and Hal ultimately defused the tension by making a joke.
Hal managed to regulate his own uncertainty in the moment and navigate through tension. That small triumph has the potential to grow. “Once they’ve been able to secure some form of regulation with one or two or three individuals who are devoted to them, the hope is that this will spread and they will be able to regulate with individuals who are not as adjusted to them,” Gisele Apter, MD, PhD, a colleague of Dr. Harrison’s and professor of child psychiatry at Normandy Medical School, France, said in an interview. Dr. Apter moderated the session where the video was shown.
Dr. Tronick believes that the infant and caretaker grow together, making meanings together that are increasingly complex and coherent. That growth occurs in part through mismatch and repair interactions. Communication between infants and caregivers is nearly always a messy dance, with waxing and waning attention, changing intentions, and other dynamic factors leading to stops and starts, and awkward moments that the two must find a way to repair before carrying on.
These momentary mismatches, which happen all the time, are in fact a key element of childhood development, according to Dr. Apter. “There’s a lack of synchrony, and we want to get back on track because we push to communicate again. To do that, we have to repair the interaction, and one of the most beautiful things about development with this unbalanced couple is that the adult is generally there to support, to scaffold the child, but just one small step ahead of the infant so that it will enrich its development,” she said.
But a caregiver with depression or another mental illness, or a child with impaired communication development because of autism, can impede that natural process.
Dr. Tronick’s method aims to provide some structure to the interaction by likening the nonverbal part of the interaction to music and dance. There are vocal rhythms, tone, and pitch, and then there are coordinated patterns of movement, gaze, and facial expressions such as smiles or frowns. The idea is that developmental growth occurs when the infant and the adult create meanings through their interactions.
Such growth can occur in microprocesses – extended moments in which child and caregiver iron out a mismatch in intent or action. Resolving these situations, and then moving forward with the rest of the interaction, helps the child grow in complexity and development by acquiring new meanings.
One-second beats after each statement or sentence lead to predictability. “He can develop an expectancy, and he can anticipate my vocal turns, and that is going to be reassuring to him,” Dr. Harrison said during the presentation. It also allows the caregiver to think through a messy moment, to try something different if one action seems not to be working. “It’s very hard to know how to repair the messiness, because it’s actually not messy enough. It’s too black and white. Something works or it doesn’t work, whereas with most kids you can be a little messy and you have time to get back on track with them.
“With these children [with autism], it requires a level of awareness which is higher. It is helpful for the adult to try to adjust and learn to interact in a different way that is more attuned to the child,” Dr. Apter said.
In the video shown by Dr. Harrison, she and Hal are in the therapy/play area, and Hal’s mother has just left before he could say goodbye. He was very upset by this, but then turned to work building a “map” out of construction toys called H-links that he had been playing with, along with his mother, before she left. Throughout the video, Dr. Harrison attempts to synchronize her body movements with Hal’s, shifting her position when he shifts his, and these get out of alignment and come back in alignment at different times. Several times, body motion synchrony is followed by a statement from Hal.
Dr. Harrison sits on the floor next to him, with Hal faced away from her. At a loss for what to do, she makes a small pile of H-links next to her. Hal notices this, and then moves some of the H-links back to their original position.
Hal says, “The H-links don’t go together that much.”
“They don’t go together that much?” repeats Dr. Harrison.
“Yeah.” He takes more H-block pieces from her pile.
“You wanted to take my ones, too?”
At this point, there is an obvious mismatch, with Hal claiming Dr. Harrison’s H-blocks.
Hal smiles as he takes a few more H-blocks and then says, “Only for boys.”
Then his smile widens and he gazes directly at Dr. Harrison, who meets his with an expression of mock surprise.
“What?”
“Only for boys,” Hal repeats.
Dr. Harrison then strings a long a series of phrases, each separated by 1-second beats. Hal orients himself away from her, smiling slightly: “You mean only boys can play with these? ... Uh oh ... Guess that means ... I’m not allowed! ... Is that right? ... Oh, my gosh ... How did they ever make up that rule, I wonder?”
At this, Hal orients himself toward Dr. Harrison again and smiles widely this time. “You’re tricking me,” says Dr. Harrison, and he gazes downward, though toward her. “But I think you’re trying to tell me that you don’t want me to hand them to you ... You want to get them yourself. ... That right?”
“Yeah. No more giving me pieces,” says Hal.
“Oh, I’m glad I understood. ... I will not give you any more pieces.”
SAN FRANCISCO – Children with autism often struggle with repairing “messy” interactions with others, and this can impair their ability to communicate and develop properly. The interactive mismatch and repair technique, developed by Ed Tronick, PhD, when he was a researcher at Harvard Medical School and Children’s Hospital, Boston, may be able to guide communication development between an adult and a child with autism.
At the annual meeting of the American Psychiatric Association, Alexandra Harrison, MD, assistant professor of psychiatry at Harvard Medical School, described her experiences applying the technique to her work with autism patients, and showed a video of an awkward interaction she had with a 3-year-old boy with autism. By working to synchronize body movements with “Hal,” as well as inserting 1-second gaps between her statements, she helped him resolve an awkward moment, and Hal ultimately defused the tension by making a joke.
Hal managed to regulate his own uncertainty in the moment and navigate through tension. That small triumph has the potential to grow. “Once they’ve been able to secure some form of regulation with one or two or three individuals who are devoted to them, the hope is that this will spread and they will be able to regulate with individuals who are not as adjusted to them,” Gisele Apter, MD, PhD, a colleague of Dr. Harrison’s and professor of child psychiatry at Normandy Medical School, France, said in an interview. Dr. Apter moderated the session where the video was shown.
Dr. Tronick believes that the infant and caretaker grow together, making meanings together that are increasingly complex and coherent. That growth occurs in part through mismatch and repair interactions. Communication between infants and caregivers is nearly always a messy dance, with waxing and waning attention, changing intentions, and other dynamic factors leading to stops and starts, and awkward moments that the two must find a way to repair before carrying on.
These momentary mismatches, which happen all the time, are in fact a key element of childhood development, according to Dr. Apter. “There’s a lack of synchrony, and we want to get back on track because we push to communicate again. To do that, we have to repair the interaction, and one of the most beautiful things about development with this unbalanced couple is that the adult is generally there to support, to scaffold the child, but just one small step ahead of the infant so that it will enrich its development,” she said.
But a caregiver with depression or another mental illness, or a child with impaired communication development because of autism, can impede that natural process.
Dr. Tronick’s method aims to provide some structure to the interaction by likening the nonverbal part of the interaction to music and dance. There are vocal rhythms, tone, and pitch, and then there are coordinated patterns of movement, gaze, and facial expressions such as smiles or frowns. The idea is that developmental growth occurs when the infant and the adult create meanings through their interactions.
Such growth can occur in microprocesses – extended moments in which child and caregiver iron out a mismatch in intent or action. Resolving these situations, and then moving forward with the rest of the interaction, helps the child grow in complexity and development by acquiring new meanings.
One-second beats after each statement or sentence lead to predictability. “He can develop an expectancy, and he can anticipate my vocal turns, and that is going to be reassuring to him,” Dr. Harrison said during the presentation. It also allows the caregiver to think through a messy moment, to try something different if one action seems not to be working. “It’s very hard to know how to repair the messiness, because it’s actually not messy enough. It’s too black and white. Something works or it doesn’t work, whereas with most kids you can be a little messy and you have time to get back on track with them.
“With these children [with autism], it requires a level of awareness which is higher. It is helpful for the adult to try to adjust and learn to interact in a different way that is more attuned to the child,” Dr. Apter said.
In the video shown by Dr. Harrison, she and Hal are in the therapy/play area, and Hal’s mother has just left before he could say goodbye. He was very upset by this, but then turned to work building a “map” out of construction toys called H-links that he had been playing with, along with his mother, before she left. Throughout the video, Dr. Harrison attempts to synchronize her body movements with Hal’s, shifting her position when he shifts his, and these get out of alignment and come back in alignment at different times. Several times, body motion synchrony is followed by a statement from Hal.
Dr. Harrison sits on the floor next to him, with Hal faced away from her. At a loss for what to do, she makes a small pile of H-links next to her. Hal notices this, and then moves some of the H-links back to their original position.
Hal says, “The H-links don’t go together that much.”
“They don’t go together that much?” repeats Dr. Harrison.
“Yeah.” He takes more H-block pieces from her pile.
“You wanted to take my ones, too?”
At this point, there is an obvious mismatch, with Hal claiming Dr. Harrison’s H-blocks.
Hal smiles as he takes a few more H-blocks and then says, “Only for boys.”
Then his smile widens and he gazes directly at Dr. Harrison, who meets his with an expression of mock surprise.
“What?”
“Only for boys,” Hal repeats.
Dr. Harrison then strings a long a series of phrases, each separated by 1-second beats. Hal orients himself away from her, smiling slightly: “You mean only boys can play with these? ... Uh oh ... Guess that means ... I’m not allowed! ... Is that right? ... Oh, my gosh ... How did they ever make up that rule, I wonder?”
At this, Hal orients himself toward Dr. Harrison again and smiles widely this time. “You’re tricking me,” says Dr. Harrison, and he gazes downward, though toward her. “But I think you’re trying to tell me that you don’t want me to hand them to you ... You want to get them yourself. ... That right?”
“Yeah. No more giving me pieces,” says Hal.
“Oh, I’m glad I understood. ... I will not give you any more pieces.”
SAN FRANCISCO – Children with autism often struggle with repairing “messy” interactions with others, and this can impair their ability to communicate and develop properly. The interactive mismatch and repair technique, developed by Ed Tronick, PhD, when he was a researcher at Harvard Medical School and Children’s Hospital, Boston, may be able to guide communication development between an adult and a child with autism.
At the annual meeting of the American Psychiatric Association, Alexandra Harrison, MD, assistant professor of psychiatry at Harvard Medical School, described her experiences applying the technique to her work with autism patients, and showed a video of an awkward interaction she had with a 3-year-old boy with autism. By working to synchronize body movements with “Hal,” as well as inserting 1-second gaps between her statements, she helped him resolve an awkward moment, and Hal ultimately defused the tension by making a joke.
Hal managed to regulate his own uncertainty in the moment and navigate through tension. That small triumph has the potential to grow. “Once they’ve been able to secure some form of regulation with one or two or three individuals who are devoted to them, the hope is that this will spread and they will be able to regulate with individuals who are not as adjusted to them,” Gisele Apter, MD, PhD, a colleague of Dr. Harrison’s and professor of child psychiatry at Normandy Medical School, France, said in an interview. Dr. Apter moderated the session where the video was shown.
Dr. Tronick believes that the infant and caretaker grow together, making meanings together that are increasingly complex and coherent. That growth occurs in part through mismatch and repair interactions. Communication between infants and caregivers is nearly always a messy dance, with waxing and waning attention, changing intentions, and other dynamic factors leading to stops and starts, and awkward moments that the two must find a way to repair before carrying on.
These momentary mismatches, which happen all the time, are in fact a key element of childhood development, according to Dr. Apter. “There’s a lack of synchrony, and we want to get back on track because we push to communicate again. To do that, we have to repair the interaction, and one of the most beautiful things about development with this unbalanced couple is that the adult is generally there to support, to scaffold the child, but just one small step ahead of the infant so that it will enrich its development,” she said.
But a caregiver with depression or another mental illness, or a child with impaired communication development because of autism, can impede that natural process.
Dr. Tronick’s method aims to provide some structure to the interaction by likening the nonverbal part of the interaction to music and dance. There are vocal rhythms, tone, and pitch, and then there are coordinated patterns of movement, gaze, and facial expressions such as smiles or frowns. The idea is that developmental growth occurs when the infant and the adult create meanings through their interactions.
Such growth can occur in microprocesses – extended moments in which child and caregiver iron out a mismatch in intent or action. Resolving these situations, and then moving forward with the rest of the interaction, helps the child grow in complexity and development by acquiring new meanings.
One-second beats after each statement or sentence lead to predictability. “He can develop an expectancy, and he can anticipate my vocal turns, and that is going to be reassuring to him,” Dr. Harrison said during the presentation. It also allows the caregiver to think through a messy moment, to try something different if one action seems not to be working. “It’s very hard to know how to repair the messiness, because it’s actually not messy enough. It’s too black and white. Something works or it doesn’t work, whereas with most kids you can be a little messy and you have time to get back on track with them.
“With these children [with autism], it requires a level of awareness which is higher. It is helpful for the adult to try to adjust and learn to interact in a different way that is more attuned to the child,” Dr. Apter said.
In the video shown by Dr. Harrison, she and Hal are in the therapy/play area, and Hal’s mother has just left before he could say goodbye. He was very upset by this, but then turned to work building a “map” out of construction toys called H-links that he had been playing with, along with his mother, before she left. Throughout the video, Dr. Harrison attempts to synchronize her body movements with Hal’s, shifting her position when he shifts his, and these get out of alignment and come back in alignment at different times. Several times, body motion synchrony is followed by a statement from Hal.
Dr. Harrison sits on the floor next to him, with Hal faced away from her. At a loss for what to do, she makes a small pile of H-links next to her. Hal notices this, and then moves some of the H-links back to their original position.
Hal says, “The H-links don’t go together that much.”
“They don’t go together that much?” repeats Dr. Harrison.
“Yeah.” He takes more H-block pieces from her pile.
“You wanted to take my ones, too?”
At this point, there is an obvious mismatch, with Hal claiming Dr. Harrison’s H-blocks.
Hal smiles as he takes a few more H-blocks and then says, “Only for boys.”
Then his smile widens and he gazes directly at Dr. Harrison, who meets his with an expression of mock surprise.
“What?”
“Only for boys,” Hal repeats.
Dr. Harrison then strings a long a series of phrases, each separated by 1-second beats. Hal orients himself away from her, smiling slightly: “You mean only boys can play with these? ... Uh oh ... Guess that means ... I’m not allowed! ... Is that right? ... Oh, my gosh ... How did they ever make up that rule, I wonder?”
At this, Hal orients himself toward Dr. Harrison again and smiles widely this time. “You’re tricking me,” says Dr. Harrison, and he gazes downward, though toward her. “But I think you’re trying to tell me that you don’t want me to hand them to you ... You want to get them yourself. ... That right?”
“Yeah. No more giving me pieces,” says Hal.
“Oh, I’m glad I understood. ... I will not give you any more pieces.”
REPORTING FROM APA 2019
Teasing OCD, OCPD apart, and coping with challenges
SAN FRANCISCO – OCPD also presents some key challenges to interpersonal therapy, especially because psychiatrists themselves sometimes share these traits.
“There’s an overlap, and some people have both OCD and OCPD, but some people have just one or the other, and that’s important to tease out because it shifts treatment,” Holly D. Crisp-Han, MD, said in an interview. Dr. Crisp-Han is a clinical associate professor of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. She and her colleague, Glen O. Gabbard, MD, clinical professor of psychiatry at Baylor, chaired a session on dynamic psychotherapy for the treatment of OCPD at the annual meeting of the American Psychiatric Association.
OCPD is the most common personality disorder, with some estimates putting its prevalence as high as nearly 8%. Whereas OCD is characterized by an ego-dystonic need for rituals and specific thoughts, OCPD is defined by ego-syntonic traits. In a study comparing patients with both disorders, researchers found that both groups had reduced psychosocial function and quality of life, but intrusive thoughts and feelings were absent in OCPD. Instead, these patients reported ritualized, methodical behaviors, such as list making, reorganizing personal effects, and repeatedly editing what they had written. OCD patients were also better at delaying rewards.
Dynamic psychotherapy has been shown to achieve better outcomes in OCPD than cognitive-behavioral therapy, though both have a place in the treatment of OCPD, according to Dr. Gabbard. However, it comes with significant challenges. The patient will often challenge the therapist’s interventions and feel threatened by any hint of losing control. Sessions can become ritualized.
OCPD patients are driven by an effort to avoid a tormenting superego rather than seeking pleasure, and they may project this superego onto the therapist. It’s important to identify and interpret patient distortion of the therapist’s attitude toward the patient. Ultimately, the goal of therapy is to modify the patient’s self-expectations.
Couples therapy can be a good idea in cases of extreme ego-syntonicity. The patient’s partner can provide a second perspective to complement the patient’s subjective view of the relationship.
A unique challenge with OCPD is that therapists may see reflections of themselves in the patient. “Many physicians, psychiatrists, and therapists themselves struggle with obsessive-compulsive types of problems. Those types of traits – perfectionism, hard work, overwork, diligence – are rewarded in a career in medicine, and in fact [are] necessary for a career in medicine. We all have to be alert to our own personality traits in order to be able to treat those traits in others,” Dr. Crisp-Han said.” If we don’t recognize those traits in ourselves, then we run the risk of falling into competitive patterns, or idealizations, or other kinds of problems with our patients.”
Therapists who are narcissistically vulnerable may get sucked into power struggles with patients, and can feel undervalued, Dr. Gabbard said. Because rituals can develop, the therapist may also become bored, and even come to feel controlled by the patient’s obsession with the therapeutic process.
But there are other challenges in sessions. The tendency toward ritualization can produce boredom in the therapist. “That’s one of the biggest problems you have, hanging in with somebody who’s repeating the same things over and over again in a dry tone. You start to feel controlled by everything the patient is doing with their agenda,” Dr. Gabbard said during the session. He suggested confronting the patient from time to time. “You can say, ‘Today you don’t sound like you’re that interested in what you’re saying to me; you sound very detached. What’s going on?’ You can feed back to the person how they’re coming across, which can be very valuable.”
Humor is another way to tackle therapy with OCPD patients, because an important therapeutic lesson is to take things a little less seriously, especially in the face of the perfectionism that often haunts OCPD patients. In fact, this can be one of the condition’s most devastating traits, always leading an OCPD patient to feel that he or she is failing, that no accomplishment is ever enough.
“You can work on perfectionism and interpersonal relationships, and the absence of fun and pleasure. This is one of the most fun things to work on in the transference, countertransference relationship. Have a little bit of fun with the patient, because that might be quite foreign,” Dr. Gabbard said. “It can be tricky, because you don’t want to act like you’re laughing at the patient, but you want to introduce some levity and lightness sometimes.”
He gave an example of a patient who was a Catholic priest, who felt intensely guilty over sex. The patient said, “In the Catholic Church, thinking about sex is exactly the same as having sex.” Dr. Gabbard thought for a moment and then replied, “Well, you know, in my experience, that’s not true.”
The patient chuckled along with him. “I tried to point out to him that not all Catholic theologians see it that way,” Dr. Gabbard said.
Dr. Crisp-Han and Dr. Gabbard have collaborated on a book focused on diagnosis and treatment challenges associated with narcissistic patients called “Narcissism and Its Discontents” (American Psychiatric Association Publishing, 2018). They reported no relevant financial disclosures.
SAN FRANCISCO – OCPD also presents some key challenges to interpersonal therapy, especially because psychiatrists themselves sometimes share these traits.
“There’s an overlap, and some people have both OCD and OCPD, but some people have just one or the other, and that’s important to tease out because it shifts treatment,” Holly D. Crisp-Han, MD, said in an interview. Dr. Crisp-Han is a clinical associate professor of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. She and her colleague, Glen O. Gabbard, MD, clinical professor of psychiatry at Baylor, chaired a session on dynamic psychotherapy for the treatment of OCPD at the annual meeting of the American Psychiatric Association.
OCPD is the most common personality disorder, with some estimates putting its prevalence as high as nearly 8%. Whereas OCD is characterized by an ego-dystonic need for rituals and specific thoughts, OCPD is defined by ego-syntonic traits. In a study comparing patients with both disorders, researchers found that both groups had reduced psychosocial function and quality of life, but intrusive thoughts and feelings were absent in OCPD. Instead, these patients reported ritualized, methodical behaviors, such as list making, reorganizing personal effects, and repeatedly editing what they had written. OCD patients were also better at delaying rewards.
Dynamic psychotherapy has been shown to achieve better outcomes in OCPD than cognitive-behavioral therapy, though both have a place in the treatment of OCPD, according to Dr. Gabbard. However, it comes with significant challenges. The patient will often challenge the therapist’s interventions and feel threatened by any hint of losing control. Sessions can become ritualized.
OCPD patients are driven by an effort to avoid a tormenting superego rather than seeking pleasure, and they may project this superego onto the therapist. It’s important to identify and interpret patient distortion of the therapist’s attitude toward the patient. Ultimately, the goal of therapy is to modify the patient’s self-expectations.
Couples therapy can be a good idea in cases of extreme ego-syntonicity. The patient’s partner can provide a second perspective to complement the patient’s subjective view of the relationship.
A unique challenge with OCPD is that therapists may see reflections of themselves in the patient. “Many physicians, psychiatrists, and therapists themselves struggle with obsessive-compulsive types of problems. Those types of traits – perfectionism, hard work, overwork, diligence – are rewarded in a career in medicine, and in fact [are] necessary for a career in medicine. We all have to be alert to our own personality traits in order to be able to treat those traits in others,” Dr. Crisp-Han said.” If we don’t recognize those traits in ourselves, then we run the risk of falling into competitive patterns, or idealizations, or other kinds of problems with our patients.”
Therapists who are narcissistically vulnerable may get sucked into power struggles with patients, and can feel undervalued, Dr. Gabbard said. Because rituals can develop, the therapist may also become bored, and even come to feel controlled by the patient’s obsession with the therapeutic process.
But there are other challenges in sessions. The tendency toward ritualization can produce boredom in the therapist. “That’s one of the biggest problems you have, hanging in with somebody who’s repeating the same things over and over again in a dry tone. You start to feel controlled by everything the patient is doing with their agenda,” Dr. Gabbard said during the session. He suggested confronting the patient from time to time. “You can say, ‘Today you don’t sound like you’re that interested in what you’re saying to me; you sound very detached. What’s going on?’ You can feed back to the person how they’re coming across, which can be very valuable.”
Humor is another way to tackle therapy with OCPD patients, because an important therapeutic lesson is to take things a little less seriously, especially in the face of the perfectionism that often haunts OCPD patients. In fact, this can be one of the condition’s most devastating traits, always leading an OCPD patient to feel that he or she is failing, that no accomplishment is ever enough.
“You can work on perfectionism and interpersonal relationships, and the absence of fun and pleasure. This is one of the most fun things to work on in the transference, countertransference relationship. Have a little bit of fun with the patient, because that might be quite foreign,” Dr. Gabbard said. “It can be tricky, because you don’t want to act like you’re laughing at the patient, but you want to introduce some levity and lightness sometimes.”
He gave an example of a patient who was a Catholic priest, who felt intensely guilty over sex. The patient said, “In the Catholic Church, thinking about sex is exactly the same as having sex.” Dr. Gabbard thought for a moment and then replied, “Well, you know, in my experience, that’s not true.”
The patient chuckled along with him. “I tried to point out to him that not all Catholic theologians see it that way,” Dr. Gabbard said.
Dr. Crisp-Han and Dr. Gabbard have collaborated on a book focused on diagnosis and treatment challenges associated with narcissistic patients called “Narcissism and Its Discontents” (American Psychiatric Association Publishing, 2018). They reported no relevant financial disclosures.
SAN FRANCISCO – OCPD also presents some key challenges to interpersonal therapy, especially because psychiatrists themselves sometimes share these traits.
“There’s an overlap, and some people have both OCD and OCPD, but some people have just one or the other, and that’s important to tease out because it shifts treatment,” Holly D. Crisp-Han, MD, said in an interview. Dr. Crisp-Han is a clinical associate professor of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. She and her colleague, Glen O. Gabbard, MD, clinical professor of psychiatry at Baylor, chaired a session on dynamic psychotherapy for the treatment of OCPD at the annual meeting of the American Psychiatric Association.
OCPD is the most common personality disorder, with some estimates putting its prevalence as high as nearly 8%. Whereas OCD is characterized by an ego-dystonic need for rituals and specific thoughts, OCPD is defined by ego-syntonic traits. In a study comparing patients with both disorders, researchers found that both groups had reduced psychosocial function and quality of life, but intrusive thoughts and feelings were absent in OCPD. Instead, these patients reported ritualized, methodical behaviors, such as list making, reorganizing personal effects, and repeatedly editing what they had written. OCD patients were also better at delaying rewards.
Dynamic psychotherapy has been shown to achieve better outcomes in OCPD than cognitive-behavioral therapy, though both have a place in the treatment of OCPD, according to Dr. Gabbard. However, it comes with significant challenges. The patient will often challenge the therapist’s interventions and feel threatened by any hint of losing control. Sessions can become ritualized.
OCPD patients are driven by an effort to avoid a tormenting superego rather than seeking pleasure, and they may project this superego onto the therapist. It’s important to identify and interpret patient distortion of the therapist’s attitude toward the patient. Ultimately, the goal of therapy is to modify the patient’s self-expectations.
Couples therapy can be a good idea in cases of extreme ego-syntonicity. The patient’s partner can provide a second perspective to complement the patient’s subjective view of the relationship.
A unique challenge with OCPD is that therapists may see reflections of themselves in the patient. “Many physicians, psychiatrists, and therapists themselves struggle with obsessive-compulsive types of problems. Those types of traits – perfectionism, hard work, overwork, diligence – are rewarded in a career in medicine, and in fact [are] necessary for a career in medicine. We all have to be alert to our own personality traits in order to be able to treat those traits in others,” Dr. Crisp-Han said.” If we don’t recognize those traits in ourselves, then we run the risk of falling into competitive patterns, or idealizations, or other kinds of problems with our patients.”
Therapists who are narcissistically vulnerable may get sucked into power struggles with patients, and can feel undervalued, Dr. Gabbard said. Because rituals can develop, the therapist may also become bored, and even come to feel controlled by the patient’s obsession with the therapeutic process.
But there are other challenges in sessions. The tendency toward ritualization can produce boredom in the therapist. “That’s one of the biggest problems you have, hanging in with somebody who’s repeating the same things over and over again in a dry tone. You start to feel controlled by everything the patient is doing with their agenda,” Dr. Gabbard said during the session. He suggested confronting the patient from time to time. “You can say, ‘Today you don’t sound like you’re that interested in what you’re saying to me; you sound very detached. What’s going on?’ You can feed back to the person how they’re coming across, which can be very valuable.”
Humor is another way to tackle therapy with OCPD patients, because an important therapeutic lesson is to take things a little less seriously, especially in the face of the perfectionism that often haunts OCPD patients. In fact, this can be one of the condition’s most devastating traits, always leading an OCPD patient to feel that he or she is failing, that no accomplishment is ever enough.
“You can work on perfectionism and interpersonal relationships, and the absence of fun and pleasure. This is one of the most fun things to work on in the transference, countertransference relationship. Have a little bit of fun with the patient, because that might be quite foreign,” Dr. Gabbard said. “It can be tricky, because you don’t want to act like you’re laughing at the patient, but you want to introduce some levity and lightness sometimes.”
He gave an example of a patient who was a Catholic priest, who felt intensely guilty over sex. The patient said, “In the Catholic Church, thinking about sex is exactly the same as having sex.” Dr. Gabbard thought for a moment and then replied, “Well, you know, in my experience, that’s not true.”
The patient chuckled along with him. “I tried to point out to him that not all Catholic theologians see it that way,” Dr. Gabbard said.
Dr. Crisp-Han and Dr. Gabbard have collaborated on a book focused on diagnosis and treatment challenges associated with narcissistic patients called “Narcissism and Its Discontents” (American Psychiatric Association Publishing, 2018). They reported no relevant financial disclosures.
EXPERT ANALYSIS FROM APA 2019