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Watch for QTc interval prolongation in patients taking antipsychotics
LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.
Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.
All antipsychotics can cause an increase in the QT interval and can cause TdP, although some likely confer a greater risk than others. “It’s most likely not an idiosyncratic effect but rather a dose-related effect,” she said. “So the higher the dose, the more the risk.” There are some data suggesting that phenothiazines, particularly thioridazine, seem to present the greatest risk for prolonging the QTc interval. , but IV haloperidol has been linked to prolonged QTc and TdP. “It’s difficult to know whether that’s the impact of the drug or a reflection of the fact that patients on IV haloperidol are usually medically complicated patients,” Dr. Ernst noted. “Unfortunately, there is limited direct comparison data between agents. Atypicals are only implicated in TdP in rare case reports, and there is less available data for the newest atypicals.”
Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”
All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”
In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).
There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.
For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”
For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.
In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”
She reported having no financial disclosures.
LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.
Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.
All antipsychotics can cause an increase in the QT interval and can cause TdP, although some likely confer a greater risk than others. “It’s most likely not an idiosyncratic effect but rather a dose-related effect,” she said. “So the higher the dose, the more the risk.” There are some data suggesting that phenothiazines, particularly thioridazine, seem to present the greatest risk for prolonging the QTc interval. , but IV haloperidol has been linked to prolonged QTc and TdP. “It’s difficult to know whether that’s the impact of the drug or a reflection of the fact that patients on IV haloperidol are usually medically complicated patients,” Dr. Ernst noted. “Unfortunately, there is limited direct comparison data between agents. Atypicals are only implicated in TdP in rare case reports, and there is less available data for the newest atypicals.”
Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”
All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”
In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).
There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.
For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”
For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.
In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”
She reported having no financial disclosures.
LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.
Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.
All antipsychotics can cause an increase in the QT interval and can cause TdP, although some likely confer a greater risk than others. “It’s most likely not an idiosyncratic effect but rather a dose-related effect,” she said. “So the higher the dose, the more the risk.” There are some data suggesting that phenothiazines, particularly thioridazine, seem to present the greatest risk for prolonging the QTc interval. , but IV haloperidol has been linked to prolonged QTc and TdP. “It’s difficult to know whether that’s the impact of the drug or a reflection of the fact that patients on IV haloperidol are usually medically complicated patients,” Dr. Ernst noted. “Unfortunately, there is limited direct comparison data between agents. Atypicals are only implicated in TdP in rare case reports, and there is less available data for the newest atypicals.”
Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”
All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”
In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).
There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.
For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”
For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.
In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”
She reported having no financial disclosures.
REPORTING FROM NPA 2018
The case for being open-minded about medical marijuana
LAS VEGAS – Even if you do not believe in medical cannabis, be open to patients who ask you if it might benefit them, Kevin P. Hill, MD, advised.
“Being willing to talk to your patient about it is important,” said Dr. Hill, of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Because what will happen is, they’ll say, ‘Look. I need medical marijuana to treat my anxiety.’ Then you can say, ‘Well, I have treatments that work for anxiety that we haven’t tried.’ Maybe you can get them into treatment because of that conversation.”
In his opinion, the appropriate candidate for medical cannabis is someone with a debilitating condition who has failed multiple first- and second-line treatments. “,” he noted. “It’s not a good place to be, but now the question becomes: How do we give people what they want while addressing the risks? I think we need to do a better job of that. We can provide a service to patients and colleagues by being informed and thoughtful on the topic.”
Food and Drug Administration–approved cannabinoids to date are dronabinol (Marinol) and nabilone (Cesamet). These agents are approved for nausea and vomiting associated with chemotherapy and for appetite stimulation in wasting illnesses such as AIDS. “Your patients may come to you and say, ‘I think I need medical cannabis for condition X,’ ” said Dr. Hill, who authored the book “Marijuana: The Unbiased Truth About the World’s Most Popular Weed” (Center City, Minn.: Hazelden Publishing, 2015). “Maybe the cannabis plant can outperform the two approved agents that we have. I think we have to be open to that possibility. Maybe they offer some things that dronabinol and nabilone don’t.”
Medical indications for cannabis in various states include 53 conditions, he said, such as cancer, glaucoma, AIDS, hepatitis C, amyotrophic lateral sclerosis, Crohn’s disease, Parkinson’s disease, and multiple sclerosis. However, data suggest that most people with medical cannabis cards do not have one of those conditions. More than 50 trials of cannabinoids, including cannabis, have been conducted, “and we definitely need a lot more,” Dr. Hill continued. “About half of the studies show positive effects for chronic pain, neuropathic pain, and spasticity associated with MS.”
Resources Dr. Hill recommended for clinicians include a review that he published in JAMA (2015;313[24]:2474-83), and a review of cannabis and pain that he coauthored that was published in the journal Cannabis and Cannabinoid Research (2017;2[1]:96-104), and a free downloadable publication from he National Academies Press entitled “Health Effects of Cannabis and Cannabinoid Research: The Current State of Evidence and Recommendations for Research.” One passage from that document reads as follows: “Despite the extensive changes in policy at the state level and the rapid rise in the use of cannabis both for medical purposes and for recreational use, conclusive evidence regarding the short- and long-term health effects (harms and benefits) of cannabis use remains elusive. A lack of scientific research has resulted in a lack of information on the health implications of cannabis use, which is a significant public health concern for vulnerable populations such as pregnant women and adolescents. Unlike other substances whose use may confer risk, such as alcohol or tobacco, no accepted standards exist to help guide individuals as they make choices regarding the issues of if, when, where, and how to use cannabis safely and, in regard to therapeutic uses, effectively.”
Dr. Hill disclosed that he has received research grants from National Institute on Drug Abuse, the Brain and Behavior Research Foundation, the American Lung Association, the Greater Boston Council on Alcoholism, and the Peter G. Dodge Foundation. He also receives book royalties from Hazelden Publishing.
[email protected]
LAS VEGAS – Even if you do not believe in medical cannabis, be open to patients who ask you if it might benefit them, Kevin P. Hill, MD, advised.
“Being willing to talk to your patient about it is important,” said Dr. Hill, of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Because what will happen is, they’ll say, ‘Look. I need medical marijuana to treat my anxiety.’ Then you can say, ‘Well, I have treatments that work for anxiety that we haven’t tried.’ Maybe you can get them into treatment because of that conversation.”
In his opinion, the appropriate candidate for medical cannabis is someone with a debilitating condition who has failed multiple first- and second-line treatments. “,” he noted. “It’s not a good place to be, but now the question becomes: How do we give people what they want while addressing the risks? I think we need to do a better job of that. We can provide a service to patients and colleagues by being informed and thoughtful on the topic.”
Food and Drug Administration–approved cannabinoids to date are dronabinol (Marinol) and nabilone (Cesamet). These agents are approved for nausea and vomiting associated with chemotherapy and for appetite stimulation in wasting illnesses such as AIDS. “Your patients may come to you and say, ‘I think I need medical cannabis for condition X,’ ” said Dr. Hill, who authored the book “Marijuana: The Unbiased Truth About the World’s Most Popular Weed” (Center City, Minn.: Hazelden Publishing, 2015). “Maybe the cannabis plant can outperform the two approved agents that we have. I think we have to be open to that possibility. Maybe they offer some things that dronabinol and nabilone don’t.”
Medical indications for cannabis in various states include 53 conditions, he said, such as cancer, glaucoma, AIDS, hepatitis C, amyotrophic lateral sclerosis, Crohn’s disease, Parkinson’s disease, and multiple sclerosis. However, data suggest that most people with medical cannabis cards do not have one of those conditions. More than 50 trials of cannabinoids, including cannabis, have been conducted, “and we definitely need a lot more,” Dr. Hill continued. “About half of the studies show positive effects for chronic pain, neuropathic pain, and spasticity associated with MS.”
Resources Dr. Hill recommended for clinicians include a review that he published in JAMA (2015;313[24]:2474-83), and a review of cannabis and pain that he coauthored that was published in the journal Cannabis and Cannabinoid Research (2017;2[1]:96-104), and a free downloadable publication from he National Academies Press entitled “Health Effects of Cannabis and Cannabinoid Research: The Current State of Evidence and Recommendations for Research.” One passage from that document reads as follows: “Despite the extensive changes in policy at the state level and the rapid rise in the use of cannabis both for medical purposes and for recreational use, conclusive evidence regarding the short- and long-term health effects (harms and benefits) of cannabis use remains elusive. A lack of scientific research has resulted in a lack of information on the health implications of cannabis use, which is a significant public health concern for vulnerable populations such as pregnant women and adolescents. Unlike other substances whose use may confer risk, such as alcohol or tobacco, no accepted standards exist to help guide individuals as they make choices regarding the issues of if, when, where, and how to use cannabis safely and, in regard to therapeutic uses, effectively.”
Dr. Hill disclosed that he has received research grants from National Institute on Drug Abuse, the Brain and Behavior Research Foundation, the American Lung Association, the Greater Boston Council on Alcoholism, and the Peter G. Dodge Foundation. He also receives book royalties from Hazelden Publishing.
[email protected]
LAS VEGAS – Even if you do not believe in medical cannabis, be open to patients who ask you if it might benefit them, Kevin P. Hill, MD, advised.
“Being willing to talk to your patient about it is important,” said Dr. Hill, of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Because what will happen is, they’ll say, ‘Look. I need medical marijuana to treat my anxiety.’ Then you can say, ‘Well, I have treatments that work for anxiety that we haven’t tried.’ Maybe you can get them into treatment because of that conversation.”
In his opinion, the appropriate candidate for medical cannabis is someone with a debilitating condition who has failed multiple first- and second-line treatments. “,” he noted. “It’s not a good place to be, but now the question becomes: How do we give people what they want while addressing the risks? I think we need to do a better job of that. We can provide a service to patients and colleagues by being informed and thoughtful on the topic.”
Food and Drug Administration–approved cannabinoids to date are dronabinol (Marinol) and nabilone (Cesamet). These agents are approved for nausea and vomiting associated with chemotherapy and for appetite stimulation in wasting illnesses such as AIDS. “Your patients may come to you and say, ‘I think I need medical cannabis for condition X,’ ” said Dr. Hill, who authored the book “Marijuana: The Unbiased Truth About the World’s Most Popular Weed” (Center City, Minn.: Hazelden Publishing, 2015). “Maybe the cannabis plant can outperform the two approved agents that we have. I think we have to be open to that possibility. Maybe they offer some things that dronabinol and nabilone don’t.”
Medical indications for cannabis in various states include 53 conditions, he said, such as cancer, glaucoma, AIDS, hepatitis C, amyotrophic lateral sclerosis, Crohn’s disease, Parkinson’s disease, and multiple sclerosis. However, data suggest that most people with medical cannabis cards do not have one of those conditions. More than 50 trials of cannabinoids, including cannabis, have been conducted, “and we definitely need a lot more,” Dr. Hill continued. “About half of the studies show positive effects for chronic pain, neuropathic pain, and spasticity associated with MS.”
Resources Dr. Hill recommended for clinicians include a review that he published in JAMA (2015;313[24]:2474-83), and a review of cannabis and pain that he coauthored that was published in the journal Cannabis and Cannabinoid Research (2017;2[1]:96-104), and a free downloadable publication from he National Academies Press entitled “Health Effects of Cannabis and Cannabinoid Research: The Current State of Evidence and Recommendations for Research.” One passage from that document reads as follows: “Despite the extensive changes in policy at the state level and the rapid rise in the use of cannabis both for medical purposes and for recreational use, conclusive evidence regarding the short- and long-term health effects (harms and benefits) of cannabis use remains elusive. A lack of scientific research has resulted in a lack of information on the health implications of cannabis use, which is a significant public health concern for vulnerable populations such as pregnant women and adolescents. Unlike other substances whose use may confer risk, such as alcohol or tobacco, no accepted standards exist to help guide individuals as they make choices regarding the issues of if, when, where, and how to use cannabis safely and, in regard to therapeutic uses, effectively.”
Dr. Hill disclosed that he has received research grants from National Institute on Drug Abuse, the Brain and Behavior Research Foundation, the American Lung Association, the Greater Boston Council on Alcoholism, and the Peter G. Dodge Foundation. He also receives book royalties from Hazelden Publishing.
[email protected]
REPORTING FROM NPA 2018
How to cope after your patient commits suicide
LAS VEGAS – Michael J. Gitlin, MD, was 6 months removed from his psychiatry residency in 1980 when, for the first time, a patient he cared for took his own life.
He was a chronically depressed young man receiving medication and psychotherapy, and had one prior suicide attempt, Dr. Gitlin, now professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, recalled at an annual psychopharmacology update held by the Nevada Psychiatric Association. “One day he came in and intimated that he was going to kill himself, but not in the near future so as to not upset his parents. I scheduled another visit with him in 2 days and told him, ‘If you’re really having trouble, I’ll put you in the hospital.’ ”
The man never showed for that planned visit. Dr. Gitlin telephoned acquaintances and eventually the police, and through the window of his apartment, they observed his dead body. “That was my first experience, where I began to think, ‘what does this do to us as psychiatrists, and how do we deal with it?’ ”
According to Dr. Gitlin, fewer than 25 papers in the medical literature address the topic of how to cope when a patient takes his or her own life. He considers it ironic, because about 42,000 people in the United States die from suicide each year. “Of that 42,000, a reasonable percentage have seen a health professional, and a little lower percentage a mental health professional, within a number of weeks before the suicide happened,” he said. “Probably 10,000 psychiatrists per year will have this experience.”
The best available literature on the topic shows that about one in six psychiatrists reports having more than five patient suicides during an entire career. “There are two issues here,” Dr. Gitlin said. “One is, because it’s such an infrequent event, nobody has a big enough series to write about. The other issue is, because it’s so infrequent, nobody learns particularly well how to cope with it. You can’t become an oncologist if you’re really phobic and overwhelmed every time a patient dies. But it happens infrequently enough in psychiatry that nobody really masters a way of coping.”
Younger age and lesser clinical experience are most powerful predictors of distress. In fact, over a 3-year training period, about one-third of psychiatry residents will have a patient commit suicide. “Is that because our young colleagues just don’t know what to do and they’re not as thoughtful and as wise, and have as good a judgment as we have and do?” Dr. Gitlin asked. “Of course not. It’s because we give the most ill patients to the people with the least experience. Residents treat much more psychiatrically ill patients, who therefore have a higher risk of suicide.”
Responses are wide-ranging and are similar to other meaningful losses in life. One study found that about 38% of psychiatrists experience levels of distress in the first few weeks after a patient suicide, which is comparable to that of a clinical population (Am J Psychiatry. 2004;161:1442-6). “If you take those same people and follow them out, that level drops rather precipitously, from 38% to 5% or 10%,” Dr. Gitlin said. “That means that it feels like an acute stress reaction. By 6 months, the effect has faded significantly. One-third of psychiatrists will say that when a patient commits suicide, it affects their personal life to some significant degree, and 15% say they thought about retirement. But if you push them on it, only about 3% think about it seriously.”
“And nobody else in this department of board-certified psychiatrists noticed a damn thing. It was all internal, and it was a striking thing. It’s the only time in my life I’ve ever felt that.”
Other reactions include “core responses” of grief, guilt, shame/fear of blame, anger, and relief. “This is not in a variant sequence and not everybody has every one of these feelings,” he emphasized. “If you’ve been working with this person for any extended period of time, you can get attached to them, so you grieve the loss of a person,” he said.
A loss of hope also can occur. “We all imagine that we’re going to help people; a suicide shoves that notion aside,” Dr. Gitlin said. “But in many ways the biggest grief is what I call loss of influence to make a change. I suspect this is truer for younger psychiatrists than for older ones. Early on in our career we all have this feeling that if we do right, if we take good care of the patients, if we’re kind to them and respect boundaries, and we return phone calls, that good things are going to happen. Then you work very hard taking care of a patient as best you can, and they kill themselves on your watch. That changes the equation.”
Another common response when a patient takes his or her own life is a sense of shame. “Think about the cardiologist who loses a patient from heart disease,” said Dr. Gitlin, who also directs the UCLA Mood Disorders Clinic. “Do they feel bad? I assume so. Do they feel a sense of shame? I suspect not. Why do we feel the shame and embarrassment, and they don’t? Even the most hard-core psychopharmacologists among us really don’t believe that it’s just the technical aspects of treatment that make our patients better. It’s us; it’s our relationship with them. That makes the failure of a patient who dies not a clinical failure, but a personal failure. To me, that is the core reason why suicide feels different from an oncologist losing a patient to a disorder that has a known fatality rate.”
A fear of blame, or of being sued, can materialize. So can anger, which can raise complicated questions. For example, are you angry at the patient for committing suicide? Is the family angry? And who are they angry at? Are they angry at you? Are they angry at the hospital? “If it’s in a broader system, let’s say a hospital system, there’s a hierarchy,” Dr. Gitlin said. “Staff could be angry at the ward chief, who could be angry at the attending physician. It can roll downhill. In a complex environment the possibility of projected blame can become a big deal.”
. “In every major religion in the world, when there’s a loss, you rally around the person,” he said. “The rituals of the rallying around differ across cultures and religions, but the rallying around is universal. As humans, we know that it’s much more painful to sit alone with your pain than with the support of family members, friends, loved ones, and community. Find the right person [to confide in]. Not everybody you know will be the right person.”
After the death of a patient from suicide, Dr. Gitlin makes it a point to offer to meet with loved ones. “If you do meet with them, be prepared,” he cautioned. “You don’t know whether the families are a family of interjectors or projectors. Are they going to come in and say, ‘Doctor, thank you so much for doing your best for helping my relative,’ or are they going to come in and say to you, ‘You jerk; my kid died under your care.’ Be prepared for anything that happens in that room.” He also recommends asking the family’s permission to attend the patient’s funeral.
Another helpful coping strategy is to conduct a “psychological autopsy” with colleagues. “Ask what could have been done differently [in the case], not to blame, but to learn,” Dr. Gitlin said. “I have been to some psychological autopsies where it was just ‘Who can be blamed?’ and it was always the youngest person on the totem pole. If the institution can’t get it right psychologically, they shouldn’t do it. That’s more destructive than not doing it at all.”
Maintaining professional boundaries with patients also can help you cope. “We don’t want to put so much into our work with our patients that if it goes bad, we get overwhelmingly devastated,” he said. “Finding that middle ground between blurring boundaries and being too detached is something that every mental health professional should do. Distinguishing between clinical and personal failure is critical. I made a decision some time ago that I want to work with people with prominent psychiatric difficulties. We have some difficult patients, but the philosophical and cognitive relief that I give myself when bad things happen is that I say to myself, ‘I chose to work with sick people. Some of them will die of their illness. I’ll save some, but I can’t save them all.’ There’s a natural mortality rate with mood disorders that is related to suicide, just like 5%-10% of anorexics die from anorexia nervosa. That’s the natural mortality rate of the disease.”
Dr. Gitlin ended his presentation by underscoring the importance of establishing support systems in your workplace or teaching institution. For example, he gives lectures to second-year psychiatry residents at UCLA on the topic of psychiatrist reactions to patient suicide, “because I’m giving them the lecture I wish somebody had given me when I was their age. I and others at UCLA make ourselves available to the residents if and when this happens to them.
“Within our field, most training programs do not deal with this issue as forthrightly as they should. It is our job as the grown-ups in the room to make sure that we do it better. We should be talking with the residents early on about it. Every training institution should have a system set up that when it happens, senior residents help junior residents and faculty is available if a resident is really having trouble dealing with it. Some residencies do this well, and others don’t do it at all.”
Dr. Gitlin reported having no financial disclosures.
LAS VEGAS – Michael J. Gitlin, MD, was 6 months removed from his psychiatry residency in 1980 when, for the first time, a patient he cared for took his own life.
He was a chronically depressed young man receiving medication and psychotherapy, and had one prior suicide attempt, Dr. Gitlin, now professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, recalled at an annual psychopharmacology update held by the Nevada Psychiatric Association. “One day he came in and intimated that he was going to kill himself, but not in the near future so as to not upset his parents. I scheduled another visit with him in 2 days and told him, ‘If you’re really having trouble, I’ll put you in the hospital.’ ”
The man never showed for that planned visit. Dr. Gitlin telephoned acquaintances and eventually the police, and through the window of his apartment, they observed his dead body. “That was my first experience, where I began to think, ‘what does this do to us as psychiatrists, and how do we deal with it?’ ”
According to Dr. Gitlin, fewer than 25 papers in the medical literature address the topic of how to cope when a patient takes his or her own life. He considers it ironic, because about 42,000 people in the United States die from suicide each year. “Of that 42,000, a reasonable percentage have seen a health professional, and a little lower percentage a mental health professional, within a number of weeks before the suicide happened,” he said. “Probably 10,000 psychiatrists per year will have this experience.”
The best available literature on the topic shows that about one in six psychiatrists reports having more than five patient suicides during an entire career. “There are two issues here,” Dr. Gitlin said. “One is, because it’s such an infrequent event, nobody has a big enough series to write about. The other issue is, because it’s so infrequent, nobody learns particularly well how to cope with it. You can’t become an oncologist if you’re really phobic and overwhelmed every time a patient dies. But it happens infrequently enough in psychiatry that nobody really masters a way of coping.”
Younger age and lesser clinical experience are most powerful predictors of distress. In fact, over a 3-year training period, about one-third of psychiatry residents will have a patient commit suicide. “Is that because our young colleagues just don’t know what to do and they’re not as thoughtful and as wise, and have as good a judgment as we have and do?” Dr. Gitlin asked. “Of course not. It’s because we give the most ill patients to the people with the least experience. Residents treat much more psychiatrically ill patients, who therefore have a higher risk of suicide.”
Responses are wide-ranging and are similar to other meaningful losses in life. One study found that about 38% of psychiatrists experience levels of distress in the first few weeks after a patient suicide, which is comparable to that of a clinical population (Am J Psychiatry. 2004;161:1442-6). “If you take those same people and follow them out, that level drops rather precipitously, from 38% to 5% or 10%,” Dr. Gitlin said. “That means that it feels like an acute stress reaction. By 6 months, the effect has faded significantly. One-third of psychiatrists will say that when a patient commits suicide, it affects their personal life to some significant degree, and 15% say they thought about retirement. But if you push them on it, only about 3% think about it seriously.”
“And nobody else in this department of board-certified psychiatrists noticed a damn thing. It was all internal, and it was a striking thing. It’s the only time in my life I’ve ever felt that.”
Other reactions include “core responses” of grief, guilt, shame/fear of blame, anger, and relief. “This is not in a variant sequence and not everybody has every one of these feelings,” he emphasized. “If you’ve been working with this person for any extended period of time, you can get attached to them, so you grieve the loss of a person,” he said.
A loss of hope also can occur. “We all imagine that we’re going to help people; a suicide shoves that notion aside,” Dr. Gitlin said. “But in many ways the biggest grief is what I call loss of influence to make a change. I suspect this is truer for younger psychiatrists than for older ones. Early on in our career we all have this feeling that if we do right, if we take good care of the patients, if we’re kind to them and respect boundaries, and we return phone calls, that good things are going to happen. Then you work very hard taking care of a patient as best you can, and they kill themselves on your watch. That changes the equation.”
Another common response when a patient takes his or her own life is a sense of shame. “Think about the cardiologist who loses a patient from heart disease,” said Dr. Gitlin, who also directs the UCLA Mood Disorders Clinic. “Do they feel bad? I assume so. Do they feel a sense of shame? I suspect not. Why do we feel the shame and embarrassment, and they don’t? Even the most hard-core psychopharmacologists among us really don’t believe that it’s just the technical aspects of treatment that make our patients better. It’s us; it’s our relationship with them. That makes the failure of a patient who dies not a clinical failure, but a personal failure. To me, that is the core reason why suicide feels different from an oncologist losing a patient to a disorder that has a known fatality rate.”
A fear of blame, or of being sued, can materialize. So can anger, which can raise complicated questions. For example, are you angry at the patient for committing suicide? Is the family angry? And who are they angry at? Are they angry at you? Are they angry at the hospital? “If it’s in a broader system, let’s say a hospital system, there’s a hierarchy,” Dr. Gitlin said. “Staff could be angry at the ward chief, who could be angry at the attending physician. It can roll downhill. In a complex environment the possibility of projected blame can become a big deal.”
. “In every major religion in the world, when there’s a loss, you rally around the person,” he said. “The rituals of the rallying around differ across cultures and religions, but the rallying around is universal. As humans, we know that it’s much more painful to sit alone with your pain than with the support of family members, friends, loved ones, and community. Find the right person [to confide in]. Not everybody you know will be the right person.”
After the death of a patient from suicide, Dr. Gitlin makes it a point to offer to meet with loved ones. “If you do meet with them, be prepared,” he cautioned. “You don’t know whether the families are a family of interjectors or projectors. Are they going to come in and say, ‘Doctor, thank you so much for doing your best for helping my relative,’ or are they going to come in and say to you, ‘You jerk; my kid died under your care.’ Be prepared for anything that happens in that room.” He also recommends asking the family’s permission to attend the patient’s funeral.
Another helpful coping strategy is to conduct a “psychological autopsy” with colleagues. “Ask what could have been done differently [in the case], not to blame, but to learn,” Dr. Gitlin said. “I have been to some psychological autopsies where it was just ‘Who can be blamed?’ and it was always the youngest person on the totem pole. If the institution can’t get it right psychologically, they shouldn’t do it. That’s more destructive than not doing it at all.”
Maintaining professional boundaries with patients also can help you cope. “We don’t want to put so much into our work with our patients that if it goes bad, we get overwhelmingly devastated,” he said. “Finding that middle ground between blurring boundaries and being too detached is something that every mental health professional should do. Distinguishing between clinical and personal failure is critical. I made a decision some time ago that I want to work with people with prominent psychiatric difficulties. We have some difficult patients, but the philosophical and cognitive relief that I give myself when bad things happen is that I say to myself, ‘I chose to work with sick people. Some of them will die of their illness. I’ll save some, but I can’t save them all.’ There’s a natural mortality rate with mood disorders that is related to suicide, just like 5%-10% of anorexics die from anorexia nervosa. That’s the natural mortality rate of the disease.”
Dr. Gitlin ended his presentation by underscoring the importance of establishing support systems in your workplace or teaching institution. For example, he gives lectures to second-year psychiatry residents at UCLA on the topic of psychiatrist reactions to patient suicide, “because I’m giving them the lecture I wish somebody had given me when I was their age. I and others at UCLA make ourselves available to the residents if and when this happens to them.
“Within our field, most training programs do not deal with this issue as forthrightly as they should. It is our job as the grown-ups in the room to make sure that we do it better. We should be talking with the residents early on about it. Every training institution should have a system set up that when it happens, senior residents help junior residents and faculty is available if a resident is really having trouble dealing with it. Some residencies do this well, and others don’t do it at all.”
Dr. Gitlin reported having no financial disclosures.
LAS VEGAS – Michael J. Gitlin, MD, was 6 months removed from his psychiatry residency in 1980 when, for the first time, a patient he cared for took his own life.
He was a chronically depressed young man receiving medication and psychotherapy, and had one prior suicide attempt, Dr. Gitlin, now professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, recalled at an annual psychopharmacology update held by the Nevada Psychiatric Association. “One day he came in and intimated that he was going to kill himself, but not in the near future so as to not upset his parents. I scheduled another visit with him in 2 days and told him, ‘If you’re really having trouble, I’ll put you in the hospital.’ ”
The man never showed for that planned visit. Dr. Gitlin telephoned acquaintances and eventually the police, and through the window of his apartment, they observed his dead body. “That was my first experience, where I began to think, ‘what does this do to us as psychiatrists, and how do we deal with it?’ ”
According to Dr. Gitlin, fewer than 25 papers in the medical literature address the topic of how to cope when a patient takes his or her own life. He considers it ironic, because about 42,000 people in the United States die from suicide each year. “Of that 42,000, a reasonable percentage have seen a health professional, and a little lower percentage a mental health professional, within a number of weeks before the suicide happened,” he said. “Probably 10,000 psychiatrists per year will have this experience.”
The best available literature on the topic shows that about one in six psychiatrists reports having more than five patient suicides during an entire career. “There are two issues here,” Dr. Gitlin said. “One is, because it’s such an infrequent event, nobody has a big enough series to write about. The other issue is, because it’s so infrequent, nobody learns particularly well how to cope with it. You can’t become an oncologist if you’re really phobic and overwhelmed every time a patient dies. But it happens infrequently enough in psychiatry that nobody really masters a way of coping.”
Younger age and lesser clinical experience are most powerful predictors of distress. In fact, over a 3-year training period, about one-third of psychiatry residents will have a patient commit suicide. “Is that because our young colleagues just don’t know what to do and they’re not as thoughtful and as wise, and have as good a judgment as we have and do?” Dr. Gitlin asked. “Of course not. It’s because we give the most ill patients to the people with the least experience. Residents treat much more psychiatrically ill patients, who therefore have a higher risk of suicide.”
Responses are wide-ranging and are similar to other meaningful losses in life. One study found that about 38% of psychiatrists experience levels of distress in the first few weeks after a patient suicide, which is comparable to that of a clinical population (Am J Psychiatry. 2004;161:1442-6). “If you take those same people and follow them out, that level drops rather precipitously, from 38% to 5% or 10%,” Dr. Gitlin said. “That means that it feels like an acute stress reaction. By 6 months, the effect has faded significantly. One-third of psychiatrists will say that when a patient commits suicide, it affects their personal life to some significant degree, and 15% say they thought about retirement. But if you push them on it, only about 3% think about it seriously.”
“And nobody else in this department of board-certified psychiatrists noticed a damn thing. It was all internal, and it was a striking thing. It’s the only time in my life I’ve ever felt that.”
Other reactions include “core responses” of grief, guilt, shame/fear of blame, anger, and relief. “This is not in a variant sequence and not everybody has every one of these feelings,” he emphasized. “If you’ve been working with this person for any extended period of time, you can get attached to them, so you grieve the loss of a person,” he said.
A loss of hope also can occur. “We all imagine that we’re going to help people; a suicide shoves that notion aside,” Dr. Gitlin said. “But in many ways the biggest grief is what I call loss of influence to make a change. I suspect this is truer for younger psychiatrists than for older ones. Early on in our career we all have this feeling that if we do right, if we take good care of the patients, if we’re kind to them and respect boundaries, and we return phone calls, that good things are going to happen. Then you work very hard taking care of a patient as best you can, and they kill themselves on your watch. That changes the equation.”
Another common response when a patient takes his or her own life is a sense of shame. “Think about the cardiologist who loses a patient from heart disease,” said Dr. Gitlin, who also directs the UCLA Mood Disorders Clinic. “Do they feel bad? I assume so. Do they feel a sense of shame? I suspect not. Why do we feel the shame and embarrassment, and they don’t? Even the most hard-core psychopharmacologists among us really don’t believe that it’s just the technical aspects of treatment that make our patients better. It’s us; it’s our relationship with them. That makes the failure of a patient who dies not a clinical failure, but a personal failure. To me, that is the core reason why suicide feels different from an oncologist losing a patient to a disorder that has a known fatality rate.”
A fear of blame, or of being sued, can materialize. So can anger, which can raise complicated questions. For example, are you angry at the patient for committing suicide? Is the family angry? And who are they angry at? Are they angry at you? Are they angry at the hospital? “If it’s in a broader system, let’s say a hospital system, there’s a hierarchy,” Dr. Gitlin said. “Staff could be angry at the ward chief, who could be angry at the attending physician. It can roll downhill. In a complex environment the possibility of projected blame can become a big deal.”
. “In every major religion in the world, when there’s a loss, you rally around the person,” he said. “The rituals of the rallying around differ across cultures and religions, but the rallying around is universal. As humans, we know that it’s much more painful to sit alone with your pain than with the support of family members, friends, loved ones, and community. Find the right person [to confide in]. Not everybody you know will be the right person.”
After the death of a patient from suicide, Dr. Gitlin makes it a point to offer to meet with loved ones. “If you do meet with them, be prepared,” he cautioned. “You don’t know whether the families are a family of interjectors or projectors. Are they going to come in and say, ‘Doctor, thank you so much for doing your best for helping my relative,’ or are they going to come in and say to you, ‘You jerk; my kid died under your care.’ Be prepared for anything that happens in that room.” He also recommends asking the family’s permission to attend the patient’s funeral.
Another helpful coping strategy is to conduct a “psychological autopsy” with colleagues. “Ask what could have been done differently [in the case], not to blame, but to learn,” Dr. Gitlin said. “I have been to some psychological autopsies where it was just ‘Who can be blamed?’ and it was always the youngest person on the totem pole. If the institution can’t get it right psychologically, they shouldn’t do it. That’s more destructive than not doing it at all.”
Maintaining professional boundaries with patients also can help you cope. “We don’t want to put so much into our work with our patients that if it goes bad, we get overwhelmingly devastated,” he said. “Finding that middle ground between blurring boundaries and being too detached is something that every mental health professional should do. Distinguishing between clinical and personal failure is critical. I made a decision some time ago that I want to work with people with prominent psychiatric difficulties. We have some difficult patients, but the philosophical and cognitive relief that I give myself when bad things happen is that I say to myself, ‘I chose to work with sick people. Some of them will die of their illness. I’ll save some, but I can’t save them all.’ There’s a natural mortality rate with mood disorders that is related to suicide, just like 5%-10% of anorexics die from anorexia nervosa. That’s the natural mortality rate of the disease.”
Dr. Gitlin ended his presentation by underscoring the importance of establishing support systems in your workplace or teaching institution. For example, he gives lectures to second-year psychiatry residents at UCLA on the topic of psychiatrist reactions to patient suicide, “because I’m giving them the lecture I wish somebody had given me when I was their age. I and others at UCLA make ourselves available to the residents if and when this happens to them.
“Within our field, most training programs do not deal with this issue as forthrightly as they should. It is our job as the grown-ups in the room to make sure that we do it better. We should be talking with the residents early on about it. Every training institution should have a system set up that when it happens, senior residents help junior residents and faculty is available if a resident is really having trouble dealing with it. Some residencies do this well, and others don’t do it at all.”
Dr. Gitlin reported having no financial disclosures.
EXPERT ANALYSIS AT NPA 2018
Gun policy reform related to mental illness ‘a complex puzzle’
LAS VEGAS – On April 16, 2007, a 23-year-old man shot 32 people to death and injured 23 others during a massacre on the campus of Virginia Tech University in Blacksburg, before taking his own life. On the same day, 231 other gun casualties occurred in other areas of the United States, 83 of them fatal and 148 nonfatal, according to Jeffrey W. Swanson, PhD.
“These were domestic violence incidents, suicides, some unintentional injuries, and a few law enforcement actions,” he said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This is the daily drip, drip, drip of gun violence in our country.”
According to data from the Substance Abuse and Mental Health Services Administration, 9.8 million adults in the United States have a serious mental illness, 2.5 million have a co-occurring substance use disorder, 1.9 million have no insurance, 3.1 million go without treatment for their mental illness, 100,000 are homeless, and about 1 million find themselves in jail or in prison. “We probably have more people with a serious mental illness in one of our big-city jails every day than we ever had in the largest asylum in the middle of the 20th century,” said Dr. Swanson, professor of psychiatry and behavioral sciences at Duke University, Durham, N.C. “I think that’s scandalous. It probably costs our society $318 billion per year. On the other hand, we have gun-related violence that claims 36,000 lives each year. One economist estimates that costs our society $174 billion per year. Those are two different public health problems that come together on their edges.”
Americans tend to think about mental illness and gun violence after all-too-frequent mass shootings at schools, workplaces, or concert events, he continued. “A mass shooting at a public place is so terrifying, and destructing and irrational,” he said. “It’s everything we don’t want our ordinary lives to be. We want our lives to be safe and to make sense. A mass shooting is none of those things. The act of going out and shooting a bunch of strangers is not the act of a healthy mind.
“But that person is very atypical in two ways: atypical of people with serious mental illnesses, most of whom are not violent and never will be, and atypical of the perpetrators of gun violence, the vast majority of whom do not have serious mental illnesses. But talking about both of these problems together in the aftermath of a mass shooting is too often the conversation that we’re stuck with.”
In 2015, there were 36,252 gun-related deaths in the United States. Of these, 61% were suicides, 36% were homicides, 2% were police-related, and 1% were unintentional. “We hear prominent voices in the public square today telling us that this is a problem related to mental health, and that the logical solution is to fix the mental health care system,” Dr. Swanson said. “As a mental health services researcher who has spent my career trying to build evidence for better policies to improve outcomes for people with serious mental illnesses, and knowing that the mental health care system we have is fragmented and overburdened – that the treatments we have don’t work very well for some people – I firmly believe we need to invest in and improve the mental health care system. But the idea that this alone is going to solve our problem of gun violence is misguided, in my opinion.”
Homicide data from the International Crime Victim Survey, conducted by Gallup Europe in 2000, found that in the United States, assaults are three more times likely to involve guns than in 14 other industrialized countries, including France, the United Kingdom, Canada, Spain, Belgium, and Australia. Moreover, there is an average of 97 guns for every 100 people in the United States, compared with an average of 17 guns per 100 people in all other industrialized countries. The violent crime rate in the United States is close to the average in 15 other industrialized countries in Western Europe, the United Kingdom, Canada, Australia, and Japan: 5.5%, compared with 6.3%.
At the same time, the United States has a homicide rate several times higher than the rate in these other countries. “How can you have this paradox where our crime rate is about average, but our homicide rate is not average?” Dr. Swanson asked. “It has something to do with our unique relationship with firearms.” The way he sees it, after the Supreme Court decision in District of Columbia v. Heller, confirming the individual right to bear arms under the Second Amendment, “gun control is really ‘people control.’ It focuses on dangerous people. We can’t broadly limit legal access to guns. We have to figure out, ‘Who are the people so dangerous that it is justified to limit their Second Amendment right?’ That’s very hard to do. Why? Because gun violence is very complicated. It’s caused by many factors that interact with each other, and they are nonspecific – meaning that they apply to many more people who are not going to do the thing you’re trying to prevent than who will.
“Serious mental illness may be one factor – particularly in terms of gun suicide – but it contributes very little (only about 4%) to overall interpersonal violence. People with serious mental illnesses are far more likely to be victims of violence than they are to be perpetrators.”
Factors linked to a propensity for violence include being young and male, poverty, exposure to violence, being abused as a child, and substance abuse. “,” he said.
Recently, Dr. Swanson led a team of researchers that set out to analyze descriptive information on 762 individuals subjected to gun removal in Connecticut between 1999 and 2013, as part of that state’s “risk warrant” gun law (Law Contemp Probl. 2017;[80]179-208). Enacted in 1999, the statute allows police, after independently investigating and determining probable cause, to obtain a court warrant and remove guns from anyone who is found to pose an imminent risk of harming someone else or himself or herself.
Dr. Swanson and his associates found that the individuals had an average of seven guns, 92% were male, and their mean age was 47 years. Most (81%) were married or cohabitating, 46% had a mental health or substance abuse record, 12% had an arrest leading to conviction in the year before or after, 61% were considered a risk of harm to self, 49% of calls to police about the individual came from family members or acquaintances, and 55% were transported to the emergency department or hospital. The researchers found that the proportion of people in treatment in the public behavioral health care system increased from 12% before the gun removal event to 29% after the gun removal event.
When they matched the death records, they found 21 suicides among these 762 patients, which was about 40 times greater than the suicide rate in the general adult population in Connecticut, 12 per 100,000. “That’s important, because if you think about suicide as a needle in a haystack, this law provides a way to identify a much smaller haystack with a lot more needles in it,” Dr. Swanson said. “So it’s more efficient to try to intervene to prevent gun suicide or violence in a group like that, and it shows that this policy is narrowly tailored.” When the researchers examined the method of suicide, they found that only 6 out of 21 individuals used a firearm, and none of the gun-involved suicides happened during the year when the firearms were retained. “They all happened when the person became eligible to get their guns back,” he said. “Using information on the fatality rate for each method of suicide, we estimated that for every 10-12 gun removals, one life was saved. Is that high or low? It depends on where you stand. If you’re someone who cares a lot about the right to own firearms, you might think that’s unacceptable. If you’re like me and you have had three gun suicides in your extended family, every one is a tragedy, a life cut short. We want to put this kind of calculation in the hands of lawmakers so they can see what is in the balance between risks and rights.”
Dr. Swanson ended his presentation by offering five principles aimed at guiding gun policy reforms related to mental illness:
- Prioritize contemporaneous risk assessment based on evidence of behaviors that correlate with violence and self-harm at specific times, not mental illness or treatment history per se as a category of exclusion.
- Preempt existing gun access, rather than simply thwarting a new gun purchase by a dangerous person.
- Provide legal due process for deprivation of gun rights.
- Preserve confidential therapeutic relationships. “You don’t want a crisis-driven law that requires doctors to report any patient who talks with them about suicide, because that can have a chilling effect and keep people away from seeking treatment, and also inhibit their disclosures in therapy,” he said.
Prevent the unpredictable through comprehensive background checks, but also by reducing the social determinant of violence and investing in improved access to mental health and substance abuse services.
“This is a complex puzzle, with maybe a couple of pieces hidden under the rug,” Dr. Swanson said.
He reported having no financial disclosures.
LAS VEGAS – On April 16, 2007, a 23-year-old man shot 32 people to death and injured 23 others during a massacre on the campus of Virginia Tech University in Blacksburg, before taking his own life. On the same day, 231 other gun casualties occurred in other areas of the United States, 83 of them fatal and 148 nonfatal, according to Jeffrey W. Swanson, PhD.
“These were domestic violence incidents, suicides, some unintentional injuries, and a few law enforcement actions,” he said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This is the daily drip, drip, drip of gun violence in our country.”
According to data from the Substance Abuse and Mental Health Services Administration, 9.8 million adults in the United States have a serious mental illness, 2.5 million have a co-occurring substance use disorder, 1.9 million have no insurance, 3.1 million go without treatment for their mental illness, 100,000 are homeless, and about 1 million find themselves in jail or in prison. “We probably have more people with a serious mental illness in one of our big-city jails every day than we ever had in the largest asylum in the middle of the 20th century,” said Dr. Swanson, professor of psychiatry and behavioral sciences at Duke University, Durham, N.C. “I think that’s scandalous. It probably costs our society $318 billion per year. On the other hand, we have gun-related violence that claims 36,000 lives each year. One economist estimates that costs our society $174 billion per year. Those are two different public health problems that come together on their edges.”
Americans tend to think about mental illness and gun violence after all-too-frequent mass shootings at schools, workplaces, or concert events, he continued. “A mass shooting at a public place is so terrifying, and destructing and irrational,” he said. “It’s everything we don’t want our ordinary lives to be. We want our lives to be safe and to make sense. A mass shooting is none of those things. The act of going out and shooting a bunch of strangers is not the act of a healthy mind.
“But that person is very atypical in two ways: atypical of people with serious mental illnesses, most of whom are not violent and never will be, and atypical of the perpetrators of gun violence, the vast majority of whom do not have serious mental illnesses. But talking about both of these problems together in the aftermath of a mass shooting is too often the conversation that we’re stuck with.”
In 2015, there were 36,252 gun-related deaths in the United States. Of these, 61% were suicides, 36% were homicides, 2% were police-related, and 1% were unintentional. “We hear prominent voices in the public square today telling us that this is a problem related to mental health, and that the logical solution is to fix the mental health care system,” Dr. Swanson said. “As a mental health services researcher who has spent my career trying to build evidence for better policies to improve outcomes for people with serious mental illnesses, and knowing that the mental health care system we have is fragmented and overburdened – that the treatments we have don’t work very well for some people – I firmly believe we need to invest in and improve the mental health care system. But the idea that this alone is going to solve our problem of gun violence is misguided, in my opinion.”
Homicide data from the International Crime Victim Survey, conducted by Gallup Europe in 2000, found that in the United States, assaults are three more times likely to involve guns than in 14 other industrialized countries, including France, the United Kingdom, Canada, Spain, Belgium, and Australia. Moreover, there is an average of 97 guns for every 100 people in the United States, compared with an average of 17 guns per 100 people in all other industrialized countries. The violent crime rate in the United States is close to the average in 15 other industrialized countries in Western Europe, the United Kingdom, Canada, Australia, and Japan: 5.5%, compared with 6.3%.
At the same time, the United States has a homicide rate several times higher than the rate in these other countries. “How can you have this paradox where our crime rate is about average, but our homicide rate is not average?” Dr. Swanson asked. “It has something to do with our unique relationship with firearms.” The way he sees it, after the Supreme Court decision in District of Columbia v. Heller, confirming the individual right to bear arms under the Second Amendment, “gun control is really ‘people control.’ It focuses on dangerous people. We can’t broadly limit legal access to guns. We have to figure out, ‘Who are the people so dangerous that it is justified to limit their Second Amendment right?’ That’s very hard to do. Why? Because gun violence is very complicated. It’s caused by many factors that interact with each other, and they are nonspecific – meaning that they apply to many more people who are not going to do the thing you’re trying to prevent than who will.
“Serious mental illness may be one factor – particularly in terms of gun suicide – but it contributes very little (only about 4%) to overall interpersonal violence. People with serious mental illnesses are far more likely to be victims of violence than they are to be perpetrators.”
Factors linked to a propensity for violence include being young and male, poverty, exposure to violence, being abused as a child, and substance abuse. “,” he said.
Recently, Dr. Swanson led a team of researchers that set out to analyze descriptive information on 762 individuals subjected to gun removal in Connecticut between 1999 and 2013, as part of that state’s “risk warrant” gun law (Law Contemp Probl. 2017;[80]179-208). Enacted in 1999, the statute allows police, after independently investigating and determining probable cause, to obtain a court warrant and remove guns from anyone who is found to pose an imminent risk of harming someone else or himself or herself.
Dr. Swanson and his associates found that the individuals had an average of seven guns, 92% were male, and their mean age was 47 years. Most (81%) were married or cohabitating, 46% had a mental health or substance abuse record, 12% had an arrest leading to conviction in the year before or after, 61% were considered a risk of harm to self, 49% of calls to police about the individual came from family members or acquaintances, and 55% were transported to the emergency department or hospital. The researchers found that the proportion of people in treatment in the public behavioral health care system increased from 12% before the gun removal event to 29% after the gun removal event.
When they matched the death records, they found 21 suicides among these 762 patients, which was about 40 times greater than the suicide rate in the general adult population in Connecticut, 12 per 100,000. “That’s important, because if you think about suicide as a needle in a haystack, this law provides a way to identify a much smaller haystack with a lot more needles in it,” Dr. Swanson said. “So it’s more efficient to try to intervene to prevent gun suicide or violence in a group like that, and it shows that this policy is narrowly tailored.” When the researchers examined the method of suicide, they found that only 6 out of 21 individuals used a firearm, and none of the gun-involved suicides happened during the year when the firearms were retained. “They all happened when the person became eligible to get their guns back,” he said. “Using information on the fatality rate for each method of suicide, we estimated that for every 10-12 gun removals, one life was saved. Is that high or low? It depends on where you stand. If you’re someone who cares a lot about the right to own firearms, you might think that’s unacceptable. If you’re like me and you have had three gun suicides in your extended family, every one is a tragedy, a life cut short. We want to put this kind of calculation in the hands of lawmakers so they can see what is in the balance between risks and rights.”
Dr. Swanson ended his presentation by offering five principles aimed at guiding gun policy reforms related to mental illness:
- Prioritize contemporaneous risk assessment based on evidence of behaviors that correlate with violence and self-harm at specific times, not mental illness or treatment history per se as a category of exclusion.
- Preempt existing gun access, rather than simply thwarting a new gun purchase by a dangerous person.
- Provide legal due process for deprivation of gun rights.
- Preserve confidential therapeutic relationships. “You don’t want a crisis-driven law that requires doctors to report any patient who talks with them about suicide, because that can have a chilling effect and keep people away from seeking treatment, and also inhibit their disclosures in therapy,” he said.
Prevent the unpredictable through comprehensive background checks, but also by reducing the social determinant of violence and investing in improved access to mental health and substance abuse services.
“This is a complex puzzle, with maybe a couple of pieces hidden under the rug,” Dr. Swanson said.
He reported having no financial disclosures.
LAS VEGAS – On April 16, 2007, a 23-year-old man shot 32 people to death and injured 23 others during a massacre on the campus of Virginia Tech University in Blacksburg, before taking his own life. On the same day, 231 other gun casualties occurred in other areas of the United States, 83 of them fatal and 148 nonfatal, according to Jeffrey W. Swanson, PhD.
“These were domestic violence incidents, suicides, some unintentional injuries, and a few law enforcement actions,” he said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “This is the daily drip, drip, drip of gun violence in our country.”
According to data from the Substance Abuse and Mental Health Services Administration, 9.8 million adults in the United States have a serious mental illness, 2.5 million have a co-occurring substance use disorder, 1.9 million have no insurance, 3.1 million go without treatment for their mental illness, 100,000 are homeless, and about 1 million find themselves in jail or in prison. “We probably have more people with a serious mental illness in one of our big-city jails every day than we ever had in the largest asylum in the middle of the 20th century,” said Dr. Swanson, professor of psychiatry and behavioral sciences at Duke University, Durham, N.C. “I think that’s scandalous. It probably costs our society $318 billion per year. On the other hand, we have gun-related violence that claims 36,000 lives each year. One economist estimates that costs our society $174 billion per year. Those are two different public health problems that come together on their edges.”
Americans tend to think about mental illness and gun violence after all-too-frequent mass shootings at schools, workplaces, or concert events, he continued. “A mass shooting at a public place is so terrifying, and destructing and irrational,” he said. “It’s everything we don’t want our ordinary lives to be. We want our lives to be safe and to make sense. A mass shooting is none of those things. The act of going out and shooting a bunch of strangers is not the act of a healthy mind.
“But that person is very atypical in two ways: atypical of people with serious mental illnesses, most of whom are not violent and never will be, and atypical of the perpetrators of gun violence, the vast majority of whom do not have serious mental illnesses. But talking about both of these problems together in the aftermath of a mass shooting is too often the conversation that we’re stuck with.”
In 2015, there were 36,252 gun-related deaths in the United States. Of these, 61% were suicides, 36% were homicides, 2% were police-related, and 1% were unintentional. “We hear prominent voices in the public square today telling us that this is a problem related to mental health, and that the logical solution is to fix the mental health care system,” Dr. Swanson said. “As a mental health services researcher who has spent my career trying to build evidence for better policies to improve outcomes for people with serious mental illnesses, and knowing that the mental health care system we have is fragmented and overburdened – that the treatments we have don’t work very well for some people – I firmly believe we need to invest in and improve the mental health care system. But the idea that this alone is going to solve our problem of gun violence is misguided, in my opinion.”
Homicide data from the International Crime Victim Survey, conducted by Gallup Europe in 2000, found that in the United States, assaults are three more times likely to involve guns than in 14 other industrialized countries, including France, the United Kingdom, Canada, Spain, Belgium, and Australia. Moreover, there is an average of 97 guns for every 100 people in the United States, compared with an average of 17 guns per 100 people in all other industrialized countries. The violent crime rate in the United States is close to the average in 15 other industrialized countries in Western Europe, the United Kingdom, Canada, Australia, and Japan: 5.5%, compared with 6.3%.
At the same time, the United States has a homicide rate several times higher than the rate in these other countries. “How can you have this paradox where our crime rate is about average, but our homicide rate is not average?” Dr. Swanson asked. “It has something to do with our unique relationship with firearms.” The way he sees it, after the Supreme Court decision in District of Columbia v. Heller, confirming the individual right to bear arms under the Second Amendment, “gun control is really ‘people control.’ It focuses on dangerous people. We can’t broadly limit legal access to guns. We have to figure out, ‘Who are the people so dangerous that it is justified to limit their Second Amendment right?’ That’s very hard to do. Why? Because gun violence is very complicated. It’s caused by many factors that interact with each other, and they are nonspecific – meaning that they apply to many more people who are not going to do the thing you’re trying to prevent than who will.
“Serious mental illness may be one factor – particularly in terms of gun suicide – but it contributes very little (only about 4%) to overall interpersonal violence. People with serious mental illnesses are far more likely to be victims of violence than they are to be perpetrators.”
Factors linked to a propensity for violence include being young and male, poverty, exposure to violence, being abused as a child, and substance abuse. “,” he said.
Recently, Dr. Swanson led a team of researchers that set out to analyze descriptive information on 762 individuals subjected to gun removal in Connecticut between 1999 and 2013, as part of that state’s “risk warrant” gun law (Law Contemp Probl. 2017;[80]179-208). Enacted in 1999, the statute allows police, after independently investigating and determining probable cause, to obtain a court warrant and remove guns from anyone who is found to pose an imminent risk of harming someone else or himself or herself.
Dr. Swanson and his associates found that the individuals had an average of seven guns, 92% were male, and their mean age was 47 years. Most (81%) were married or cohabitating, 46% had a mental health or substance abuse record, 12% had an arrest leading to conviction in the year before or after, 61% were considered a risk of harm to self, 49% of calls to police about the individual came from family members or acquaintances, and 55% were transported to the emergency department or hospital. The researchers found that the proportion of people in treatment in the public behavioral health care system increased from 12% before the gun removal event to 29% after the gun removal event.
When they matched the death records, they found 21 suicides among these 762 patients, which was about 40 times greater than the suicide rate in the general adult population in Connecticut, 12 per 100,000. “That’s important, because if you think about suicide as a needle in a haystack, this law provides a way to identify a much smaller haystack with a lot more needles in it,” Dr. Swanson said. “So it’s more efficient to try to intervene to prevent gun suicide or violence in a group like that, and it shows that this policy is narrowly tailored.” When the researchers examined the method of suicide, they found that only 6 out of 21 individuals used a firearm, and none of the gun-involved suicides happened during the year when the firearms were retained. “They all happened when the person became eligible to get their guns back,” he said. “Using information on the fatality rate for each method of suicide, we estimated that for every 10-12 gun removals, one life was saved. Is that high or low? It depends on where you stand. If you’re someone who cares a lot about the right to own firearms, you might think that’s unacceptable. If you’re like me and you have had three gun suicides in your extended family, every one is a tragedy, a life cut short. We want to put this kind of calculation in the hands of lawmakers so they can see what is in the balance between risks and rights.”
Dr. Swanson ended his presentation by offering five principles aimed at guiding gun policy reforms related to mental illness:
- Prioritize contemporaneous risk assessment based on evidence of behaviors that correlate with violence and self-harm at specific times, not mental illness or treatment history per se as a category of exclusion.
- Preempt existing gun access, rather than simply thwarting a new gun purchase by a dangerous person.
- Provide legal due process for deprivation of gun rights.
- Preserve confidential therapeutic relationships. “You don’t want a crisis-driven law that requires doctors to report any patient who talks with them about suicide, because that can have a chilling effect and keep people away from seeking treatment, and also inhibit their disclosures in therapy,” he said.
Prevent the unpredictable through comprehensive background checks, but also by reducing the social determinant of violence and investing in improved access to mental health and substance abuse services.
“This is a complex puzzle, with maybe a couple of pieces hidden under the rug,” Dr. Swanson said.
He reported having no financial disclosures.
REPORTING FROM NPA 2018
Long-term effects of ketamine uncertain
LAS VEGAS – Low doses of ketamine, an N-methyl-D-asparate glutamate receptor antagonist, can produce benefits that are unprecedented in the history of treating major depression, according to David Feifel, MD, PhD.
“When have we ever had the ability to be sitting in front of a patient who is extremely suicidal and have an intervention that will work within [an] hour that will remediate that?” he asked at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Ketamine is that tool. If nothing else, that’s what ketamine already presents to us in this field.”
Then there’s the potential for abuse. he asked. “What about other long-term side effects?”
A recent consensus statement authored by Gerard Sanacora, PhD, MD, and associates acknowledged that data on the long-term effects of using ketamine in psychiatry practice are limited or nonexistent (JAMA Psychiatry. 2017 Apr 1;74[4]:399-405), even though an increasing number of clinicians are providing off-label ketamine for depression and other psychiatric disorders. First synthesized in the 1960s, ketamine’s primary site of action in the central nervous system seems to be the thalamocortical projection system, said Dr. Feifel, who has been providing the drug to patients since 2008. In a handout that accompanied his talk, he wrote that ketamine “selectively depresses neuronal function in parts of the cortex and thalamus while stimulating parts of the limbic system, including the hippocampus. This process creates what is termed a functional disorganization of nonspecific pathways in midbrain and thalamic areas.”
Ketamine creates acute subjective experiences that vary with doses, including a sense of “melting into people or things” at lower doses, and visions and hallucinations at higher doses. “Patients will tell me that they deliberately tried to move their hands and feet, to make sure they were still connected to their bodies,” Dr. Feifel said. “There’s often a sensation of moving through space. At higher doses, they often experience a profound sense of connection to all things, an ineffable universal unity that can change their perspective on themselves and their depression. It’s very profound.”
Antidepressant benefits with ketamine are usually dramatic, said Dr. Feifel, who also is founder and director of the Kadima Neuropsychiatry Institute in La Jolla, Calif. The drug is most commonly administered as an IV infusion over a 40 minute period at a dosage of 0.5 mg/kg. It also can be administered orally, intranasally, and intramuscularly. “Patients may achieve response and even remission of depression within a day, even when the depression was previously medication refractory,” he said. “The benefits are usually lost in 3-21 days. Maintenance treatment with ketamine, scheduled once every 2-4 weeks, can maintain the treatment gains. Dissociative and psychotomimetic effects are common but very seldom problematic.”
Dr. Feifel noted that ketamine’s remarkable results have piqued the interest of pharmaceutical companies. “But it is off patent – non proprietary,” he said. “Several novel agents by different pharmaceutical companies quickly have been developed and are in development. Some have modified pharmacology and are claimed to produce less acute dissociative/psychedelic effects. Janssen is developing intranasal esketamine for acutely suicidal patients that has been fast-tracked by the FDA.”
Dr. Feifel reported having no financial disclosures.
LAS VEGAS – Low doses of ketamine, an N-methyl-D-asparate glutamate receptor antagonist, can produce benefits that are unprecedented in the history of treating major depression, according to David Feifel, MD, PhD.
“When have we ever had the ability to be sitting in front of a patient who is extremely suicidal and have an intervention that will work within [an] hour that will remediate that?” he asked at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Ketamine is that tool. If nothing else, that’s what ketamine already presents to us in this field.”
Then there’s the potential for abuse. he asked. “What about other long-term side effects?”
A recent consensus statement authored by Gerard Sanacora, PhD, MD, and associates acknowledged that data on the long-term effects of using ketamine in psychiatry practice are limited or nonexistent (JAMA Psychiatry. 2017 Apr 1;74[4]:399-405), even though an increasing number of clinicians are providing off-label ketamine for depression and other psychiatric disorders. First synthesized in the 1960s, ketamine’s primary site of action in the central nervous system seems to be the thalamocortical projection system, said Dr. Feifel, who has been providing the drug to patients since 2008. In a handout that accompanied his talk, he wrote that ketamine “selectively depresses neuronal function in parts of the cortex and thalamus while stimulating parts of the limbic system, including the hippocampus. This process creates what is termed a functional disorganization of nonspecific pathways in midbrain and thalamic areas.”
Ketamine creates acute subjective experiences that vary with doses, including a sense of “melting into people or things” at lower doses, and visions and hallucinations at higher doses. “Patients will tell me that they deliberately tried to move their hands and feet, to make sure they were still connected to their bodies,” Dr. Feifel said. “There’s often a sensation of moving through space. At higher doses, they often experience a profound sense of connection to all things, an ineffable universal unity that can change their perspective on themselves and their depression. It’s very profound.”
Antidepressant benefits with ketamine are usually dramatic, said Dr. Feifel, who also is founder and director of the Kadima Neuropsychiatry Institute in La Jolla, Calif. The drug is most commonly administered as an IV infusion over a 40 minute period at a dosage of 0.5 mg/kg. It also can be administered orally, intranasally, and intramuscularly. “Patients may achieve response and even remission of depression within a day, even when the depression was previously medication refractory,” he said. “The benefits are usually lost in 3-21 days. Maintenance treatment with ketamine, scheduled once every 2-4 weeks, can maintain the treatment gains. Dissociative and psychotomimetic effects are common but very seldom problematic.”
Dr. Feifel noted that ketamine’s remarkable results have piqued the interest of pharmaceutical companies. “But it is off patent – non proprietary,” he said. “Several novel agents by different pharmaceutical companies quickly have been developed and are in development. Some have modified pharmacology and are claimed to produce less acute dissociative/psychedelic effects. Janssen is developing intranasal esketamine for acutely suicidal patients that has been fast-tracked by the FDA.”
Dr. Feifel reported having no financial disclosures.
LAS VEGAS – Low doses of ketamine, an N-methyl-D-asparate glutamate receptor antagonist, can produce benefits that are unprecedented in the history of treating major depression, according to David Feifel, MD, PhD.
“When have we ever had the ability to be sitting in front of a patient who is extremely suicidal and have an intervention that will work within [an] hour that will remediate that?” he asked at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Ketamine is that tool. If nothing else, that’s what ketamine already presents to us in this field.”
Then there’s the potential for abuse. he asked. “What about other long-term side effects?”
A recent consensus statement authored by Gerard Sanacora, PhD, MD, and associates acknowledged that data on the long-term effects of using ketamine in psychiatry practice are limited or nonexistent (JAMA Psychiatry. 2017 Apr 1;74[4]:399-405), even though an increasing number of clinicians are providing off-label ketamine for depression and other psychiatric disorders. First synthesized in the 1960s, ketamine’s primary site of action in the central nervous system seems to be the thalamocortical projection system, said Dr. Feifel, who has been providing the drug to patients since 2008. In a handout that accompanied his talk, he wrote that ketamine “selectively depresses neuronal function in parts of the cortex and thalamus while stimulating parts of the limbic system, including the hippocampus. This process creates what is termed a functional disorganization of nonspecific pathways in midbrain and thalamic areas.”
Ketamine creates acute subjective experiences that vary with doses, including a sense of “melting into people or things” at lower doses, and visions and hallucinations at higher doses. “Patients will tell me that they deliberately tried to move their hands and feet, to make sure they were still connected to their bodies,” Dr. Feifel said. “There’s often a sensation of moving through space. At higher doses, they often experience a profound sense of connection to all things, an ineffable universal unity that can change their perspective on themselves and their depression. It’s very profound.”
Antidepressant benefits with ketamine are usually dramatic, said Dr. Feifel, who also is founder and director of the Kadima Neuropsychiatry Institute in La Jolla, Calif. The drug is most commonly administered as an IV infusion over a 40 minute period at a dosage of 0.5 mg/kg. It also can be administered orally, intranasally, and intramuscularly. “Patients may achieve response and even remission of depression within a day, even when the depression was previously medication refractory,” he said. “The benefits are usually lost in 3-21 days. Maintenance treatment with ketamine, scheduled once every 2-4 weeks, can maintain the treatment gains. Dissociative and psychotomimetic effects are common but very seldom problematic.”
Dr. Feifel noted that ketamine’s remarkable results have piqued the interest of pharmaceutical companies. “But it is off patent – non proprietary,” he said. “Several novel agents by different pharmaceutical companies quickly have been developed and are in development. Some have modified pharmacology and are claimed to produce less acute dissociative/psychedelic effects. Janssen is developing intranasal esketamine for acutely suicidal patients that has been fast-tracked by the FDA.”
Dr. Feifel reported having no financial disclosures.
REPORTING FROM NPA 2018
Embrace the complexity of marijuana use in adolescents
Las Vegas – When talking with adolescents and their families about marijuana use, Kevin M. Gray, MD, recommends embracing the complexity of the issue.
“Avoid polarizing this topic and avoid vilifying cannabis,” he advised at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Take an interest in what they have to say about cannabis. Work in a gentle, nonconfrontational way where you avoid polarization and find some common ground where you can agree that maybe there’s some good and some bad [about cannabis], but the overwhelming evidence in adolescents is that there’s more harm than good with cannabis use, particularly recreationally.”
Dr. Gray, professor and director of child and adolescent psychiatry at the Medical University of South Carolina, Charleston, acknowledged that clinicians face a delicate balance between risk and benefit, even among Food and Drug Administration–approved medications. However, teens and families may struggle with these nuances, especially in light of the term “medical marijuana.” Some assume that “medical” implies “beneficial.” Others may equate “marijuana” with “natural,” which they may, in turn, equate with being “harmless.”
“Perception is critically important,” Dr. Gray said at an annual psychopharmacology update held by the Nevada Psychiatric Association.
Cannabis initiation typically occurs during adolescence, and rates of initiation and use are increasing. According to Dr. Gray, 55% of U.S. high school seniors have used marijuana, 23% use currently, and 6% use daily. “Those are the ones who have adverse outcomes,” he said. Young users are particularly prone to dependence symptoms and an inability to cut back their use. The odds of meeting criteria for cannabis use disorder are substantially greater in adolescent users than they are in adults regardless of time frame or intensity of use.
“In a dose-dependent manner, adolescent cannabis use is associated with adverse academic, occupational, cognitive, psychiatric, and substance use outcomes,” Dr. Gray said, adding that the average potency of delta-9-tetrahydrocannabinol (THC) in seized cannabis increased from 3% in 1992 to 11% in 2010. “Cannabis use in adolescence is associated with increased incidence and worsened course of psychotic, mood, and anxiety disorders. Serious cannabis-associated risks are well recognized and are particularly striking in adolescents. Adult-onset cannabis users may experience fewer adverse effects.”
Evidence-based psychosocial approaches for adolescents with cannabis use disorder include motivational enhancement therapy, which involves building rapport in a gentle way, with phrasing such as “Tell me what you like about marijuana use” and “What don’t you like about it?” Dr. Gray described motivational enhancement therapy as “a gentle nudge for behavior change” that serves as a bridge to cognitive-behavioral therapy, family therapy, and contingency management. “That said, long-term abstinence outcomes are generally poor,” he said. “People tend to go back to use.”
N-acetylcysteine (NAC) shows promise as a medication for adolescents with cannabis use disorder. NAC activates the cystine/glutamate exchanger and upregulates the GLT-1 receptor, which leads to reduction in reinstatement of drug seeking in animal models. One trial of NAC supported efficacy in 116 cannabis-dependent adolescents (Am J Psychiatry. 2012 Aug;169[8]:805-12). Led by Dr. Gray, the trial consisted of 8 weeks of active treatment on placebo or NAC 1,200 mg BID. All participants received weekly brief cessation counseling and twice-weekly contingency management. The researchers found that adolescents in the NAC group were more than twice as likely to submit a negative urine specimen during treatment than were their counterparts in the placebo group (odds ratio, 2.4; P = .029). In addition, those in the NAC group also were significantly more likely than were those in the placebo group to achieve end-of-treatment abstinence, which was defined as self-reported abstinence confirmed by negative urine testing throughout the last 2 weeks of treatment (OR, 2.3; P = .054).
A similarly designed adult trial indicated that adolescent findings did not translate to adults (Drug Alcohol Depend. 2017 Aug 1;177:249-57). “Whether this may be due to developmental differences in the course and phenomenology of cannabis use disorder, we don’t know,” Dr. Gray said. “For now, NAC remains the only pharmacotherapy with positive published intent-to-treat clinical trial abstinence findings for cannabis use disorder in adolescents. Positive adolescent findings must be replicated, but the necessary behavioral treatment platform must be clarified to translate successfully to real-world practice.”
Dr. Gray disclosed that he receives research funding from the National Institutes of Health.
[email protected]
Las Vegas – When talking with adolescents and their families about marijuana use, Kevin M. Gray, MD, recommends embracing the complexity of the issue.
“Avoid polarizing this topic and avoid vilifying cannabis,” he advised at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Take an interest in what they have to say about cannabis. Work in a gentle, nonconfrontational way where you avoid polarization and find some common ground where you can agree that maybe there’s some good and some bad [about cannabis], but the overwhelming evidence in adolescents is that there’s more harm than good with cannabis use, particularly recreationally.”
Dr. Gray, professor and director of child and adolescent psychiatry at the Medical University of South Carolina, Charleston, acknowledged that clinicians face a delicate balance between risk and benefit, even among Food and Drug Administration–approved medications. However, teens and families may struggle with these nuances, especially in light of the term “medical marijuana.” Some assume that “medical” implies “beneficial.” Others may equate “marijuana” with “natural,” which they may, in turn, equate with being “harmless.”
“Perception is critically important,” Dr. Gray said at an annual psychopharmacology update held by the Nevada Psychiatric Association.
Cannabis initiation typically occurs during adolescence, and rates of initiation and use are increasing. According to Dr. Gray, 55% of U.S. high school seniors have used marijuana, 23% use currently, and 6% use daily. “Those are the ones who have adverse outcomes,” he said. Young users are particularly prone to dependence symptoms and an inability to cut back their use. The odds of meeting criteria for cannabis use disorder are substantially greater in adolescent users than they are in adults regardless of time frame or intensity of use.
“In a dose-dependent manner, adolescent cannabis use is associated with adverse academic, occupational, cognitive, psychiatric, and substance use outcomes,” Dr. Gray said, adding that the average potency of delta-9-tetrahydrocannabinol (THC) in seized cannabis increased from 3% in 1992 to 11% in 2010. “Cannabis use in adolescence is associated with increased incidence and worsened course of psychotic, mood, and anxiety disorders. Serious cannabis-associated risks are well recognized and are particularly striking in adolescents. Adult-onset cannabis users may experience fewer adverse effects.”
Evidence-based psychosocial approaches for adolescents with cannabis use disorder include motivational enhancement therapy, which involves building rapport in a gentle way, with phrasing such as “Tell me what you like about marijuana use” and “What don’t you like about it?” Dr. Gray described motivational enhancement therapy as “a gentle nudge for behavior change” that serves as a bridge to cognitive-behavioral therapy, family therapy, and contingency management. “That said, long-term abstinence outcomes are generally poor,” he said. “People tend to go back to use.”
N-acetylcysteine (NAC) shows promise as a medication for adolescents with cannabis use disorder. NAC activates the cystine/glutamate exchanger and upregulates the GLT-1 receptor, which leads to reduction in reinstatement of drug seeking in animal models. One trial of NAC supported efficacy in 116 cannabis-dependent adolescents (Am J Psychiatry. 2012 Aug;169[8]:805-12). Led by Dr. Gray, the trial consisted of 8 weeks of active treatment on placebo or NAC 1,200 mg BID. All participants received weekly brief cessation counseling and twice-weekly contingency management. The researchers found that adolescents in the NAC group were more than twice as likely to submit a negative urine specimen during treatment than were their counterparts in the placebo group (odds ratio, 2.4; P = .029). In addition, those in the NAC group also were significantly more likely than were those in the placebo group to achieve end-of-treatment abstinence, which was defined as self-reported abstinence confirmed by negative urine testing throughout the last 2 weeks of treatment (OR, 2.3; P = .054).
A similarly designed adult trial indicated that adolescent findings did not translate to adults (Drug Alcohol Depend. 2017 Aug 1;177:249-57). “Whether this may be due to developmental differences in the course and phenomenology of cannabis use disorder, we don’t know,” Dr. Gray said. “For now, NAC remains the only pharmacotherapy with positive published intent-to-treat clinical trial abstinence findings for cannabis use disorder in adolescents. Positive adolescent findings must be replicated, but the necessary behavioral treatment platform must be clarified to translate successfully to real-world practice.”
Dr. Gray disclosed that he receives research funding from the National Institutes of Health.
[email protected]
Las Vegas – When talking with adolescents and their families about marijuana use, Kevin M. Gray, MD, recommends embracing the complexity of the issue.
“Avoid polarizing this topic and avoid vilifying cannabis,” he advised at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Take an interest in what they have to say about cannabis. Work in a gentle, nonconfrontational way where you avoid polarization and find some common ground where you can agree that maybe there’s some good and some bad [about cannabis], but the overwhelming evidence in adolescents is that there’s more harm than good with cannabis use, particularly recreationally.”
Dr. Gray, professor and director of child and adolescent psychiatry at the Medical University of South Carolina, Charleston, acknowledged that clinicians face a delicate balance between risk and benefit, even among Food and Drug Administration–approved medications. However, teens and families may struggle with these nuances, especially in light of the term “medical marijuana.” Some assume that “medical” implies “beneficial.” Others may equate “marijuana” with “natural,” which they may, in turn, equate with being “harmless.”
“Perception is critically important,” Dr. Gray said at an annual psychopharmacology update held by the Nevada Psychiatric Association.
Cannabis initiation typically occurs during adolescence, and rates of initiation and use are increasing. According to Dr. Gray, 55% of U.S. high school seniors have used marijuana, 23% use currently, and 6% use daily. “Those are the ones who have adverse outcomes,” he said. Young users are particularly prone to dependence symptoms and an inability to cut back their use. The odds of meeting criteria for cannabis use disorder are substantially greater in adolescent users than they are in adults regardless of time frame or intensity of use.
“In a dose-dependent manner, adolescent cannabis use is associated with adverse academic, occupational, cognitive, psychiatric, and substance use outcomes,” Dr. Gray said, adding that the average potency of delta-9-tetrahydrocannabinol (THC) in seized cannabis increased from 3% in 1992 to 11% in 2010. “Cannabis use in adolescence is associated with increased incidence and worsened course of psychotic, mood, and anxiety disorders. Serious cannabis-associated risks are well recognized and are particularly striking in adolescents. Adult-onset cannabis users may experience fewer adverse effects.”
Evidence-based psychosocial approaches for adolescents with cannabis use disorder include motivational enhancement therapy, which involves building rapport in a gentle way, with phrasing such as “Tell me what you like about marijuana use” and “What don’t you like about it?” Dr. Gray described motivational enhancement therapy as “a gentle nudge for behavior change” that serves as a bridge to cognitive-behavioral therapy, family therapy, and contingency management. “That said, long-term abstinence outcomes are generally poor,” he said. “People tend to go back to use.”
N-acetylcysteine (NAC) shows promise as a medication for adolescents with cannabis use disorder. NAC activates the cystine/glutamate exchanger and upregulates the GLT-1 receptor, which leads to reduction in reinstatement of drug seeking in animal models. One trial of NAC supported efficacy in 116 cannabis-dependent adolescents (Am J Psychiatry. 2012 Aug;169[8]:805-12). Led by Dr. Gray, the trial consisted of 8 weeks of active treatment on placebo or NAC 1,200 mg BID. All participants received weekly brief cessation counseling and twice-weekly contingency management. The researchers found that adolescents in the NAC group were more than twice as likely to submit a negative urine specimen during treatment than were their counterparts in the placebo group (odds ratio, 2.4; P = .029). In addition, those in the NAC group also were significantly more likely than were those in the placebo group to achieve end-of-treatment abstinence, which was defined as self-reported abstinence confirmed by negative urine testing throughout the last 2 weeks of treatment (OR, 2.3; P = .054).
A similarly designed adult trial indicated that adolescent findings did not translate to adults (Drug Alcohol Depend. 2017 Aug 1;177:249-57). “Whether this may be due to developmental differences in the course and phenomenology of cannabis use disorder, we don’t know,” Dr. Gray said. “For now, NAC remains the only pharmacotherapy with positive published intent-to-treat clinical trial abstinence findings for cannabis use disorder in adolescents. Positive adolescent findings must be replicated, but the necessary behavioral treatment platform must be clarified to translate successfully to real-world practice.”
Dr. Gray disclosed that he receives research funding from the National Institutes of Health.
[email protected]
REPORTING FROM NPA 2018