Medscape Professional Network
Official podcast feed of MDedge Psychiatry, part of the Medscape Professional Network. Episodes include interviews with leaders in psychiatry and psychology, masterclass lectures, and clinical perspective. Interviews are hosted by Dr. Lorenzo Norris, MD, Clinical Correlaction featuers Dr. Renee Kohanski, MD, and lecturers are chosen by MDedge Psychiatry. The information in this podcast is provided for informational and educational purposes only.
Cannabis and cannabinoids: Weighing the benefits and risks of use by psychiatric patients with Dr. Diana M. Martinez
Diana M. Martinez, MD, conducts a Masterclass on marijuana’s effects on psychiatric disorders. Dr. Martinez, a professor of psychiatry at Columbia University, New York, specializes in addiction research. She disclosed receiving medication (cannabis) from Tilray for one study and has no other financial relationships with this company. Take-home points The use of cannabis, recreationally and medically, has been a controversial topic for ages, and the classification of cannabis as a schedule I controlled substance has made it all the more difficult to research and meaningfully understand its harms and benefits. Based on information from the National Academies of Sciences publication Health Effects of Marijuana: An Evidence Review and Research Agenda, Dr. Martinez presents a sweeping overview of the role of cannabis in two domains: Its ability to worsen psychiatric symptoms, and its role in causing psychiatric disorders. The cannabis plant has 100 cannabinoids. The two most commonly studied are tetrahydrocannabinol (THC), which creates the "high," and cannabidiol (CBD), which does not create a high and has many subjective effects. Cannabis is researched and used in several forms, including the smoked plant or flower form, and prescription cannabinoids based on THC – namely dronabinol (Marinol), nabilone (Cesamet), and CBD. Research suggests that both benefits and risks are tied to using cannabis and cannabinoids. Clinicians should have rational discussions with their patients about the use of cannabis. If patients are no longer responding to psychiatric treatment, and the clinician wants to talk about their cannabis use, it is important to understand the common reasons patients use cannabis, including for chronic pain, anxiety, and insomnia. Benefits There is substantial evidence supporting the use of cannabis and cannabinoids for the treatment of chronic pain. Most studies evaluated the smoked or vaporized form. Research suggests a dose of 5-20 mg of oral THC is about as effective as 50-120 mg of codeine, although there are few head-to-head studies to reinforce this finding. Cannabis will likely have a role in the pain treatment armamentarium. The risks of use include intoxication and development of an addiction. Cannabinoids may have a role in achieving abstinence from addiction to cannabis and other substances. THC in the form of cannabinoids shows some promise for its use in disorders such as PTSD and obsessive-compulsive disorder, but larger controlled studies are needed. In addition, cannabinoids have an effect when combined with other behavioral interventions, such as exposure therapy. Risks There is substantial evidence that cannabis has a moderate to large association with increased risk of developing psychotic spectrum disorders in a dose-dependent fashion, particularly in patients who are genetically vulnerable. Moderate evidence suggests that cannabis causes increased symptoms of mania and hypomania in people with bipolar disorder who use it regularly. Cannabis can cause addiction. About 9% of people who use it will develop a substance use disorder, and the risk of developing a substance use disorder increases to 17% in people who start using cannabis in their teenage years. Frequent cannabis use is associated with withdrawal symptoms, such as irritability, sleep problems, cravings, decreased appetite, and restlessness. References National Academies of Sciences, Engineering, and Medicine. Health Effects of Marijuana: An Evidence Review and Research Agenda. Washington, DC: National Academies Press, 2017. Whiting PF et al. JAMA. 2015;313(24):2456-73. Fischer B et al. Am J Public Health. 2017 Jul 12. doi: 10.2105/AJPH.2017.303818. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to Email the show:  
Nov 19
22 min
Have we lost too much? | Clinical Correlation
In this week's installment of Clinical Correlation, Renée Kohanski, MD, ponders the loss of professional courtesy and the larger implications of medicine-shifting paradigms. Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at, and you can learn more about MDedge Psychiatry here:
Nov 16
8 min
Anxiety, OCD, and the use of ACT therapy to help children and adolescents cope amid the COVID-19 pandemic and beyond with Dr. Lisa W. Coyne
Lisa W. Coyne, PhD, spoke with Psychcast host Lorenzo Norris, MD, about strategies that can be used to help children and adolescents deal with anxiety and obsessive-compulsive disorder amid COVID-19. Dr. Coyne, a clinical psychologist, is founder of the McLean OCD Institute for Children and Adolescents in Belmont, Mass. She also is director with the New England Center for OCD and Anxiety in Cambridge, Mass. Dr. Coyne disclosed receiving royalties from New Harbinger and Little Brown Publishing. Dr. Norris has no disclosures. Take-home points Much of the anxiety experienced by some children and adolescents is caused by uncertainty about the future. Some children and adolescents also are watching cases of COVID-19 tick up across the country and are concerned about the mixed messages they are receiving from adults. Different cultures exist around belief in science. Rates of anxiety in general are on the rise as are demands for more mental health services. Clinicians are supporting each other to support their patients. Anxiety in young patients might present as disruptions in sleep and appetite. Look for an increase in oppositional behavior. Young patients with anxiety also might resist going to bed. Clinicians also are seeing increases in depressed mood and nonsuicidal self-injury. Acceptance and commitment therapy, a type of cognitive-behavioral therapy that is exposure based, is a strategy that can be used to help patients develop psychological flexibility and put distance between themselves and their thoughts. References Mazza MT with foreword by Coyne LW. The ACT Workbook for OCD: Mindfulness, Acceptance, and Exposure Skills to Live Well With Obsessive-Compulsive Disorder. Oakland, Calif.: New Harbinger Publications, 2020. Allmann AE et al. Acceptance and commitment therapy-enhanced exposures for children and adolescents. Exposure Therapy for Children and Adolescents with Obsessive-Compulsive Disorder: Clinician’s Guide to Integrated Treatment. Academic Press, 2020. *  *  * For more MDedge Podcasts, go to Email the show:
Nov 11
40 min
Brain imaging, ‘neuropolarization,’ and why it’s so difficult to bridge the partisan divide with Dr. Yuan Chang Leong
*** There is a transcript available for this episodes at Yuan Chang Leong, PhD, spoke with Psychcast host Lorenzo Norris, MD, about his research into the neural underpinnings of right- and left-leaning individuals. Dr. Leong is a postdoctoral scholar in cognitive neuroscience at the University of California, Berkeley. He has no disclosures. Dr. Norris has no disclosures. Take-home points Dr. Leong and colleagues looked for further evidence of “neural polarization,” which is defined as divergent brain activity based on conversative versus liberal political attitudes. The prefrontal cortex is the part of the frontal lobe responsible for executive and higher-order brain function that makes sense and organizes what a person is seeing, hearing, and experiencing. Participants were shown news clips about immigration policy and their brain activity showed differences in activity of their dorsomedial prefrontal cortex (DMPFC), which is active in interpreting narrative content. The findings suggest there is a neural basis for the way in which individuals with different political attitudes interpret political information and news. The research suggests that words related to threat, morality, emotions, anger, and differentiation/community drive neural polarization. Summary Dr. Leong and colleagues asked participants to watch news clips about immigration policy while undergoing functional MRI with the goal of identifying the neural correlates of neural polarization, which is thought to parallel the behavioral aspects of political polarization. Dr. Leong and colleagues identified an association of divergence in connectivity to the DMPFC to the ventral striatum, a structure involved in reward processing and sensing the valence and tone of information. Their study, published in the Proceeding of the National Academy of Sciences, suggests that information from the ventral striatum is transmitted differently to the DMPFC between groups. The findings suggest that our political beliefs might influence our interpretation of other information, as the DMPFC helps humans interpret narrative content. Dr. Leong pointed out that this study provides evidence about why it is so difficult to bridge the partisan divide. He also discussed the psychology of social identity theory and how any categorization of people makes individuals think along the lines of in-group and out-group, and how the human drive is to protect the in-group. References Leong YC et al. PNAS. 2020 Oct 20. doi: 10.1073/pnas.2008530117. McLeod S. Social identity theory. Simply Psychology. Updated 2019. University of Texas, Austin. Ethics unwrapped. In-group/out-group (video). Brooks M. Brain imaging reveals a neural basis for partisan politics. 2020 Oct 27. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to Email the show:
Nov 4
28 min
Getting to "No" you |Clinical Correlation
Renee Kohanski, MD, discusses managing difficult referrals from trusted colleagues. Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at, and you can learn more about MDedge Psychiatry here:  
Nov 2
9 min
Preventing suicide & destigmatizing mental anguish during the COVID-19 pandemic with Dr. Christine Moutier
Christine Moutier, MD, joins Lorenzo Norris, MD, to discuss how clinicians can scale up interventions to reduce suicide rates amid the pandemic. Dr. Moutier is chief medical officer of the American Foundation for Suicide Prevention. She reported no disclosures. Dr. Norris also reported no disclosures. Take-home points Death by suicide is a health outcome, which means that there is always a place to intervene, whether clinically, socially, or through research. Risks for suicide during the pandemic are known to increase; however, it is not a foregone conclusion that suicide deaths will rise during or afterward. Mental health diagnoses are a risk factor for suicide, and there will be interplay with stressors such as unemployment, financial stress, grief, and socioeconomic disparities. The basics of suicide prevention include screening for suicidal ideation at behavioral health appointments. If a change in risk is identified, clinicians should use a patient-centered intervention, such as a safety plan. Summary The U.S. suicide rate has risen by 35% from 1999 to 2018, and the rates of suicide are particularly increasing in middle-aged populations as well as among youths of color. Evidence-based efforts are underway to mitigate suicide deaths through national suicide prevention plans. Yet, everyone has a role to play in suicide prevention, since part of prevention includes reducing stigma related to conversations about mental health and asking about crises and suicidal thoughts. In behavioral health settings, routine screening should be implemented for suicidal ideation and deterioration in any aspect of mental health. Asking about suicidal ideation is the bare minimum, and not all patients will admit to suicidal ideation when asked. Other risk factors for suicide include acute stressors such as decompensation and losses of relationships and employment. Most individuals with suicidal thoughts do not need to be psychiatrically hospitalized. Suicidal thoughts, as symptoms of a mental illness, can be treated with interventions other than hospitalization. The goal is to maintain safety and respond appropriately. In-office interventions include creating a safety plan or adding to an existing plan. As a silver lining, the pandemic has normalized conversations about mental health and reduced stigma around mental health experiences. Dr. Moutier discusses how, as the pandemic set in, the AFSP experienced a notable increase in requests for education about mental health and suicide prevention. References Moutier C. JAMA Psychiatry. 2020 Oct 16. Chung DT et al. American Foundation for Suicide Prevention: Policy priorities: Safety plan worksheet: Centers for Disease Control and Prevention suicide risk factors: *  *  * Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.  Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to Email the show:
Oct 28
32 min
Using technology and data-driven systems to help detect signs of mental distress with Dr. Rebecca Resnik and Dr. Philip Resnik
Philip Resnik, PhD, returns to the Psychcast, this time with his research partner and wife, Rebecca Resnik, PsyD, to discuss the interface between language, psychiatry, psychology, and health. Dr. Philip Resnik appeared on the show previously to discuss artificial intelligence, natural language processing, and mental illness. He is a professor in the department of linguistics at the University of Maryland, College Park, and has a joint appointment with the university’s Institute for Advanced Computer Studies. Dr. Philip Resnik has disclosed being an adviser for Converseon, a social media analysis firm; FiscalNote, a government relationship management platform; and SoloSegment, which specializes in enterprise website optimization. Some of the work Dr. Philip Resnik discusses has been supported by an Amazon AWS Machine Learning Research Award. Dr. Rebecca Resnik is a licensed psychologist in private practice who specializes in neuropsychological assessment. In 2014, she served as cofounder of the Computational Linguistics and Clinical Psychology workshop at the North American Association for Computational Linguistics. She continues to serve as a workshop organizer and clinical consultant to the cross-disciplinary community. She has no disclosures. Dr. Norris disclosed having no conflicts of interest. Take-home points Dr. Rebecca Resnik and Dr. Philip Resnik are interested in finding measurable, observable features to apply to the assessment of psychological and psychiatric diagnoses. They point out that finding an objective measure is essential for scaling up mental health evaluations and treatment. Natural language processing (NLP) is focused on analyzing language content. NLP technology has generated tools such as Siri, Alexa, and Google Translate, and NLP allows computers to do things more intelligently with human language. Individuals are using machine learning and NLP to analyze language data sets to evaluate diagnostic criteria. The goal is to create or use language sets that can be analyzed outside of the clinic. Dr. Rebecca Resnik imagines a world where a patient gives a “language sample” to an app or an avatar that would be evaluated by NLP that would, in turn, offer some overarching hypotheses about the person. So much of evaluations is trying to home in on the correct signal, explicit and implicit, from the patient. In addition, neuropsychiatric tests/scales are standardized against a limited scope of the population, so NLP would be matched to the individual. Dr. Philip Resnik looks at signals in text and speech content, acoustics, microexpressions, and even biometric data. Machine learning can process and distill a huge amount of data with various signals more easily than any human. Dr. Rebecca Resnik revisits the idea of clinical white space, which is the “space” or the time between clinical encounters, and this is where decompensation and high-risk suicidal behaviors occur. She suggests that NLP software could be used to fill this white space by using apps to collect text samples from patients, and the software would analyze the samples and warn of patients who are at risk of decompensation or suicide. If clinicians were to use text or speech samples from people’s smart technology, we could assess an individual's risk in the moment and use nudge-type interventions to prevent suicide. Finally, Dr. Philip Resnik emphasizes that there are technologists who have the skills and technology that is on the verge of helping clinicians, but the key to progress is collaborating with clinicians. References Resnik P et al. J Analytical Psychol. 2020 Sep 10. doi: 10.111/sltb.12674. Coppersmith G et al. Biomed Inform Insights. 2018;10:1178222618792860. Zirikly A et al. CLPsych 2019 shared task: Predicting the degree of suicide risk in Reddit posts. Proceedings of the Sixth Workshop on Computational Linguistics and Clinical Psychology. 2019 Jun 16. Yoo DW et al. JMIR Mental Health. 2020;7(8):e16969. American Medical Informatics Association and Mental Health: Selanikio J. The big-data revolution in health care.  TEDxAustin. 2013 Feb. CLPsych: Computational Linguistics and Clinical Psychology Workshop. 2019 Program. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to Email the show:
Oct 21
38 min
Professional passive aggression|Clinical Correlation
Dr. Renee Kohanski discusses how important personal and professional development is among physicians in the workplace. Is your current job worth it? Clinical Correlation is a bi-monthly drop on the Psychcast feed. You can email the show at and you can learn more about MDedge Psychiatry here:  
Oct 19
9 min
Assessing and treating older adults with dementia symptoms during the COVID-19 pandemic: A Masterclass with Dr. Sanjay Gupta
Sanjay Gupta, MD, conducts a Masterclass on treating geriatric patients with symptoms of dementia, particularly amid the restrictions tied to COVID-19. Dr. Gupta is chief medical officer at BryLin Hospital in Buffalo, N.Y. He is also is a clinical professor in the department of psychiatry at the State University of New York, Syracuse, and is affiliated with SUNY at Buffalo. Dr. Gupta attends at 8-10 nursing homes. He disclosed serving on the speakers’ bureaus of AbbVie, Acadia, Alkermes, Intra-Cellular Therapies, Janssen, and Otsuka. Take-home points Common neuropsychiatric symptoms in patients with dementia include agitation, aggression, delusions, insomnia, anxiety, and depression. One-third of community-dwelling elders and between 60%-80% of nursing facility patients have these neuropsychiatric symptoms. The most common medication class Dr. Gupta uses is antipsychotics. The use of these medications in individuals with dementia is off label. The Food and Drug Administration maintains a black-box warning on the use of antipsychotics for geriatric patients because of the increased risk of sudden death. Risperidone is supported by the most data, then olanzapine, then aripiprazole, and finally quetiapine. Quetiapine has very limited data to support its efficacy. Most antipsychotics have modest efficacy data for their use in this population. The riskiest adverse effects are cardiovascular adverse events, which are higher in risperidone. Dr. Gupta starts risperidone at a low dose of 0.25 mg taken by mouth b.i.d. and titrates to a maximum dose of 2 mg/24 hours. The starting dose for olanzapine is 2.5 mg up to a maximum dose of 10 mg. The starting dose of aripiprazole is 1 mg, and maximum dose 5 mg or less. Selective serotonin reuptake inhibitors (most commonly sertraline or citalopram), the atypical antidepressant mirtazapine, and anticonvulsants (valproic acid) are also used for agitation in dementia but there is limited evidence for their efficacy. Melatonin and trazodone have a positive effect on sleep that can have downstream improvement on aggressive behaviors. Summary To choose an effective treatment, it’s essential to obtain a detailed history of the symptoms from patients and collateral, such as relatives and staff members from the facility. Staff members can be educated about what information is most important to the clinician, or they may provide vague information, such as “the patient is confused.” Specific symptoms that can be used guide treatment include the presence of disorganized thoughts, delusions and paranoia, or visual and/or auditory hallucinations; the timing of the behavior (day vs. night); and patterns of aggressive behaviors. Dr. Gupta emphasizes that it’s important to rule out delirium as the cause of agitation by evaluating underlying medical issues with laboratory evaluations, and when possible, a physical exam. Antipsychotics work best in the context of aggression driven by paranoia and/or delusions of persecution. Antipsychotics seem to work less well for general agitation that may be driven by triggers that need to be uncovered through investigation of the history and environment. Reasons for agitation and aggression might include sensory or activity deprivation, difficulty emptying bladder or bowels, or depression and loneliness, both of which are prevalent during the pandemic. Adverse effects of antipsychotics will be greater in older adults, and include sedation, gait problems that increase the risk of falls, and extrapyramidal or Parkinsonian symptoms. In a geriatric patient, tardive dyskinesia can occur with as little as 1 month of exposure to an antipsychotic, compared with 3 months in younger adults. Before starting an antipsychotic, the clinician must obtain informed consent from the health-care proxy and inform them that using antipsychotics in a patient with dementia is a non–FDA-approved treatment with a black-box warning. Gradual dose reduction, a Medicare policy about the use of psychotropic medications within nursing homes, is defined as “stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.” Dr. Gupta addresses this policy by assessing which medications are essential and often stopping some medications once the patient is started on antipsychotics. References Steinberg M, Lyketsos CG. Am J Psychiatry. 2012 Sep;169(9):900-6. Maher AR et al. JAMA. 2011 Sep 28;306(12):1359-69. Schneider LS et al. JAMA. 2005 Oct 19;294(15):1934-43. Seitz DP et al. Cochrane Database Sys Rev. 2001 Feb 16;(12):CD0089. Ballard C et al. Cochrane Database Sys Rev. 2006 Jan 25. doi: 10.1002/14651858. Ballard C, Waite J. Cochrane Database Sys Rev. 2006 Jan 25;(1):CD003476. Department of Health & Human Services. State Operations Manual Surveyor Guidance Revisions Related to Psychosocial Harm in Nursing Homes. 2016 Mar 25. *  *  * Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. *  *  * For more MDedge Podcasts, go to Email the show:
Oct 14
20 min
Psychcast/Blood & Cancer crossover episode: Using cognitive-behavioral therapy to help cancer patients cope with depression and anxiety in the COVID-19 era
David Henry, MD, host of the Blood & Cancer podcast, joins Psychcast host Lorenzo Norris, MD, to discuss steps clinicians can take to alleviate the distress associated with receiving a diagnosis of cancer. Dr. Henry is clinical professor of medicine at the University of Pennsylvania, Philadelphia. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures. Take-home points Cancer patients have always been susceptible to developing depression and anxiety after receiving their distressing diagnoses. During the COVID-19 pandemic, the risk for depression and anxiety are even greater because patients face separation from their oncology treatment teams and for some, delays in treatment. Major depressive disorder (MDD) occurs in up to one-third of cancer patients, and any depressive disorder can be seen in about half. Another concern is how to screen for depression in the context of cancer. Dr. Norris suggests using the Patient Health Questionnaire–2 (PHQ-2) screener, or the question: “Are you sad or depressed?” Answering those questions can give patients the opportunity to open up about their emotions. Signs of depression in cancer include nonadherence to treatment, changes in mood and anxiety affecting daily functioning at home or work, and demoralization, which is defined as helplessness, isolation, and despair in the face of overwhelming stressors. Summary An emotional upset, such as disbelief, despair, or even denial, might occur immediately after receiving a cancer diagnosis. A depressive disorder, however, is a persistently depressed, sad mood with changes in functioning that affect the patient, his/her family, and even engagement with treatment. Findings of studies about the prevalence of depression in patients with cancer vary depending on the type of screening and/or diagnostic tool used. In general, the prevalence of MDD is up to 38%, and the prevalence of any depressive disorder is up to 58%. The prevalence of depression is even greater in patients with advanced cancer. In the general population, the 12-month prevalence of MDD is 6%, and the lifetime prevalence is 16%. It’s useful to think about stress along a continuum of diagnoses ranging from a normal expected stress syndrome, an adjustment disorder, MDD triggered by the event, depression secondary to a general medical condition as can occur in central nervous system and pancreatic cancer, or even a substance-induced mood disorder from either prescribed medications or perhaps a form of coping that has turned maladaptive. Cognitive-behavioral therapy (CBT) can be explained as examining the way thoughts influence emotions and behavior. When using CBT with cancer patients, a good place to start is checking in on their understanding of their diagnosis, their prognosis, and current and future treatments. The goal is to see whether they have unnecessary cognitive distortions that may be affecting their emotions and behaviors. During periods of extreme stress, CBT can help patients by emphasizing the use of adaptive thoughts, and identifying maladaptive thoughts and behaviors as opportunities for intervention. To screen for depression, it may be enough to ask: “Are you depressed?” As a screening tool, the PHQ-2 asks only two questions: “Over the last 2 weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things, or been feeling down, depressed or hopeless? The PHQ-2 score ranges from 1 to 6, and even at the lowest score, it has a sensitivity and specificity of 90.6% and 65.4%, respectively, in detecting any depressive disorder. References Krebber AMH et al. Psycho-oncology. 2014 Feb;23(2)121-30. Walker J et al. Ann Oncol. 2013 Apr 1;24(4):895-900. Trinidad AC et al. Psychiatr Ann. 2011;4(9):439-42. Daniels S. J Adv Pract Oncol. 2015 Jan-Feb;6(1):54-6. Other resources PHQ-2: National Cancer Institute: Depression–Health Professional Version:
Oct 7
24 min
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