VOLUME 57, NUMBER 6, JUNE 2022

NEWS
ISSN 0033-2704

SEE SPECIAL REPORT ON PAGE 35

iStock/peakSTOCK

Members Report Uptick in Plans’ five insurance networks because she

wants working families in her area to

Claims Denials, Scrutiny, and Hassles

have access to mental health care. She
said administrative difficulties with car-
riers are very labor intensive and, coupled
with poor reimbursement, make it hard
APA’s Practice Management Helpline is noticing an increase in the line, said APA is assisting several mem- for her to cover her overhead. “Insurance
number of members with claims processing problems. A change in bers with claims problems and encour- companies are making it increasingly
coding rules last year may be playing a role, and one legal expert ages impacted members to contact the difficult for psychiatrists to stay in-net-
weighs in on potential parity violations. BY LINDA M. RICHMOND Helpline, either by email or phone. APA work. I am very concerned about what

A
PA’s Practice Management Help-
line is fielding an increased vol-
ume of calls from members
reporting greater scrutiny of
psychiatric claims from commercial
insurers. Problems include reduced
PERIODICALS: TIME SENSITIVE MATERIALS
claims payments, denials, and increas-
ing administrative barriers. Some net-
work-participating psychiatrists are
also reporting contract offers for lower
than Medicare payment rates.
Ellen Jaffe, manager of APA’s Help-
wants to understand the pervasiveness
of these types of problems, she said. “We
need to have sufficient documentation
of this so we can put pressure on the
plans to make some serious changes.”
Psychiatrists are reporting a signif-
icant increase in utilization review by
insurance plans, including prepayment
review and postpayment audits, both
in and out of network. Others are
reporting insurers have “down coded”
their evaluation and management
(E/M) claims from level four to level
three visits, lowering the amount paid
with no request for documentation and
no explanation.
Marnie Neill, M.D., clinical director
of Silver Lake Psychiatry in Stowti, Ohio,
told Psychiatric News she participates in
this means for our communities and
their access to mental health care.”
Neill also cited problems with
patient coverage for psychiatric ill-
nesses. “A large proportion of patients
at my practice have health insurance
that covers certain psychiatric diagno-
ses—ones that their insurer deems
see Claims on page 44
Coming in Next Issue
This issue of Psychiatric News
went to press immediately
before the start of APA’s 2022
Annual Meeting in New Orleans.
Coverage of the meeting will
begin in the next issue.
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Psychiatrists Feel the Financial Pinch of MIPS
Psychiatrists tend to score
lower than other physicians on
Medicare’s Merit-Based Incentive
Payment System (MIPS), but is
the system biased against them?
BY TERRI D’ARRIGO

P
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OFFICERS OF THE ASSOCIATION Merit-Based Incentive Payment
Rebecca Brendel, M.D., J.D., President System (MIPS) and are more
Petros Levounis, M.D., M.A., President-elect
Sandra DeJong, M.D., M.S., Secretary
likely to incur payment penalties than
other physicians who participate in the

Saint Louis University/Neil E. Das

Richard Summers, M.D., Treasurer
Adam Nelson, M.D., Speaker of the Assembly system, a study published in JAMA
Saul Levin, M.D., M.P.A., F.R.C.P.-E., CEO and
Medical Director Health Forum has found. MIPS is a man-
datory, outpatient value-based pay-
STAFF OF PSYCHIATRIC NEWS ment program under Medicare that
Jeffrey Borenstein, M.D., Editor in Chief
Catherine F. Brown, Executive Editor ties reimbursement to performance on
Jennifer Carr, Associate Editor cost and quality measures.
Mark Moran, Nick Zagorski, “The increased administrative and Psychiatrists have to offset the lower payments and MIPS penalties by limiting
Terri D’Arrigo, Katie O’Connor, Senior Staff Writers
Sergey Ivanov, Art Director financial burdens introduced by MIPS the number of patients insured by Medicare in their practices, says Kenton J.
Michelle Massi, Production Manager may further disincentivize psychia- Johnston, Ph.D., M.P.H.
Marco Bovo, Online Content Manager
Aaron Levin, Linda Richmond, Eve Bender,
trists from treating Medicare patients,
Richard Karel, Contributors resulting in an even greater number of 9,356 psychiatrists and 196,306 other chiatrists received a bonus payment
Rebeccah McCarthy, Advertising Manager psychiatrists who require patients to outpatient physicians who participated adjustment compared with 88.7% of
PSYCHIATRIC NEWS
pay out of pocket for services,” wrote in the 2020 MIPS, which covered per- other physicians.
EDITORIAL ADVISORY BOARD Kenton J. Johnston, Ph.D., M.P.H., an formance in 2018. The mean final MIPS MIPS adjusts Medicare Part B pay-
Steven Chan, M.D., M.B.A., Ezra Griffith, M.D., and associate professor of health manage- performance score for psychiatrists ments based on performance in four
Diana Perkins, M.D., M.P.H.
ment and policy in the College for Pub- was 84.0 compared with 89.7 for other performance categories: quality, cost,
EDITOR-IN-CHIEF EMERITUS lic Health and Social Justice at Saint physicians. Furthermore, 6.1% of psy- promoting interoperability, and
James P. Krajeski, M.D. Louis University, and colleagues. “This chiatrists received a penalty compared improvement activities. Most of the
EDITORIAL OFFICES
factor has concerning implications for with 2.9% of other physicians, 92.6% of performance disparities were driven
Email: cbrown@psych.org; submit letters to the access to mental health care for Medi- psychiatrists received a positive pay- by lower scores in the quality and
editor and opinion pieces to this address. care beneficiaries.” ment adjustment compared with 96.3% interoperability domains. For exam-
Website: psychnews.org
The researchers analyzed data from of other physicians, and 82.0% of psy- see MIPS on page 44
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The content of Psychiatric News does

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Psychiatric News nor APA guarantees,
warrants, or endorses information or
advertising in this newspaper. Clinical
8 34 40
opinions are not peer reviewed and thus
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The information or advertising contained

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8 | APA Challenges Law
That Would Restrict
34 | Tic-Like Behaviors
in Adolescents
DEPARTMENTS
a substitute for professional treatment or
6 | APA’S GOVERNMENT, POLICY, AND
diagnosis. Reliance on such information is Abortion Access Found to Be Increasing ADVOCACY UPDATE
at the reader’s own risk; neither APA nor
Psychiatric News shall be liable if a reader The South Dakota law would Why are adolescents, particu-
relies on information in the newspaper force a woman seeking an larly girls, experiencing severe 8 | ETHICS CORNER
rather than seeking and following abortion to receive nonmedical and frequent tic-like behaviors
professional advice in a timely manner. 18 | ON MENTAL HEALTH, PEOPLE,
counseling after consultation during the COVID-19 pandemic? AND PLACES
Those who submit letters to the editor with her physician.
and other types of material for Psychiatric 20 | VIEWPOINTS
News are agreeing that APA has the 40 | Some Pregnant Women 22 | WHAT’S NEW ON APA’S WEBSITE?
right, in its sole discretion, to use their
submission in print, electronic, or any
26 | Hormone Therapy Can Experience Breakthrough
other media. Benefit Mental Health of Depression, Anxiety 40 | CLIMATE CHANGE & MENTAL HEALTH

© Copyright 2022, American Psychiatric Association

Trans Youth
Transgender and nonbinary
youth who received gender-
affirming hormone therapy are
less likely to report depression
and attempted suicide.
Despite a history of respond- 42 | JOURNAL DIGEST
ing to SSRIs, 32% of pregnant 43 | MED CHECK
women experienced worsening
depression while on SSRIs, and 44 | LETTERS TO THE EDITOR
40% had problems with anxiety,
a small study found.
PSYCHNEWS.ORG 5
GOVERNMENT

Incoming APA President Testifies authorize grant funding to state

insurance departments to help them

Before House Subcommittee

implement and enforce MHPAEA.
“Congressional action is clearly
needed to bring insurers into
compliance with the parity law,”
The Subcommittee on Health of the House Committee on Brendel told the subcommittee.
Energy and Commerce reviewed numerous bills to bolster
the nation’s mental health system. In her testimony before • The Mental Health Justice and
the committee, Rebecca Brendel, M.D., J.D., outlined APA’s Parity Act of 2022 (HR 7254), intro-
priorities, focusing on the collaborative care model and duced by Reps. Katie Porter (D-Calif.)
mental health parity. BY KATIE O’CONNOR and Debbie Dingell (D-Mich.), would

D
uring a recent congressional
hearing, Rep. Ann Eshoo
(D-Calif.) bluntly described the
state of the mental health sys-
tem in the United States: It is inade-
quate. This is due to insufficient insur-
ance coverage, limited access because
of poor provider reimbursement, and
an aging system that too often relies
prohibit nonfederal governmental
emphasizing the importance health plans from opting out of
of adequately funding the parity law coverage requirements.
nation’s mental health system,
enforcing the Mental Health • The Collaborate in an Orderly and
Parity and Addiction Equity Cohesive Manner Act (HR 5218),
Act of 2008 (MHPAEA), and introduced by Reps. Lizzie Fletcher
integrating mental health and (D-Tex.) and Jaime Herrera Beutler
primary care. (R-Wash.), would expand access to
During the hearing, the quality mental health care through

on jails and shelters, she explained.
But numerous bills are currently
before Congress that attempt to
address many of the problems plagu-
ing the mental health system. During
a hearing titled “Communities in
Need: Legislation to Support Mental
Health and Well-Being,” the Subcom-
mittee on Health of the Committee
on Energy and Commerce reviewed 19
of those bills. Eshoo is the subcom-
mittee’s chair.
Incoming APA President Rebecca
Brendel, M.D., J.D., provided expert
testimony to the subcommittee,
answering several questions and
Steve Lipofsky
subcommittee focused on the collaborative care model (CoCM)
reauthorizations for several by providing grants to primary care
mental and substance use dis- practices to cover startup costs and
order programs that fall under The collaborative care model can be imple- by establishing technical assistance
the Public Health Service Act, mented quickly within the existing workforce centers to implement CoCM. Brendel
such as the Community Men- and can help alleviate workforce shortage explained that CoCM is supported by
problems, says Rebecca Brendel, M.D., J.D.
tal Health Services Block more than 90 high-quality studies,
Grant and programs within and its population-based approach
the National Mental Health and Sub- APA-endorsed bills that would help helps to alleviate the psychiatric
stance Use Policy Laboratory. Brendel address the nation’s ongoing mental workforce shortage.
applauded that work and emphasized health and substance use disorder crises:
that “the programs must be reautho- Brendel was joined on her panel by
rized at levels that better address the • The 988 and Parity Assistance Act Sandy Chung, M.D., president-elect of
years of underfunding of public mental of 2022 (HR 7232), introduced by the American Academy of Pediatrics;
health programs.” Reps. Tony Cardenas (D-Calif.) and Steven Adelsheim, M.D., a clinical pro-
She also outlined several other Brian Fitzpatrick (R-Pa.), would see Brendel on page 24

APA’S GOVERNMENT, POLICY, AND ADVOCACY UPDATE

APA Urges Members to Ask Representatives to Cosponsor Parity
Implementation Assistance Act
APA is encouraging its members to ask their Congressional representatives
and senators to cosponsor the Parity Implementation Assistance Act (HR
3753/S 1962) and support granting the U.S. Department of Labor (DOL) the
ability to levy monetary penalties against health plans that are not in compli-
ance with the federal parity law.
The bipartisan, bicameral legislation would authorize $25 million annually to
help state insurance departments step up parity enforcement. A report issued
earlier this year from the DOL showed that many health plans are out of compli-
ance with the Mental Health Parity and Addiction Equity Act (MHPAEA) (Psychiatric
News, https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2022.03.3.32).
Additionally, APA sent a letter to Sens. Chris Murphy (D-Conn.) and Bill
Cassidy (R-La.) to thank them for their leadership in helping to strengthen com-
pliance with MHPAEA. Four similar letters were sent to champions of parity in
the House: Reps. Tony Cárdenas (D-Calif.), Gus Bilirakis (R-Fla.), Katie Porter
(D-Calif.), and Brian Fitzpatrick (R-Pa.).
The APA action alert is posted at https://cqrcengage.com/psychorg/app/
write-a-letter?0&engagementId=514032.
APA Requests Funds for Parity Enforcement, Evidence-Based
Mental Health Programs
APA requested greater resources for federal agencies to enforce the federal
parity law in a letter to a subcommittee of the House Committee on Appropri-
ations regarding fiscal year 2023 funding. The letter was addressed to Reps.
Rosa DeLauro (D-Conn.) and Tom Cole (R-Okla.), chair and ranking member,
respectively, of the Subcommittee on Labor, Health and Human Services, Edu-
cation, and Related Agencies.
In the letter, signed by APA CEO and Medical Director Saul Levin, M.D.,
M.P.A., APA requested $27.5 million for parity compliance resources for DOL’s
Employee Benefits Security Administration (EBSA), as well as $25 million for
the Centers for Medicare and Medicaid Services (CMS). The CMS funds would
provide grants to states to enforce parity at the state level. “These federal and
state agencies need resources to enforce the law and hold plans accountable
when they are not in compliance,” the letter states.
APA also requested that the subcommittee take the following actions:
• Increase funding for the Substance Abuse and Mental Health Services Admin-
istration “to implement and sustain evidence-based programs that provide
delivery and financing of prevention, treatment, and recovery services” for
people experiencing mental health and substance use disorders.
• Prioritize workforce-building programs administered by the Health Resourc-
es and Services Administration, such as the Loan Repayment Program for
Substance Use Disorder Treatment Workforce and the Mental and Substance
Use Disorder Workforce Training Demonstration Program.
• Increase funding for other federal agencies, including the National Institutes
of Health, the Centers for Disease Control and Prevention (CDC), and the
Agency for Healthcare Research and Quality.
“It is vital that as you consider funding levels for the coming fiscal year,
you continue to invest in programs that support the delivery of high-qual-
ity, evidence-based [mental health and substance use disorder] services,”
wrote Levin.
The letter is posted at https://www.psychiatry.org/getattachment/
c4478269-cb3f-42e2-8214-7787bbafde64/APA-Letter-House-Appropriations-
Committee-FY2023-Requests-04262022.pdf.
APA Holds Bipartisan 988 Briefing With House Energy and
Commerce Staff
APA partnered with the National Association of State Mental Health Program
Directors and the National Association of Counties to provide a briefing for House
continued on facing page

6 PSYCHIATRIC NEWS | JUNE 2022

 GOVERNMENT

Senate Committee Holds Hearing

On Parity, Care Integration
APA member Anna Ratzliff, M.D., Ph.D., encouraged associated with implementing CoCM,
the Senate Committee on Finance to consider policies removing cost-sharing requirements
allowing primary care practices to implement the under Medicare, and increasing reim-
collaborative care model, thus allowing more patients bursement for CoCM to more appro-
to access quality mental health care. BY KATIE O’CONNOR priately reflect the value and benefits

T
he Mental Health Parity and
Addiction Equity Act of 2008 was
supposed to be a game changer
to improve access to mental
health care by ensuring that health
of the care provided.
can be fatal,” said Sen. Ron Wyden Other witnesses included John
(D-Ore.), chair of the Senate Commit- Dicken, director of the U.S. Govern-
tee on Finance, during the committee’s ment Accountability Office’s health
hearing, “Behavioral Health Care When care team; Andy Keller, Ph.D., presi-
Americans Need It: Ensuring Parity dent and CEO of the Meadows Mental

University of Washington/Gavin W. Sisk

plans provide equal coverage for both and Care Integration.” Health Policy Institute in Dallas; and
physical and mental health treatment. Prior to the hearing, the committee Reginald Williams II, vice president
Yet 14 years later, patients seeking released a report that details its for international health policy and
mental health care still run into seem- planned next steps to understand the practice innovations with the Com-
ingly insurmountable barriers. Some country’s mental health crisis and to monwealth Fund.
cannot find a professional who takes craft a legislative package, which it During the hearing, Wyden asked
their insurance, and their health plans’ plans to consider this summer. APA about ghost insurance networks, a
directories are often wrong or out- has advocated vigorously around par- term that refers to networks that list
dated. Others have their inpatient hos- ity enforcement and integrated care In her written testimony, Anna Rat- health care professionals in their
pital stays cut short by their insurers, throughout the 117th Congress, build- zliff, M.D., Ph.D., urged the commit- directories who are not accepting
regardless of their doctors’ orders. Still ing off legislative successes during the tee to consider policies to expand patients or are no longer on their pro-
access to mental health care via
others run into onerous prior-autho- 116th Congress. APA’s staff have telehealth. vider panels, leaving the patient with-
rization requirements that further worked with members of the House out any options.
delay needed care. and Senate to introduce legislation at APA’s recommendation. She is the “I’ve had patients who needed care
Additionally, the lack of integration that helps states properly implement co-director of the Advancing Inte- go to their insurers’ provider directo-
between physical and mental health and enforce parity, as well as legisla- grated Mental Health Solutions (AIMS) ries and call, sometimes, 30 or 40 pro-
care all too often prevents patients tion that helps primary care practices Center and a professor at the University viders, only to be told there was no
from accessing the mental health care implement the collaborative care of Washington. She shared the poten- availability, be put on a waitlist, or just
they need. “Mental health should not model (CoCM). tial of CoCM to expand access to care, never receive a response,” Ratzliff said.
be fenced off from the rest of the health APA member Anna Ratzliff, M.D., save costs, and improve health equity, “This often resulted in people not being
care system. This lack of integration Ph.D., testified before the committee illustrating her points with the case of able to access the care they needed.”
a patient she had worked with through “I personally think this is making a
CoCM, whom she called Daniel. mockery out of the parity law,” Wyden
“Daniel is a young adult who had said. During the hearing, he was ada-
been struggling with untreated mental mant that he and his colleagues were
continued from facing page health conditions since he was an ado- taking action to address the lack of
lescent, and these eventually led to a mental health parity enforcement
Energy and Commerce majority and minority staff on the forthcoming launch of suicide attempt,” she said. He visited among insurers, which was recently
988, the new three-digit dialing code for the National Suicide and Crisis Lifeline. his primary care provider, who recog- highlighted in a report from three gov-
The briefing included Carrie Slatton-Hodges, commissioner of the
nized his symptoms and connected ernment agencies (Psychiatric News,
Oklahoma Department of Mental Health and Substance Use, as well as
him to a behavioral health care man- https://psychnews.psychiatryonline.
representatives from each organization. The focus was on state and local
government needs in strengthening crisis services to support the launch of ager whose office was just down the org/doi/10.1176/appi.pn.2022.03.3.32).
988 in July. APA representatives expressed the organization’s commitment hall. “As a psychiatric consultant, I was Wyden said he believes more must be
to continue working with stakeholders to support the 988 launch and to able to review his case within a few days done to hold the executives of insur-
expand access to the full continuum of mental health crisis services. during my regular meeting with the ance companies accountable.
behavioral health care manager,” she Patients seeking mental health
APA Comments on CDC’s Opioid Prescribing Guidelines Draft said. “This approach allowed me to care are “all too often bogged down
APA provided comments and recommendations to the CDC in response to review multiple patients in the clinic in insurance company foot dragging,
the agency’s proposed guidelines for prescribing opioids. in the same time it would normally red tape, and piles of excuses,” Wyden
In the letter, APA noted that the agency’s proposed guidelines are, over- take me to see only one patient.” said. “This committee is coming
all, an improvement compared with those issued in 2016. “The 2022 draft Ratzliff was able to determine Dan- together to finally fix this on a bipar-
intends to apply to acute, subacute, and chronic pain, whereas the 2016 iel’s diagnosis and recommend treat- tisan basis.” 
guideline intended only to address chronic pain, and the inclusion of all ment. “Within weeks, he was feeling
types of pain is a notable improvement,” the letter stated. better, and he enrolled in a local com-  A recording of the hearing is posted at
Additionally, the letter outlined concerns APA has regarding “the munity college,” she said. “This exam- https://www.finance.senate.gov/hearings/
guideline’s heavy emphasis towards tapering, which can destabilize many
ple is important because Daniel says behavioral-health-care-when-americans-
patients.” It continued: “If a patient with chronic pain is well controlled at a
he never would have sought mental need-it-ensuring-parity-and-care-integration.
particular dosage of opioid medication, is tolerating that dosage well, shows
functional improvement, and does not wish to reduce the dosage, [he or health care if it hadn’t been so seam- Ratzliff’s written testimony is posted at https://
she] should be maintained at the present dosage.” lessly available in his primary care www.finance.senate.gov/imo/media/doc/2022-
Further, APA requested some additional changes to the guidelines, setting. And his mother feels that this 03-2 8-Rat zliff%20Tes timony%20f or%20
including a greater emphasis on psychotherapy and clarifying the recom- access saved his life.” Finance%20Integrated%20Care%20Parity%20
mendations concerning medications to treat opioid use disorder. She urged the senators to adopt pol- Workforce%20Hearing.pdf. “Mental Health Care
The letter is posted at https://www.psychiatry.org/getattachment/4b062 icies that would significantly improve in the United States: The Case for Federal Action”
15a-0c21-4642-b773-9a90a2ff49e2/APA-Letter-CMS-Opioids-Prescribing- access to quality mental health care, is posted at https://www.finance.senate.gov/
Guidelines-04112022.pdf. including funding primary care prac- imo/media/doc/SFC%20Mental%20Health%20
tices to assist with the startup costs Report%20March%202022.pdf.
PSYCHNEWS.ORG 7
GOVERNMENT

APA Joins Amicus Brief Opposing Abortion Restrictions

A South Dakota law, which has been blocked by a federal delays in care, as it does not include a
court since 2011, would require pregnant women to timeframe by which a pregnancy help
receive counseling from a “pregnancy help center” before center must schedule the counseling
receiving an abortion, even after consulting with their appointment. That delay can pose risks
physicians about the procedure. BY KATIE O’CONNOR to patients’ health, as women with

A
PA has joined numerous health
care professional organiza-
tions in filing an amicus brief
to a lawsuit filed in the 8th Cir-
cuit Court of Appeals. The suit chal-
lenges a South Dakota law that would
force women to receive counseling at
a nonmedical facility before receiving
an abortion.
The lawsuit, filed by the ACLU and
Planned Parenthood Minnesota, South
underlying conditions can experience
options and communicate in the pregnancy-related complications, the
way that best advances patients’ brief explains. Additional dangerous
health care,” the amicus brief conditions, such as preeclampsia, can
states. “The compulsory, hostile also develop during pregnancy.
counseling imposed by the Denying a wanted abortion can also
[pregnancy help center require- negatively impact a patient’s mental
ment] creates the harmful health, increasing the likelihood of
implication that informed con- anxiety, low self-esteem, and lower life
sent does not work as intended satisfaction. “Long term, patients
and that patients are incapable denied an abortion are more likely to
of making decisions in consul- remain with abusive partners and in

Dakota, and North Dakota, was origi-
nally filed in 2011 to prevent the
enforcement of House Bill 1217 in South
Dakota. The bill requires a woman
seeking an abortion to visit a so-called
“pregnancy help center” (PHC) after
an initial consultation with her physi-
cian and before she receives the abor-
tion. The help center then conducts a
private interview with the patient in
which she is informed about what ser-
vices are available “to help the preg-
nant mother keep and care for her
child” and discuss the “circumstances
that may subject her decision to coer-
cion,” according to the text of the bill.
Though the bill passed the legislature
and was signed into law, it is not in effect.
A South Dakota federal court granted a
preliminary injunction in June 2011 and
upheld that injunction again in 2020
against a motion to have it dismissed.
But in August 2021, South Dakota Gov.
Kristi Noem and other defendants on
behalf of the state filed an appeal with
the 8th Circuit Court of Appeals.
iStock/Ted Frigillana
tation with their doctors regard- poverty, resulting in collateral mental
ing their own care.” health burdens,” the brief states.
Under South Dakota law, The injunction that originally
women are already required to blocked the law in 2011 remains in
make two trips to receive an APA joined an amicus brief challenging a force, and the law will remain blocked
abortion, one for an initial con- law (now under injunction) in South Dakota while the case is litigated, according to
sultation with their physicians requiring women to receive additional, an ACLU media release. 
and another for the procedure nonmedical counseling before receiving an
itself. Adding yet another trip abortion. The lawsuit was filed in the 8th   The amicus brief is posted at https://www.
Circuit Court of Appeals, which is based
for an interview with a preg- primarily at the Thomas F. Eagleton United psychiatry.org/getattachment/311df04b-9767-4
nancy help center simply adds States Courthouse (pictured) in St. Louis. d66-9ceb-b5f1eeb7b3d1/amicus-2022-Planned-
to the burden patients experi- Parenthood-Minnesota-et-al-v-Kristi-Noem-et-
ence, the brief argues. “Each al-Court-of-Appeals-Nos-21-2913-21-2922.pdf.
added trip exacerbates difficulties in absence to an abusive partner opposed The ACLU media release is posted at https://
finding childcare and money for travel, to the patient’s choice,” the brief states. www.aclu.org/cases/planned-parenthood-
taking time off work, or justifying The mandate will further cause minnesota-north-dakota-south-dakota-v-noem.
ETHICS CORNER
Outpatient Psychiatric Care Not for the Poor—
What Is Our Obligation?
BY CHARLES C. DIKE, M.D., M.P.H. Charles C. Dike, M.D., pandemic in the past two years. There

APA filed its amicus brief along with
more than a dozen professional orga-
nizations, including the American
College of Obstetricians and Gynecol-
ogists, the American Academy of Pedi-
atrics, and the AMA. The brief details
the numerous ways in which HB 1217
puts patients’ health at risk, under-
mines the relationship between physi-
cians and patients, and presents an
extraordinary burden for those seeking
abortion services, especially low-in-
come women.
Requiring a patient to submit
involuntarily to a private interview
at a pregnancy help center is “directly
contrary to well-established princi-
ples of medical ethics,” the brief
states. The requirement further vio-
lates patient autonomy and intrudes
on the privacy of the patient-physician
relationship, suggesting “that a phy-
sician is otherwise incapable of secur-
ing informed consent.”
“Laws should not interfere with the
ability of physicians and patients to
determine appropriate treatment
8 PSYCHIATRIC NEWS | JUNE 2022
A
nonphysician colleague reached
out to me in frustration. She had
tried in vain to find a psychia-
trist in private practice for her
17-year-old son. When she finally found
one, she was immediately informed
that the practice did not take private
insurance, Medicare, or Medicaid. Fur-
ther, the initial assessment would last
two hours—one hour to meet with her
son and another hour to meet with her
and her husband. With each intake ses-
sion costing $500, they would have to
spend $1,000 for an initial evaluation,
compared with a total copay of $80 had
the practice accepted private insur-
ance. Then there were additional costs
for follow-up visits, which were recom-
mended weekly at the start. When psy-
chological testing was recommended
and they were informed it would cost
upward of $3,000, they were aghast, but
what choice did they have? That they
had great insurance was irrelevant;
thankfully, the parents could afford it.
In this couple’s experience, many
M.P.H., is chair of the are, of course, psychiatrists who accept
APA Ethics Committee third-party payments, but their num-
and former chair of the bers are small and their practices full.
Ethics Committee of the There are also community mental
American Academy of health agencies (government and pri-
Psychiatry and the Law. vate) from which individuals could
He is also an associate receive excellent mental health care,
professor of psychiatry; co-director of the Law and but the volume of patients is such that
Psychiatry Division at the Yale University School of access to a psychiatrist in these settings
Medicine; and medical director in the Office of the is often delayed, thereby increasing the
Commissioner, Connecticut Department of Mental risk of patients becoming more ill or
Health and Addiction Services. worse. In addition to patients’ inability
to see the psychiatrist of their choice
psychiatrists did not take insurance, and lack of privacy as afforded by a
Medicare, or Medicaid. Likewise, insur- private psychiatrist’s office, there is
ance did not cover psychological test- also lack of flexibility of scheduling,
ing. She wondered how less financially leaving an employed patient scram-
stable individuals are able to obtain bling and frantic. Most community
outpatient psychiatric care. Is access mental health agencies do not have
to these services reserved for mid- evening or early morning hours to
dle-upper class U.S. citizens? accommodate working individuals.
This is a serious matter as millions In a national survey of office-based
of U.S. adults (52.9 million in 2020, or physicians by Tara F. Bishop, M.D.,
1 in 5 adults) experience mental illness M.P.H., and colleagues reported in Feb-
a year. This number did not account ruary 2014 in JAMA Psychiatry, almost
for many more individuals dealing with half of all psychiatrists did not accept
the emotional burden of COVID-19 continued on facing page

iStock/Aron M
Pride or Prejudice: A Call to Action
Mounting state government attacks on the rights of
LGBTQ+ individuals is a call to action to get involved
in advocacy—not just for our patients, but also for our
profession and for our colleagues across the gender and
sexuality spectrum. BY FIONA FONSECA, M.B.B.CH., B.A.O., M.S.
J
une may mark the beginning of
summer, but it is also Pride Month.
This month has been designated
to honor LGBTQ+ individuals,
emphasize their rights, and acknowl-
edge their struggles. June was selected
to commemorate the 1969 Stonewall
Uprising in Manhattan, which
occurred on June 28. It was spear-
headed by transgender women of color
continued from facing page
private, noncapitated insurance, and
more than half did not accept Medicare
or Medicaid, numbers that were sig-
nificantly lower than those of physi-
cians of other specialties. Factors such
as low reimbursement rates, the admin-
istrative burden of dealing with insur-
ance companies, and the shortage of
psychiatrists have been cited as reasons
that psychiatrists do not accept insur-
ance, the laws of supply and demand
being firmly in their favor (see story on
page 1). Notably, however, the authors
of the JAMA Psychiatry article observed
that the rates of reimbursement for
private practice psychiatrists’ services
were the same as primary care physi-
cians’, excluding psychotherapy ser-
vices. That means, consistent with the
Mental Health Parity and Addiction
Equity Act and related laws, that if psy-
chiatrists provided billable services
equivalent to that of primary care phy-
sicians, they would be reimbursed at
the same rate. It is not clear if the latter
statement still holds true as anecdotal
reports from some psychiatrists sug-
gest it is variable.
Other encouraging news is the obser-
vation of the increased number of med-
ical school graduates matching into
including Marsha P. Johnson and Syl-
via Rivera.
This Pride Month, as a queer immi-
grant of color with a uterus, I am
alarmed by the flood of bills filed in
multiple state legislatures focusing on
opposing immigrant rights, rescinding
reproductive rights, and reducing the
rights of LGBTQ+ individuals. As a psy-
chiatrist, I am especially concerned
psychiatric residency programs. In 2021,
6.5% of U.S. allopathic medical school
graduates matched into psychiatry com-
pared with 4.1% in 2011.Unfortunately,
in the context of an aging workforce
and retirements, the increase is unlikely
to make a difference in the short term.
These positive developments are also
not likely to increase access to private
practice psychiatrists for low socioeco-
nomic patients. More is required of psy-
chiatrists. Although low reimbursement
rates by private insurance companies,
coupled with significant administrative
burdens impeding access to said reim-
bursements are real and must be chal-
lenged, Atul Gawande’s investigation of
McAllen, Texas, reported in the New
Yorker in 2009, suggests that the prob-
lem is not always with insurance com-
panies or other third-party payers. It
could sometimes stem from doctors’
practices, hence the need for organized
medicine to always examine itself.
Increasing access to psychiatric care
(including in private psychiatric offices)
for the less financially fortunate among
us is a spiritual, moral, and ethical
imperative. A position statement by APA
in 2017 declares, “The American Psychi-
atric Association believes that Health
Care, inclusive of mental health care, is
a human right.” Further, Section 9 of the
about how these anti-rights bills will
affect the mental health of the millions
of individuals they impact.
As of April, 175 anti-LGBTQ+ bills
have been filed. This contrasts sharply
to the 45 bills filed throughout 2018 and
represents an already staggering 400%
increase in anti-LGBTQ+ bills within
just four years. And more bills may be
filed later this year. Approximately half
of these bills target transgender indi-
viduals, with some going so far as to
target the clinicians who serve them.
For example, two Texas bills, SB 1646
and SB 1311, target physicians involved
in providing lifesaving, transition-re-
Principles of Medical Ethics With Anno-
tations Expecially Applicable to Psychiatry
mandates physicians to support access
to medical care for all people. Some
private practitioners have responded by
establishing a sliding scale for indigent
patients, while some accept Medicare/
Medicaid. Others work hard to ensure
insurance companies reimburse their
patients for out-of-pocket expenses. Still
others have embedded some of their
practice with primary care physicians
or pediatricians.
Laudable as these measures are, they
are still wholly inadequate. In comply-
ing with Section 7 of our ethics princi-
ples, psychiatrists are obliged to advo-
cate for measures that will break down
barriers to access to care. We must also
challenge ourselves to explore and
embrace innovations that would open
our doors to all comers as we strive to
meet our ethical obligation to support
access to care for all regardless of their
socioeconomic status.  must advocate to protect not just the
  “Acceptance of Insurance by Psychiatrists
and the Implications for Access to Mental Health
Care” is posted https://jamanetwork.com/
journals/jamapsychiatry/fullarticle/1785174.
“The Cost Conundrum” is posted at https://
www.newyorker.com/magazine/2009/06/01/
the-cost-conundrum.
GOVERNMENT
Fiona Fonseca,
M.B.B.Ch., B.A.O., M.S.,
is a chief resident
at St. Mary Mercy
Hospital in Livonia,
Mich. They are
pursuing a career in
academic medicine
and advocacy for underserved populations, with
special interests in cultural psychiatry, psychother-
apy, medical ethics, and physician wellness. They
would like to thank Katherine Kennedy, M.D., for her
mentorship and support in developing this piece.
Kennedy is chair of APA’s Council on Advocacy and
Government Relations.
lated health care: They seek to revoke
a physician’s license to practice medi-
cine under the guise of framing such
medical interventions as “child abuse.”
Another state, Alabama, recently
passed SB 184, which makes it a felony,
punishable by up to 10 years in prison,
for physicians to provide gender-affirm-
ing medical care to minors. Similar bills
were passed in Louisiana (HB 675), Ari-
zona (SB 1138), and Idaho (HB 675). What
comes next for a marginalized popula-
tion that loses access to care that
directly correlates with a reduction in
suicidality? This June, we may be proud,
but we are also exhausted.
Our professional organization, APA,
has been outspoken in opposing any
type of legislation that compromises
patient safety, including access to gen-
der-affirming care for all individuals
regardless of age. For example, in
response to the two Texas bills, APA
tweeted its 2020 Position Statement on
the Treatment of Transgender and Gen-
der Diverse Youth and published a sim-
ilar position in collaboration with five
other medical organizations. APA has
also joined in an amicus brief in a law-
suit to block a directive issued by Texas
Gov. Greg Abbott related to SB 1646 and
SB 1311 that directs state agencies to
classify gender-affirming care as child
abuse; it has also joined in an amicus
brief against an Arkansas law banning
gender-affirming therapy.
APA stands strong in opposition to
state legislative efforts to criminalize
or penalize physicians for providing
necessary care for their patients.
Patients and their physicians
together—not policymakers—should
be the ones to make decisions about
what care is best. As physicians, we
rights of our patients, but our own right
to provide evidence-based and affirma-
tive patient care.
Over half the states (29 to be precise)
do not offer full protection from dis-
crimination for LGBTQ+ individuals.
We must look to federal legislation for
see LGBTQ+ on page 23
PSYCHNEWS.ORG 9
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COMMUNITY
Artist and ADHD Advocate Finds Her Outlet on Canvas
Using art to counter the stigma surrounding mental illness and
ADHD in adults, Tracey Meisslein Newport has found a focus for
her cognitive restlessness. One of her paintings was featured in the
October 2021 issue of Psychiatric News. BY EVE BENDER
P
eople who work on computers
all day are adept at navigating
among numerous documents,
webpages, and software appli-
cations. If there are too many pages
open and software programs operat-
ing in the background, the computer
may crash.
That’s not unlike the typical person’s
brain with attention-deficit/hyperac-
tivity disorder (ADHD), says mental
health advocate and Chicago-based
artist Tracey Messlein Newport. Each
“open page” in the brain represents a
distracting thought, emotion, impulse,
or feeling that can easily overwhelm
an individual or prevent tasks from
being completed.
After a referral from her endocri-
nologist when she was an adult, New-
port’s primary care physician diag-
nosed her with ADHD. Looking back
over the years, Newport said, she real-
ized that classic symptoms of ADHD
had impacted most aspects of her life.
“The more I thought about it, the
ON MENTAL HEALTH, PEOPLE, AND PLACES
Welcome Happy Morning
BY EZRA E. H. GRIFFITH, M.D.
I
t was like a rushing wind. I crossed
the threshold of a church’s door on
Easter Sunday this year and was met
by a blast of joyfulness and hope.
The noise of uncontrollable conversa-
tions. The rustle of paper. The to-and-
fro of people undecided about where
to sit. The crowd in the chancel placing
chairs in a small and sacred space
unaccustomed to the bustle. Different
instruments and their owners invad-
ing where only laity usually appear.
Oh yes, it was joy in the morning. Even
the program handed to me at the door
signaled the change. I was surprised
by the shine on its cover and the orig-
inal artwork sprinkled throughout its
24 pages. On the front cover was
emblazoned “You Are Welcome Here,”
and a quarter inch lower was the state-
ment that masks are optional. In the
center was a multicolored rendering
of abstractions melded with the stone
image of a cave. I could see inside
because it appeared that the large
stone blocking the entrance had been
moved to the side.
What a contrast with the column
I wrote in May 2020, which I called
“My Fable of Contagion.” I wrote then
18 PSYCHIATRIC NEWS | JUNE 2022
more I realized ‘I cannot believe I didn’t
recognize the diagnosis before, and no
one around me noticed it either,’ ” she
told Psychiatric News.
For instance, Newport had a diffi-
cult time focusing on academic stud-
ies and sticking with one job for very
long. She noted that for people with
ADHD, “our brains are constantly
searching for dopamine in a new
hobby, new job, or the next shiny
bright object. Boredom sets in, and it’s
Tracey Misselein Newport
harder to maintain focus.”
Her experience is that many people
erroneously think that adults with
ADHD are “lazy or not as bright as oth-
ers—in fact, our brains are moving
twice as fast and picking up on all the Tracey Misselein Newport enjoys expressing her emotions through color and
little sounds, movements, and activity form. The title of the above painting is “Opia.”
in the room. The sensory overload is
exhausting.”
While academics proved difficult, Newport explained that she more She privately sold and donated
art came easily to her. “I’ve been drawn readily absorbs and uses visual infor- dozens of paintings over the years,
to art since I was young—it has been mation, and painting enables her to and one of her paintings, “reVeriE,”
the only thing that enables me to focus stand up and move around freely, which was featured for ADHD Awareness
for long periods,” she said. are easier for her than sitting still. month in October 2021 (Psychiatric
Ezra E. H. Griffith, M.D.,
is professor emeritus of
psychiatry and African
American Studies at
Yale University.
about the experience in another
church at the time of the pandemic’s
appearance. I was preoccupied with
the circumscribing of hope, the
imminence of death, the upcoming
isolation, the short-circuiting of rit-
uals that had long symbolized com-
munity. The experience this year was
summed up in the very first hymn. It
referred to life and health of all, van-
quished darkness, sorrow ended, days
of lengthening light, and bloom in
every meadow.
As the time came for the sermon,
Photo by Brigitte Griffith
I readied myself for the usual docu-
mentation of the resurrection. The
rector surprised us all. He just walked
up into the pulpit and declared that
life was good. We ought to embrace
it, as well as the people around us. It Cherry Blossoms in New Haven, Conn.
continued on facing page

News, https://psychnews.psychiatry
o n l i n e . o r g / d o i / p d f / 1 0 . 11 7 6 /
pn.2021.56.issue-10). “When I started
noticing the positive impact I was
making through my art, I wanted to
share my art with the public,” she
noted. “I want others to understand
what it is like to have ADHD and to
dissolve the stigma surrounding [the
disorder],” she added.
Newport’s treatment has included
medication and behavioral strategies
such as mindfulness, but she is inter-
ested in learning more about com-
plementary and alternative therapies
for ADHD.
“Some people with ADHD don’t want
to or cannot take medications, and I
wish that there was more information
available about alternative forms of
treatment for those seeking relief from
their symptoms,” said Newport.
Newport is now blending her pas-
sions—art and mental health advo-
cacy—as she works her way toward an
art therapy degree.
“With the proper diagnosis, therapy,
and treatment, I have a better chance
at succeeding this time. I’m more hope-
ful than ever.”  you maintain compliance. It is best
  Tracey Messlein Newport can be reached
for questions about her art or advocacy work at
TraceMeArt@yahoo.com.
continued from facing page
may, of course, only be my interpre-
tation, but I think I heard him say
that in loving and enjoying life, we
make God’s becoming man worth all
the effort.
The service ended with Charles-Ma-
rie Widor’s organ piece, Toccata from
Symphony No. 5, opus 42. Members of
the congregation were crowded around
the young organist, bearing witness to
a resurgence of a community spirit and
the resilience of an institution.
A week later, I attended a commu-
nitywide cherry tree music festival in
one of the city’s parks. The day was
sunny, with a brisk wind warm enough
to encourage conversation and inter-
action through smiles and the occa-
sional touch on the arm. One can
always tell when people are relaxed in
a park. The young families bring
infants in prams and strollers. Spon-
taneous interchanges take place with
minimal fuss. Police are generous,
polite, and committed to helping the
young, the old, and the disabled.
The musicians fitted right in as well.
It was evident that they had been
invited with an eye on representing the
community, to showcase diversity with-
out fuss. I liked the group that played
Bomba, the percussion-driven musical
tradition from Puerto Rico. Conga
Telepsychiatry:
Risk Management Best Practices
Because some of the relaxed rules put in place for telehealth
during the COVID-19 pandemic are ending, be sure to review
current federal and state requirements as well as best practices
for engaging in telepsychiatry. BY CARA H. STAUS
T
here is no question that the use
of telehealth increased expo-
nentially during the COVID-19
pandemic. In fact, the pandemic
hastened implementation of tele-
health for many health care profes-
sionals. As a result, swift legislation
and executive orders facilitated a
seamless delivery of health care to
ease patient access to mental health
services. Two years later, telehealth
continues to be an essential tool to
afford patients the necessary access
to their mental health professional.
The end of the pandemic appears
to be on the horizon, and it will be
important to stay abreast of the fed-
eral and state regulations to ensure
to check the websites for the Federa-
tion of State Medical Boards (fsmb.
org/) and the Interstate Medical
Licensure Compact (imlcc.org/) for
drummers were present, as was a musi-
cian playing the Bomba barrel with
sticks. A group of three women led the
chanting. I recognized that an effort
was being made to get past the fear and
isolation imposed by the pandemic. I
noticed that pizza was on sale, along
with hot dogs and other finger foods. I
laughed when I saw the long lines one
had to endure to reach the food. Not a
person complained that others were
too close for comfort.
I learned that the cherry blossom
celebration had been in existence
since the early 1970s and had become
a major afternoon event, except
during the pandemic years. Cherry
blossom viewing, I was told, is com-
mon in other cities across the country.
It derives from a very old Japanese
custom of aristocrats enjoying the
viewing practice and finding inspira-
tion for their poetry writing. This year,
I marveled at the constellation of
institutions marking in unique fash-
ions their celebration of life. In my
saunter through the park, I noted the
most improbable backdrop: music and
dancers jumping for joy, untroubled
by the fact that they were moving to
their own rhythms. They were out of
step with the sounds emanating from
the stage. Who cared? Everything one
could see was a testament to health
and life.  such, at the start of the visit, the
Cara H. Staus is a
risk management
consultant in the Risk
Management Group of
AWAC Services Compa-
ny, a member company
of Allied World.
up-to-date information on the licen-
sure as well as reimbursement impacts
in your state or a state in which you
may wish to provide telehealth ser-
vices. Keep in mind the following
when utilizing telehealth:
• Standard of Care
The standard of care should be the
same as in traditional face-to-face
office visits. The same standards and
expectations for the patient and
health care professional exist as if
the patient is present in your office.
It is important to set clear expecta-
tions at the onset of using tele-
health, such as normal business
hours and a consistent private
location for visits.
• Licensure
You must be licensed in the state
where the patient is physically
located at the time of the visit. Be
aware of the regulations in the state
where the patient is located, as state
laws may vary on issues such as
mandatory reporting for minors,
commitment process, duty to warn,
prescribing, and collaboration with
other providers.
• Informed Consent
Prior to initiating telehealth
sessions, you must obtain informed
consent from the patient. Be aware
that some states may require both
written and verbal consent. The
basic elements of consent should
cover the risks and benefits of
telehealth visits. Include confidenti-
ality language as well as privacy and
security information when address-
ing the technology used. Lastly, at
the onset of each session confirm
and document the patient’s consent
to the telehealth visit.
• Documentation
The documentation for a telehealth
encounter should be similar to that
for a face-to-face encounter. As
LEGAL
provider should obtain the patient’s
consent to continue with the
telehealth visit. In addition, it is
important to document the patient’s
location, the health care profession-
al’s location, the type of technology
platform used, and the presence of
other participants in the session and
their role.
• Safety and Security
Safety is paramount when providing
telehealth services. For that reason,
prior to initiating telehealth
services, consider the patient’s
appropriateness for telehealth
services and develop an emergency
plan in the event your patient
experiences a crisis.
• Technology Platforms
Use a HIPAA-compliant platform
and obtain a Business Associate
Agreement from the vendor to
ensure appropriate technology
security measures, such as encryp-
tion, are in place to safeguard
protected health information
exchanged or stored on the plat-
form. Use of social media platforms
such as FaceTime, Skype, and
Messenger are not HIPAA compliant
and pose privacy risks and have the
potential for fines and penalties.
• International Telepsychiatry
It is important to understand the
regulations in the country where
the patient is located at the time of
the encounter. Considerations
include but are not limited to
licensure, privacy laws, emergency
planning, and prescribing implica-
tions. Also, contact your malprac-
tice insurance carrier to confirm
coverage is extended to interna-
tional practice. 
Risk Management services are pro-
vided as an exclusive benefit to insureds
of the APA-endorsed American Profes-
sional Agency Inc. liability insurance
program.
This information is provided as a risk
management resource for Allied World
policyholders and should not be con-
strued as legal or clinical advice. This
material may not be reproduced or dis-
tributed without the express, written
permission of Allied World Assurance
Company Holdings Ltd., a Fairfax com-
pany (“Allied World”). Risk management
services are provided by or arranged
through AWAC Services Company, a mem-
ber company of Allied World. © 2022
Allied World Assurance Company Hold-
ings, Ltd. All Rights Reserved.
PSYCHNEWS.ORG 19
 VIEWPOINTS
We Must Continue Screening Youth For Suicide Risk
BY GABRIELLE SHAPIRO, M.D.
O
ur nation’s youth are experienc-
ing a severe mental health cri-
sis. We are increasingly seeing,
both in our practices and in
newly released data, that the pandemic
has taken a severe toll on our children
and adolescents. Yet the pandemic has
only worsened what was already a trou-
bling trend: As of 2018, suicide was the
second leading cause of death for youth
aged 10 to 24.
The best way to broach the topic of
suicide and truly ascertain whether our
youth are having suicidal thoughts is to
ask them. Yet, in recent draft recommen-
dations, the U.S. Preventive Task Force
(USPTF) concluded that there is not
enough evidence-based research to rec-
ommend for or against screening for
suicide among youth who are not already
showing signs or symptoms of anxiety,
depression, or suicide. (The comment
period on the draft recommendations
closed May 9; according to its website,
USPTF will consider all comments while
writing the final recommendations.)
Eliminating universal screening for
suicide among youth aged 12 and older
would be a dangerous mistake. Now, in
the shadow of the pandemic, is the time
to encourage families to talk about
mental illness and suicide, not to sweep
those conversations under the rug. We
cannot erase the stigma around mental
Cannabis Regulations Being Evaded by Use of Novel THC Isomers
BY SAMUEL J. DOTSON, M.D.
T
he public discourse over the legal
status of marijuana has largely
centered on traditional cannabis
products, including whole plant
material and its major purified canna-
binoids, delta-9-tetrahydrocannabinol
(delta-9-THC) and cannabidiol (CBD).
Many psychiatrists remain unaware,
however, of the ways that nuanced legal
distinctions between cannabis, mari-
juana, hemp, and these specific constit-
uent molecules can profoundly impact
the availability of these substances.
Delta-9-THC is the molecule classi-
cally credited with the plant’s psycho-
active properties, while CBD is nonin-
toxicating but has been reported to have
anxiolytic and possible antipsychotic
effects. Delta-9-THC, however, is not the
only form of intoxicating THC in can-
nabis plants. THC is best understood as
a family of natural and synthetic iso-
mers that have varying activity at the
CB1 receptor and can thereby induce a
20 PSYCHIATRIC NEWS | JUNE 2022
Gabrielle Shapiro, M.D., is
chair of APA’s Council on
Children, Adolescents,
and Their Families and
a clinical professor of
psychiatry at the Icahn
School of Medicine at
Mount Sinai.
illness without asking questions and
having difficult conversations. Asking
youth if they or one of their friends
have ever had suicidal thoughts gives
them the opportunity to share feelings
that they may have kept hidden out of
fear and shame. For some, directly
being asked about suicide could be the
only avenue they have to talk about
their thoughts and experiences.
We should avoid over screening
youth, and physicians should use their
discretion when deciding to screen chil-
dren aged 7 to 11. But we are currently
seeing disturbing trends that suggest
more screenings may be necessary, not
fewer. In a study published in the May
Journal of the American Academy of Child
& Adolescent Psychiatry, Arielle Sheftall,
Ph.D., and colleagues found that, from
2003 to 2017, the rate of suicide among
Black youth increased every year across
all age groups. The greatest increase
was among Black youth aged 15 to 17,
followed by those aged 5 to 11 years. The
rate of suicide among Black girls
increased annually at 6.6%, which was
Samuel J. Dotson, M.D.,
is a psycho-oncologist
in the Department of
Supportive Oncology
at the Levine Cancer
Institute and an attend-
ing psychiatrist in the
Ambulatory Integrated
Continuum for severe and persistent mental illness
at Atrium Behavioral Health in Charlotte, N.C.
variety of desirable (for example, eupho-
ria, relaxation) and undesirable psycho-
active effects (for example, addiction,
psychosis). Cannabis strains differ not
only in their delta-9-THC and CBD con-
tent, but also in the trace content of
these other THC isomers that naturally
can include small amounts of delta-8-
THC and delta-10-THC. DSM-5-TR
nomenclature reflects this reality by
using the broad term “cannabis use dis-
order” rather than exclusively focusing
on one component molecule.
more than twice the rate among Black
boys. We cannot hope to understand
what is causing this devastating
increase in suicides among Black chil-
dren without screening this population.
We may be able to halt this increase and
gather vital data through utilization of
screening tools for this specific popu-
lation, particularly Black girls.
Research indicates that many peo-
ple who die by suicide had an encoun-
ter with a medical professional in the
weeks or months before their death. By
incorporating suicide screenings into
routine health care, we can both catch
youth in need who may not have any
other outlet for expressing their
thoughts and chip away at the enor-
mous mental health stigma still per-
vading our society.
Ensuring youth are routinely
screened is only one important part
of reducing the rate of youth suicide.
Primary care providers must have the
resources necessary to connect youth
to quality mental health care when
they screen positive for suicide risk.
Integrated, collaborative primary and
mental health care is an evi-
dence-based method that allows fam-
ilies to seamlessly access the care their
children need. Additionally, integrat-
ing a social-emotional health curric-
ulum in schools beginning in kinder-
garten can assist with normalizing
mental health issues for both children
Although Cannabis species have
many uses beyond their controversial
recreational and medicinal applications,
their cultivation has long been limited
within the United States by regulation
of the Drug Enforcement Administra-
tion under the Controlled Substances
Act. Congress therefore passed the Agri-
culture Improvement Act of 2018 (also
known as “the 2018 Farm Bill”) in an
effort to support the growth of America’s
domestic hemp market.
This law led to a rapid proliferation
of hemp and CBD products within the
United States. These products, how-
ever, can be easily converted into del-
ta-8-THC and a variety of other intox-
icating compounds including the
THC-O acetate derivatives, hexahy-
drocannabinol (HHC), tetrahydrocan-
nabiphorol (THCP), and tetrahydro-
cannabivarin (THCV). Manufacturers
have subsequently used this loophole
to create a new market for psychoac-
and families and assist with erasing
stigma. Further, our mental health
care system is on the precipice of a
major shift with the implementation
of 988 as the nationwide, three-digit
dialing code for people experiencing
a mental health crisis. This provides
an opportunity to direct funding spe-
cifically toward youth mental health.
There is a dangerous misconception
among the public that talking about
suicide will only encourage suicidal
thoughts or behaviors. In my clinical
experience working with children, ado-
lescents, and their families, I have seen
many suicides prevented because the
patients were simply asked if they were
having thoughts of “not wanting to be
here.” And I have also, unfortunately,
seen suicides completed because no
one said anything, and no one asked.
The increase of suicides among our
youth is tragic. We are not without
options to address the problem. We
must show our youth that there are
adults around them with whom they
can have safe conversations about these
thoughts. We must ask them these dif-
ficult questions. 
  “Screening for Depression and Suicide Risk
in Children and Adolescents” is posted at https://
www.uspreventiveservicestaskforce.org/uspstf/
document/draft-evidence-review/screening-
depression-suicide-risk-children-adolescents.
“Black Youth Suicide: Investigation of Current
Trends and Precipitating Circumstances” is
posted at https://www.jaacap.org/article/S0890-
8567(21)01365-4/fulltext.
tive THC isomers that are sold as “legal
hemp derivatives.”
These emerging psychoactive can-
nabinoids are now bypassing regula-
tion around the country, and they have
become especially popular in states
that still have restrictive marijuana
laws. Many are being marketed as “diet
weed” or “marijuana light” in candy-
like packaging that gives an impres-
sion of safety, especially to adoles-
cents. The few available clinical
reports, however, show qualitatively
similar effects to traditional delta-9-
THC during short-term use. These
molecules appear to primarily differ
in their potency, with delta-8-THC
being about two-thirds that of delta-
9-THC, and delta-9-THC-O acetate
being about twice as potent. Safety
concerns are surfacing, but these dis-
cussions remain largely relegated to
emergency medicine and public health
continued on facing page

Violent Suicides Show Distinct Biological Footprint
iStock/JuSun
Analysis of postmortem brain tissue revealed significantly different
gene expression patterns in individuals who died by suicide with
violent means compared with nonviolent means. BY NICK ZAGORSKI
P
eople who die by suicide by vio-
lent means (such as the use of a
firearm) show distinct biological
signatures compared with those
who die by suicide by nonviolent means
(such as carbon monoxide poisoning),
according to a report in the American
Journal of Psychiatry. Using data from
an extensive collection of human brain
tissue, investigators at the Lieber Insti-
tute for Brain Development in Balti-
more and colleagues identified differ-
ent gene expression signatures in
people who died by suicide by violent
means compared with others who died.
“Suicides by violent means are dis-
tinct in that people usually don’t have
time to change their mind; they are
continued from facing page
circles with a focus on acute intoxica-
tion and contamination risks. The
academic literature has thus far
neglected the potential for long-term
adverse impacts on mental health,
which are especially salient for addic-
tion and psychosis specialists.
Throughout the United States, delta-
8-THC has now become the fastest
growing segment of the cannabis mar-
ket. An industry report by the Bright-
field Group found that consumers
interested in switching from CBD to
delta-8-THC are more likely to use the
drug daily and more likely to have a
mental illness than the average CBD
consumer. Further supporting these
concerns, a survey posted November
19, 2021, in Cannabis and Cannabinoid
Research found that many people are
using delta-8-THC to self-treat mental
illness without informing their medi-
cal providers. Notably, the authors
found that 35.6% of respondents had
substituted the drug for their antide-
pressant, and 23.3% had done the same
for their prescribed antipsychotic.
extreme behavioral acts that end pre-
cipitously,” said Daniel Weinberger,
M.D., director and CEO of the Lieber
Institute for Brain Development and
senior author of the study. “Still, we
were surprised at the extent of genetic
differences this study uncovered.”
Weinberger and colleagues com-
pared the gene expression profiles of
226 brain tissue samples from individ-
uals with schizophrenia, major depres-
sion, or bipolar disorder. Based on
available information on the manner
and circumstances of death, the
researchers divided the samples into
three groups: 77 individuals who died
by suicide by violent means, 50 who
died by suicide by nonviolent means,
Many communities are now strug-
gling to regulate these products given
the increasing power of the marijuana
lobby. Without further research, poli-
cymakers and medical professionals
will be left in an evidence vacuum.
While we await more data, we can serve
as advocates in our communities by
educating politicians, parents, and
patients on the known risks of tradi-
tional marijuana use, as well as the
unknown and potential risks of novel
THC isomers.
Editor’s note: In May, the Food and
Drug Administration issued warning
letters to five companies illegally selling
products labeled as containing delta-8
THC in ways that violate the Federal Food,
Drug, and Cosmetic Act selling CBD and
delta-8 THC products. 
 “What’s the Fate of Delta-8? Consumer,
Product, and Regulatory Trends” is posted at
https://blog.brightfieldgroup.com/delta-8-thc.
“Consumer Experiences With Delta-8-THC: Medi-
cal Use, Pharmaceutical Substitution, and Com-
parisons With Delta-9-THC” is posted at https://
www.liebertpub.com/doi/10.1089/can.2021.0124.
CLINICAL & RESEARCH
paring individuals who died by violent
suicide with those with a psychiatric
diagnosis who did not die by suicide,
the researchers found variation in gene
expression in 189 genes. When compar-
ing individuals who died by nonviolent
suicide with those with a psychiatric
diagnosis who did not die by suicide,
the researchers found that the genetic
differences were more modest, with
variation in the expression of 44 genes.
When comparing individuals who died
by violent suicide with individuals in
the neurotypical group, the researchers
found variation in the expression of
eight genes.
Weinberger cautioned that the find-
and 99 who did not die by suicide. As ings should not be taken too broadly.
an additional comparison, the “We are getting a glimpse of one brain
researchers included brain tissue sam- region at one moment frozen in time,
ples from 103 individuals who did not right before an individual’s death.”
have a psychiatric diagnosis and did Several of the genes that were
not die by suicide (the researchers over-expressed in people who died by
called this group the neurotypical violent suicide relative to the other
group). The researchers focused their groups were involved in purine signal-
attention on the dorsolateral prefron- ing. Purines are a class of neurotrans-
tal cortex (DLPFC), a brain region mitters that regulate energy metabo-
involved in higher cognitive functions, lism as well as some behaviors, notably
such as planning and decision-making. aggressive behaviors.
“Suicide is a rarely accessible phe- “It is a big ask, but we do need to see
notype, so most research investi- data from other brain regions to form
gates patients who, thankfully, sur- more solid conclusions,” said Alexis
vived a previous suicidal attempt,” said Edwards, Ph.D., an associate professor
lead study author Giovanna Punzi, at the Virginia Institute for Psychiatric
M.D., Ph.D., a research scientist at the and Behavioral Genetics at Virginia
Lieber Institute. “But these brain sam- Commonwealth University. Edwards
ples might offer an exceptional ‘biolog- added that an individual may have cho-
ical snapshot’ of what was going on sen a firearm for suicide simply because
during suicide completion.” it was most readily available and/or
There were gene expression differ- made the decision hours, days, or even
ences in all four groups, but the stark- weeks before the actual act. It’s therefore
est difference was between people who possible that gene expression at death
died by violent suicide and those who reflects factors other than the individ-
died by nonviolent suicide: over 800 ual’s selection of a violent method.
genes were differently expressed Additionally, Edwards noted, experts
between these two groups. When com- see Suicides on page 23
Activity of Stem Cell–Derived Neurons
May Predict Psychiatric Symptoms
While researchers have used induced pluripotent stem cells (iPSCs) to
create a host of other human cell types, including neurons, how to model
psychiatric disease using these cells has proven complicated. This is largely
because it is difficult to determine if these cells can recapitulate any clinical
features of disorders such as depression or schizophrenia.
In a study published in PNAS in January, Lieber Institute researchers led
by Brady Maher, Ph.D., identified differences in the function of ion channels
in neurons derived from schizophrenia patients compared with those who
did not have schizophrenia. The researchers conducted detailed physio-
logical assessments of these neurons and identified patterns of electrical
activity that correlated with the positive, negative, and cognitive symptoms
of the donors.
“Based on the way these cells interacted with each other, we could
predict whether the donor patient had certain cognitive deficits with almost
absolute accuracy,” explained Daniel Weinberger, M.D., who was a co-au-
thor on the study.
“Electrophysiological Measures From Human iPSC-Derived Neurons Are Associated
With Schizophrenia Clinical Status and Predict Individual Cognitive Performance” is
posted at https://www.pnas.org/doi/abs/10.1073/pnas.2109395119.
PSYCHNEWS.ORG 21
 CLINICAL & RESEARCH

Computer-Assisted CBT May Help Alleviate Depression

program a lot since it can do many of
the structured tasks that require rep-
etition during sessions, such as teach-
ing patients certain behavioral skills,”
Wright said. That frees up time so cli-
nicians can devote their energy to more
interactive elements of CBT like
role-playing, he said.
Wright stressed that some level of
human interaction is critical for CBT to
work. “There are many self-guided pro-
grams that use a CBT framework, but
no software can match the empathy or
flexibility of a human therapist.”
Wright added that the CBT program
iStock/FreshSplash

used telephone-based support since

telepsychiatry was not covered by insur-
ance when the study launched in 2016.
“Today, a similar hybrid CBT strategy
would likely use video-based clinician
Patients who participated in a 12-week CBT computer program and The participants were predominantly support, which might improve the effi-
telephone-support sessions showed greater improvements in mood female (84.5%) and included members cacy even more,” he noted. Since 2016,
than those who did not participate in the program. BY NICK ZAGORSKI of racial and ethnic minorities (39.6%), Mindstreet Inc.—the company that dis-

P
adults with less than a college education tributes Good Days Ahead—has also
atients being treated for depres- and no internet access. (74.6%), adults with an annual income released a mobile version of their pro-
sion by their primary care doctor “These findings hopefully reinforce under $30,000 (61.5%), and adults with gram, which can further increase access
may benefit from participating that CBT is an adaptable therapy that no internet access (29.8%). To accom- as wireless plans provide internet access.
in a 12-week computer program can benefit anyone,” said lead study modate the last group, the researchers Brian Kiluk, Ph.D., an associate pro-
that teaches cognitive-behavioral ther- author Jesse Wright, M.D., Ph.D., a pro- provided low-cost loaner laptops and a fessor of psychiatry at Yale University
apy (CBT) skills, suggests a study in fessor of psychiatry and director of basic internet plan to participants who School of Medicine and director of
JAMA Network Open. the Depression Center at the Univer- requested them. Yale’s Psychotherapy Development
This study was notable in that it sity of Louisville. The participants were randomly Center, said these new findings were
included many participants who have Wright and colleagues recruited 175 assigned to receive 12 weeks of their really encouraging. “We have reached
typically not been included in previous adults with depression from universi- usual depression care or 12 weeks of the point where we know computerized
computerized CBT trials, such as those ty-affiliated clinics across Louisville (as usual care plus a computer-assisted CBT CBT is efficacious in clinical trials and
with low incomes, limited education, well as one clinic in rural Glasgow, Ky.). program known as Good Days Ahead. are now building evidence that it works
The program consists of nine multime- in real-world settings.”
dia lessons that cover the core concepts Kiluk, who was not involved with
WHAT’S NEW ON APA’S WEBSITE? of CBT, such as identifying negative
thoughts and developing skills to redi-
this study, has been conducting similar
research testing computer-based CBT
rect negative thoughts into positive ones; in people with substance use disorders
Psychiatric News is launching a new column in this issue to alert members
about new and revised content on APA’s website at psychiatry.org. Mem- the computer lessons are supplemented at outpatient treatment centers. He has
bers visiting the website have probably noticed by now that it was updated by up to 12 telephone support sessions also been inclusive when conducting
earlier this year and features a cleaner, streamlined design that requires with a master’s-level mental health cli- his clinical trials, even ensuring people
fewer clicks to reach the desired content, a much-improved search engine, nician. Usual care could include psycho- on probation or parole are represented.
more intuitive navigation, and links to more areas of interest that can be therapy and/or antidepressants, though Additionally, his team is developing
reached directly from the homepage. many participants were not receiving culturally relevant versions of his CBT
either at the start of the study. program (known as CBT4CBT), such as
Some notable updates to APA’s website include these: After 12 weeks, the adults who a Spanish language version, and tested
• New telepsychiatry blog: https://psychiatry.org/psychiatrists/ received the computer-assisted CBT had delivery of the program in diverse set-
practice/telepsychiatry/blog/comparison-of-telehealth- significantly greater improvements in tings, such as in the Black church.
provisions-during-the-pub. APA devoted much advocacy effort to
their depressive symptoms (measured “Computerized CBT is great because
retain, either totally or in part, the telehealth flexibilities that were
put in place during the COVID-19 public health emergency (PHE). A with the 9-item Patient Health Ques- it increases access to and flexibility of
document posted at this site summarizes current telehealth policies tionnaire, or PHQ-9) compared with the care (since users can work at their own
and the policies that will be in effect when the PHE provisions usual care group; average PHQ-9 scores pace),” Kiluk told Psychiatric News.
expire. Psychiatrists are also advised to check their teleheath state were 8.6 for the CBT group and 11.1 for “However, we need to be mindful of the
laws and regulations (see story on page 19). the usual care group. In addition, 27.3% digital divide as we start bringing this
• New perinatal research initiative: https://www.psychiatry.org/ of participants who received comput- technology into wider use.”
psychiatrists/research/mental-health-needs-assessment-in-the- er-assisted CBT experienced remission This study was supported by a grant
management-o. APA has launched a new initiative with the goal of of their depression (defined as a PHQ-9 from the Agency for Healthcare
better understanding the experiences and attitudes of psychiatrists score of less than 5) compared with Research and Quality. Wright helped
and mental health professionals around treating pregnant women 12.0% in the usual care group. PHQ-9 write some of the content for Good Days
with mental and substance use disorders.
scores remained lower for the CBT group Ahead and has equity interest and con-
• Implementation of 988, the new nationwide mental health
crisis and suicide prevention number: https://www.psychiatry. relative to the usual care group at fol- sults for Mindstreet Inc.  
org/psychiatrists/advocacy/implementing-9-8-8. The hotline goes low-up three and six months later, show-
into effect July 16, but the infrastructure to make it work as intended ing the program had durable effects.  “Effect of Computer-Assisted Cognitive
is not in place in all states. Overall, the mental health clini- Behavior Therapy vs Usual Care on Depres-
• New “Patients and Families” page on prolonged grief disorder: cians spent an average of 164 minutes sion Among Adults in Primary Care” is posted
https://www.psychiatry.org/patients-families/prolonged-grief-disorder. talking with patients over the phone. at https://jamanetwork.com/journals/jama
“I think clinicians like this computer networkopen/fullarticle/2788926.
22 PSYCHIATRIC NEWS | JUNE 2022

Suicides
continued from page 21
remain divided on what to consider a
violent suicide. For instance, poisonings
may be considered nonviolent, yet they
can be more prolonged and painful than
firearm suicides, she said. Still, she said,
this study is valuable in detailing the
complexity and heterogeneity of sui-
cidal behaviors. “Many people still see
suicide solely as a feature of depression,
and that is not the case.”
As part of the study, Weinberger
and colleagues also analyzed genome
data from another set of 888 DNA sam-
ples collected from people who were
neurotypical or diagnosed with
schizophrenia, depression, or bipolar
disorder who died by various means.
They found that people with schizo-
phrenia or depression who died by
violent suicide appeared to have less
genetic risk for their diagnosed psy-
chiatric disorder compared with peo-
ple with these illnesses who died by
nonviolent suicide or other means.
These genetic discrepancies between
people who died by violent suicide ver-
sus nonviolent suicide were not as
pronounced in people with bipolar
disorder, they noted.
Taken together, these findings sup-
port the idea that biological mecha-
CLINICAL & RESEARCH
People Who Died by Suicide by Violent Means Showed LGBTQ+
Distinct Gene Expression Profile at Time of Death continued from page 9
People with SMI (schizophrenia, bipolar disorder, major depression) who die by redress. Please contact your U.S. sena-
suicide by violent means show dramatically different gene expression in the tors to urge them to pass the HR 5 Equal-
prefrontal cortex at the time of death compared with people who died by suicide ity Act. This bill has already been passed
by nonviolent means. Many genes associated with aggressive behaviors were by the House of Representatives with
among those that were more highly expressed in people who died by suicide by APA’s support and will amend the 1964
violent means. Civil Rights Act to protect people from
being discriminated against based on
Violent suicide vs. sexual orientation or gender identity.
nonviolent suicide 843
Ask your senators to support this criti-
cal bill by contacting them directly. You
Violent suicide vs.
nonsuicide death 189 can do this here: https://act.hrc.org/
page/76330/action/1?locale=en-US.
Nonviolent suicide vs.
44 Want to go above and beyond? Sup-
nonsuicide death
port organizations like the Transgen-
0 200 400 600 800 der Law Center (TLC), which is the
Differentially expressed genes largest national trans-led organization
Source: Giovanna Punzi, M.D., Ph.D., et al., American Journal of Psychiatry, March 2022. grounded in legal expertise and com-
mitted to racial justice. TLC employs
community-driven strategies to keep
nisms underlying violent suicide may date from a patient who is not shifting transgender and gender nonconform-
be distinct from those that increase from considering death to actually ing people alive, thriving, and fighting
suicide risk in people who have a psy- pursuing it, offering novel and more for liberation. Its website is www.trans
chiatric illness, Weinberger noted. precise targets for therapy in short- genderlawcenter.org.
“[A]ddressing suicide by violent term risk for suicide.” We could reflect on key moments of
means as a separate condition may This study was supported by the Lieber injustice in history, hypothesizing what
prove decisive to inform prevention,” Institute for Brain Development.   would have been done if we had been
Punzi and colleagues concluded in alive then, but we are alive now, and
the paper. “Violent suicide [biomark-  “Genetics and Brain Transcriptomics of this moment is a call to action—not just
ers] in brain specimens, if mimicked Completed Suicide” is posted at https://ajp. for our patients, but also for our profes-
by peripheral biomarkers, may poten- p syc h ia t r yo n l i n e .o r g / d o i / 1 0 .11 7 6 / a p p i . sion and for our colleagues across the
tially differentiate a suicide candi- ajp.2021.21030299. gender and sexuality spectrum.
Advertisement
PSYCHNEWS.ORG 23
 CLINICAL & RESEARCH
iStock/SeventyFour
C-L Psychiatrists Can Support Social Justice
In Medical-Surgical Settings
C-L psychiatrists are crucial in assisting
medical and surgical teams as they
work through implicit biases to provide
equitable care. This article is one of a
series coordinated by APA’s Council on
Consultation-Liaison Psychiatry and the
Academy of Consultation-Liaison Psychiatry.
BY ADRIENNE D. TAYLOR, M.D., AND DIANA M. ROBINSON, M.D.
T
he impact of police shootings and
the coronavirus pandemic on
people of color has led to an accel-
erated urgency to incorporate
social justice principles into medical
training. Consultation-liaison (C-L) psy-
chiatrists are trained to think about the
relationship between medical and psy-
chiatric illness within systems of care,
allowing them to be uniquely poised to
highlight systemic racism and struc-
tural vulnerabilities. The following case
highlights how C-L psychiatrists can
conceptualize clinical care through a
social justice lens.
Mr. M is a 37-year-old Haitian man
with a reported history of schizophre-
nia who was admitted to the trauma
surgery service in police custody after
being shot several times during an
altercation with the police. Per reports,
Mr. M had attacked police with a
weapon during a psychotic episode.
Psychiatry was consulted three weeks
into his hospitalization for assistance
with agitation associated with delir-
ium. He remained in the surgical inten-
sive care unit for several months for
surgical management, including fur-
ther abdominal injury repair and
reconstruction. Further history indi-
cated that he had been nonadherent to
psychiatric treatment for several
24 PSYCHIATRIC NEWS | JUNE 2022
months before the incident and had a
history of contact with the criminal
justice system. After stabilization on
antipsychotics, Mr. M was able to report
that he had been experiencing com-
mand auditory hallucinations at the
time of his injury and had attempted
“suicide by cop” to end his suffering.
Throughout his eight-month hospi-
talization, the C-L psychiatry service
assisted the surgical team in coordi-
nating his care with his outpatient
physicians and other health care pro-
fessionals at the correctional facility,
given the high risk of recurrence of
psychiatric symptoms, potential legal
consequences of this psychotic episode,
Brendel
continued from page 6
fessor of psychiatry and director of the
Stanford Center for Youth Mental
Health and Wellbeing and a member
of APA’s Council on Children, Adoles-
cents, and Their Families; Cassandra
Price, M.B.A., director of the Office of
Addictive Diseases with the Georgia
Department of Behavioral Health and
Developmental Disabilities; Debra
Pinals, M.D., medical director of behav-
ioral health and forensic programs with
and post-trauma support. At the start
of the COVID-19 pandemic, Mr. M was
discharged to a prison unit at a local
rehabilitation center.
Mr. M’s case is not uncommon, and
many psychiatrists will recognize sim-
ilarities in cases that they have encoun-
tered in their own practice. Law enforce-
ment agencies frequently serve as first
responders to mental health emergen-
cies, including crises involving violence.
About 20% of people hospitalized for
severe mental illness have been arrested
or picked up by police for a suspected
crime during the four-month period
prior to admission. Racial inequities in
lethal force cases may reflect differences
in the way that some law enforcement
officers or agencies perceive and inter-
act with Black communities. In medi-
cine, many people hold culturally
derived “implicit biases”—attitudes or
stereotypes that affect our understand-
ing, actions, and decisions in an uncon-
scious manner. Resisting implicit bias
requires constant vigilance and actively
the Michigan Department of Health
and Human Services and chair of APA’s
Council on Psychiatry and Law; and
LeVail Smith, C.P.S.S., peer support spe-
cialist instructor and mentor.
In her written testimony, Brendel
referenced numerous additional bills
that APA supports and the subcommit-
tee reviewed during the hearing. She
also fielded several questions from sub-
committee members, particularly
around collaborative care and mental
health parity.
Especially in light of the COVID-19
Adrienne D. Taylor, M.D.,
is a consultation-liaison
(C-L) psychiatrist and
program director of C-L
psychiatry at Brigham
and Women’s Hospital.
She is also a psychiatry
instructor at Harvard
Medical School. Diana
M. Robinson, M.D., is a
C-L psychiatrist, the as-
sociate medical director
of C-L psychiatry at
Parkland Hospital, and
an assistant professor
of psychiatry at UT
Southwestern Medical Cent in Dallas.
working toward developing an anti-rac-
ist approach.
The presence of police within the
health care space may further reinforce
stereotypes of injured patients as devi-
ants and criminals and cause patients
to feel unsafe in hospital settings and
disenfranchised, when wrongly or
rightly, they are held accountable for
the cause of their injuries. Police at the
bedside can contribute to long-term
racial disparities after injury, including
risk of re-injury, higher rates of mental
illness, and the use of risky strategies,
such as substance use, to cope with the
physical and mental aftermath of
injury. Physicians should consider pro-
cedural justice—processes used by
people in positions of authority to
reach specific outcomes or decisions
and understanding—as people’s per-
ception of fairness is strongly impacted
by the quality of their experience and
not only the end result of these expe-
riences. This concept is critical for
building trust and strengthening the
physician-patient relationship.
As the case highlights, C-L psychi-
atrists are crucial in assisting medical
and surgical teams as we work
through implicit biases and help pro-
vide equitable care at the individual,
clinical, institutional, and educa-
tional levels. Recognizing these biases
and eliminating them provide a way
forward as psychiatrists continue
working to promote equity for
patients at the intersection of psychi-
atry and general medicine. 
pandemic, ensuring mental health
parity is more important than ever, she
pointed out. While frontline workers
are in serious need of quality mental
health care, many are covered under
health plans that do not provide cov-
erage for mental health treatment,
Brendel explained. “The Mental Health
Justice and Parity Act of 2022 would
ensure that our nation’s frontline work-
ers have comprehensive access to men-
tal health services,” she said.
Additionally, Fletcher asked Brendel
continued on facing page

Data, Patient Narratives Must Be Integrated
To Address Racial Inequities
iStock/Metkalova
Medical anthropology is the study of how health and illness are
shaped, experienced, and understood in light of global, historical,
and political forces. Such information can help us address racial
and ethnic health disparities. This article is part of a series by
APA’s Council on Advocacy and Government Relations.
BY J. NIKKI STEINSIEK, M.D., M.P.H, AND LAURA M. WILLING, M.D.
A
s psychiatrists, researchers, and
advocates working to untangle
the sociopolitical underpin-
nings of inequities, it is essential
that we center the experiences of Black,
Hispanic, and other historically
oppressed communities in our work.
In this article, we will discuss data on
the inequitable diagnosis and treat-
ment of Black children with autism
spectrum disorder (ASD) and intellec-
tual and developmental disabilities.
Numerous studies demonstrate that
White children are more likely to be
diagnosed with ASD than Black, His-
panic, and Asian children. In the last
two years, heightened attention to
racial inequities and the factors that
create and support those inequities
have revealed how our implicit biases
reinforce stereotypes that lead to errors
in diagnosis. Black and Hispanic chil-
dren are diagnosed later in life than
White children. In a large cross-sec-
tional study, half of Black parents
reported visiting multiple health care
continued from facing page
to explain what makes CoCM different
from other integrated behavioral
health models.
“The Collaborative Care Model
enables a single psychiatrist to work
alongside a care manager and a pri-
mary care doctor to provide consulta-
tion,” Brendel said. Rather than seeing
four to six patients in one or two hours,
in this model psychiatrists can provide
consultation to as many as 50 to 70
patients in the same amount of time.
professionals before their child received
an ASD diagnosis, and 31.3% stated that
the lack of available professionals con-
tributed to this delay, according to a
study by John N. Constantino, M.D., in
the September 2020 Pediatrics.
Rather than being diagnosed with
ASD, Black children are more likely
to be diagnosed with intellectual
developmental disorder. Researchers
at Duke University found that in
North Carolina the majority of stu-
dents diagnosed with ASD were
non-Hispanic Whites, while the
majority of students diagnosed with
intellectual developmental disorder
were non-Hispanic Blacks. Racial
inequities seen in the overall cohort
were consistent across urban and
rural areas. Low resource availability
was associated with higher probabil-
ities of a diagnosis of intellectual
developmental disorder than ASD,
according to studies by Eunsoo Tim-
othy Kim and colleagues and Jill How-
ard, Ph.D., and colleagues.
Brendel detailed other benefits of
CoCM, such as reducing the stigma of
requiring patients to make separate
mental health appointments and help-
ing to save costs. “It really is a model
that has everything and can be imple-
mented very quickly within the exist-
ing workforce,” she said.
It is vitally important that behav-
ioral and primary care become inte-
grated, Brendel said. “Population- and
evidence-based integrated care models
hold great promise to enhance access
for the millions of Americans who
J. Nikki Steinsiek,
M.D., M.P.H., is an APA
Leadership Fellow and
third-year psychiatry
resident at the Univer-
sity of North Carolina.
Laura M. Willing, M.D., is
an assistant professor
at Children’s National
Hospital and a corre-
sponding member of
APA’s Council on Advo-
cacy and Government
Relations.
This association is consistent with
data from a national database indi-
cating that the prevalence of ASD
was higher among those of high
socioeconomic status compared with
those of low socioeconomic status
for all races and ethnicities, accord-
ing to a study by Maureen S. Durkin,
Ph.D., and colleagues in the July 12,
2010, PLOS One.
While we should strive to address
poverty, it is also essential to under-
stand why inequities might linger
when issues of access and poverty are
eliminated. Stephanie Keeney Parks
is a UCLA doctoral candidate and Rob-
struggle with undiagnosed and
untreated mental health and substance
use disorders.”  article?id=10.1371/journal.pone.0011551. “Educa-
  A recording of the hearing and a list of the
bills the subcommittee considered are posted at
https://energycommerce.house.gov/committee
-activity/hearings/hearing-on-communities-
in-need-legislation-to-support-mental-health-
and. Brendel’s written testimony is posted at
https://energycommerce.house.gov/sites/
democrats.energycommerce.house.gov/files/
documents/Witness%20Testimony_Brendel_
HE_2022.04.05.pdf.
CLINICAL & RESEARCH
ert Wood Johnson Health Policy
Research Scholar whose work looks at
how disability is experienced and
understood within the Black commu-
nity. Parks presented at APA’s 2021
Mental Health Services Conference,
sharing two stories of upper-middle
class Black families touched by ASD
and intellectual developmental disor-
der. One vignette featured a Black fam-
ily’s long-standing and evolving sup-
port for a family member with
undiagnosed ASD and intellectual and
developmental disability. The second
example explored the experience of a
mother, who is both a psychologist and
an applied behavioral analysis thera-
pist, and her young son with ASD. In
these vignettes, Parks highlighted
some of the negative consequences of
an ASD diagnosis for a Black person as
well as the numerous ways that Black
families attend to their own needs,
loving and caring for disabled loved
ones with or without the use of bio-
medical standards and supports.
Without the work of medical
anthropology, we miss essential con-
tributors to inequity as well as sources
of resiliency that can be identified by
asking our patients. We encourage
readers to learn more about their
patients’ experience of being diag-
nosed and help create systems in
which people of all races and ethnic-
ities are supported and positively
impacted by their encounters with the
medical system.
To educate state and federal legis-
lators on factors that perpetuate men-
tal health disparities, APA members
are encouraged to get involved in one
of APA’s advocacy programs. Don’t leave
it to others to do what you can do. For
more information and the latest issues
on which APA needs your advocacy, go
to https://w w w.psychiatr y.org/
psychiatrists/advocacy. 
The authors would like to recognize
Stephanie Keeney Parks for the additional
time she spent with them so that they
could better understand her work.
  “Timing of the Diagnosis of Autism in Af-
rican American Children” is posted at https://
publications.aap.org/pediatrics/article/146/3/
e20193629/77116/. “Socioeconomic Inequality
in the Prevalence of Autism Spectrum Disorder:
Evidence From a U.S. Cross-Sectional Study” is
posted at https://journals.plos.org/plosone/
tional Classifications of Autism Spectrum Dis-
order and Intellectual Disability Among School-
Aged Children in North Carolina: Associations
With Race, Rurality, and Resource Availability”
is posted at https://onlinelibrary.wiley.com/doi/
abs/10.1002/aur.2492. “Brief Report: Classifying
Rates of Students With Autism and Intellectual
Disability in North Carolina: Roles of Race and
Economic Disadvantage” is posted at https://
link.springer.com/article/10.1007/s10803-020-
04527-y.
PSYCHNEWS.ORG 25
CLINICAL & RESEARCH
Gender-Affirming Hormone Therapy
Linked to Better MH in Trans Youth
Depression and suicidality occur less frequently in transgender youth
who receive gender-affirming hormone therapy. BY TERRI D’ARRIGO
A
dolescents and young adults who
are transgender or gender non-
binary face several hurdles in
finding, accessing, and receiv-
ing gender-affirming hormone therapy.
Physicians and other health care pro-
fessionals who are trained in providing
gender-affirming care are in short
supply, patients may encounter stigma
from health professionals who are not
well versed in the medical and mental
health needs of transgender and non-
binary people, and financing and trans-
portation present logistical challenges
to accessing care. Furthermore, these
patients may live in a state that has
proposed legislation to restrict or out-
law gender-affirming hormone therapy.
Yet evidence is mounting that
receiving gender-affirming hormone
therapy in youth is associated with bet-
ter mental health outcomes in patients
who wish to receive it. A study pub-
lished in the April issue of the Journal
of Adolescent Health found a link
between gender-affirming hormone
therapy and lower rates of depression
and suicidality among transgender and
nonbinary youth who received it when
they wanted it, compared with those
who wanted it but did not receive it.
Amy E. Green, Ph.D., vice president
of research at The Trevor Project in
West Hollywood, and colleagues ana-
lyzed data from 11,914 transgender or
nonbinary youth aged 13 to 24 years
who participated in a 2020 survey of
34,759 lesbian, gay, bisexual, transgen-
der, queer, and questioning people. Half
of the transgender and nonbinary
youth reported that they were not using
gender-affirming hormone therapy but
would like to receive it, 36% reported
that they were not interested in receiv-
ing it, and 14% said they were receiving
Psychiatrists who are not experienced in providing gender-affirming care need
to know how to refer youth and their parents or caregivers for appropriate care,
says William Byne, M.D., Ph.D.
26 PSYCHIATRIC NEWS | JUNE 2022
analysis of participants under 18
years old, those who received gen-
der-affirming hormone therapy were
also 39% less likely to report recent
depression and 38% less likely to have
a past-year suicide attempt than their
peers who wanted the therapy but did
not receive it.
“These data are part of a larger body
of research pointing to a significant
relationship between access to gen-
der-affirming care and better mental
health outcomes among transgender
and nonbinary youth,” Green said.
“Health care professionals, including
mental health professionals, should
seek out continuing education oppor-
The Trevor Project
tunities to increase their cultural com-
petence in working with transgender
and nonbinary populations.”
Evidence of the mental health ben- Jack L. Turban, M.D., a psychiatrist
efits of gender-affirming hormones and chief fellow in child and adolescent
highlights the need to oppose legis- psychiatry at Stanford University
lation that restricts gender-affirming
School of Medicine, agrees. He is the
care, says Amy E. Green, Ph.D.
it. Participants who lived in the South,
where several states have proposed
banning gender-affirming hormone
therapy, had the lowest rates of access
to it. Participants of color reported
lower rates of access to the therapy
compared with White participants.
“The large gap in access to desired
care, particularly among transgender
and nonbinary youth of color, points
to the need for expanded access to ser-
vices that understand and support
Stanford Children’s Health
transgender and nonbinary youth,”
Green told Psychiatric News.
Participants who received gen-
der-affirming hormone therapy were
27% less likely to have symptoms of
depression as measured by the Patient Training in gender-affirming care in
Health Questionnaire-2 and 26% less medical schools, residencies, and
likely to report seriously considering fellowships is crucial to addressing
the shortage of physicians who
suicide than those who desired the
can provide such care, says Jack L.
therapy but did not receive it. In an Turban, M.D.
lead author of a study published in Jan-
uary in PLOS One that found that trans-
gender people who received gender-af-
firming hormone therapy during early
or late adolescence were less likely to
have past-month suicidal ideation and
past-month severe psychological dis-
tress in adulthood compared with those
who desired the therapy in adolescence
Stanford Children’s Health
but did not receive it.
“Unfortunately, there are too few
physicians trained in providing gen-
der-affirming care to transgender and
gender diverse youth. This means that
clinics often have long waitlists, some-
times over a year long. Many families
travel over 100 miles to receive care,”
Turban said. “It is vital that we imple-
ment more training initiatives in med-
ical schools, residencies, and fellow-
ships to build a workforce capable of
providing competent and compassion-
ate care.”
In their study, Turban and his col-
leagues analyzed data from 21,598
transgender adults in the 2015 U.S.
Transgender Survey who reported ever
desiring gender-affirming hormone
therapy. They found that 41% of partic-
ipants never received it, 0.6% received
it in early adolescence when they were
aged 14 to 15 years, 1.7% received it in
late adolescence when they were aged
16 to 17 years, and 56.8% received it in
adulthood (aged 18 years and older).
Compared with participants who
desired gender-affirming hormone
therapy but never received it, those who
received it in early adolescence, late
adolescence, or adulthood had a 135%,
62%, and 21% decrease in odds of sui-
cidal ideation, respectively. Further-
more, participants who received the
therapy between the ages of 14 and 17
years had lower odds of past-month
severe psychological distress, past-
month binge drinking, and lifetime
illicit substance use compared with
those who received it in adulthood.
William Byne, M.D., Ph.D., a profes-
sor of clinical psychiatry in the Division
of Gender, Sexuality, and Health at
Columbia University College of Physi-
cians and Surgeons in New York, said
that these two studies add to the liter-
ature supporting gender-affirming care
in transgender youth.
“These survey analyses may be par-
ticularly helpful for mental health
professionals with little experience
working with gender diverse patients
in understanding the range of experi-
ences across the population,” said
Byne, who was not involved in either
study. “Medical and mental health pro-
fessionals, however, treat individual
patients, not populations, and there-
fore must work within a model of
patient-centered care that entails care-
fully assessing and appropriately
addressing the particular needs of each
individual patient.”
Byne noted the challenges of aligning
care should physicians worry that their
patients may later regret the treatment.
“[These physicians] may insist on a
prolonged or interminable period of
assessment, often with a mental
health professional, that does not
address the youth’s gender-affirming
needs and associated dysphoria,” Byne
explained. “As a result, the youth may
become increasingly frustrated, dys-
phoric, and emotionally dysregulated,
all of which may be interpreted as
psychological instability that must be
adequately controlled before affirming
their experienced gender or initiating
hormonal treatment.”
see Hormone Therapy on page 47
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 CLINICAL & RESEARCH
iStock/AntonioGuillem
‘Outbreak’ of Sudden Tics Among Teen Girls
Has Surprising Global Similarity
Researchers around the globe are reporting that the
pandemic has triggered an increase in the number
of teen girls with tic-like behaviors that are severely
disabling and eerily similar. BY LINDA M. RICHMOND
P
hysicians are reporting a global
increase in the number of young
people with functional tic-like
behaviors, with symptoms that
are severe, frequent, and highly dis-
abling. The numbers have increased
markedly during the past two years of
the COVID-19 pandemic.
The tic-like behaviors come on rap-
idly and have been strikingly similar,
and individuals have only a limited
ability to suppress them, according to
an article by Tamara Pringsheim, M.D.,
and colleagues. They published their
findings from eight tourette syndrome
clinics in five countries in the Decem-
ber 2021 Movement Disorders. Before
the pandemic, referrals for functional
tic-like behaviors as a primary prob-
lem accounted for only about 1% to
2% of caseloads, but now account for
up to 35%.
What’s driving this increase?
Researchers found that all patients
developed their symptoms after watch-
ing influencers on social media, pri-
marily TikTok and YouTube, with tics
or Tourette syndrome. The pages are
wildly popular: On TikTok alone,
#tourettes had racked up 5.2 billion
views by press time. These patients
share other similarities: They were
more than four times as likely to have
an anxiety disorder and five times as
34 PSYCHIATRIC NEWS | JUNE 2022
likely to have a depressive disorder as
those with primary tic disorders.
“The magnitude of functional dis-
ability and level of parental distress
caused by the tic-like behaviors are
extreme,” the authors wrote. They
included large amplitude arm move-
ments, hitting and punching self or
family members, and blurting out
obscenities or bizarre words or phrases.
One teenager on YouTube, whose con-
dition appeared abruptly 16 months
ago, likened her symptoms to what
happens “if you shake a can of [soda]
and open the tab.”
“Functional tic-like behaviors have
always been around, like other func-
tional movement disorders, but until
recently they were not common in clin-
ical practice,” Alexander Münchau,
M.D., professor and director of the
Institute of Systems Motor Science in
Lübeck, Germany, told Psychiatric
News. He is a co-author of an article on
the phenomena also published in the
December 2021 Movement Disorders.
“We know that this subconscious, auto-
matic picking up of movements from
others is not uncommon and has been
referred to as echo-phenomena.”
Münchau pointed to similar “out-
breaks” of functional movement dis-
orders within communities, such as
“jumping Frenchmen of Maine” syn-
drome, characterized by an extreme
startle reaction and echolalia. It caught
on among lumberjacks in a logging
camp in the 19th century. “This usually
happens when people meet others face
to face. What is new is that such
echo-phenomena can also occur
through social media, without personal
contact,” he added.
Tammy Hedderly, M.D., an acute
pediatric neurologist who specializes
in movement disorders at the Evelina
London Children’s Hospital, told Psy-
chiatric News that the brains of people
affected are often highly suggestible.
“Watching tics on social media may
therefore be a perpetuating factor that
makes symptoms worse.” Factors such
as social isolation, pandemic stressors,
and loss of routine in relation to the
pandemic is also playing a role. “I was
surprised at how many children and
young adolescents were also engaging
in self harm and the percentage that
reported suicidality, which demon-
strates the level of distress the chil-
dren and families are experiencing,”
she added.
Screen Time Affecting Mental Health
Adolescents’ screen time has sky-
rocketed during the pandemic, and
now amounts to a whopping 7.7 hours
a day, according to research by Jason
Nagata, M.D., M.Sc., and colleagues,
published by JAMA Pediatrics on
November 1, 2021. This includes 2.4
hours a day streaming videos, 1 hour a
day on social media, and nearly an hour
of internet browsing. A slew of studies
implicates smartphone and social
media use in the increase in mental
distress, body image issues, self-inju-
rious behavior, and suicidality among
young people.
“We make body image issues worse
for 1 in 3 teen girls” was the summation
of internal company research leaked
by a former employee at Meta Platforms
Inc., formerly called Facebook, about
its own Instagram app. A nationwide
coalition of state attorneys general is
investigating Meta Platforms Inc. and
the techniques it uses to boost young
users’ engagement with Instagram and
the resulting harms.
A study by Sarah Coyne, Ph.D., and
colleagues published February 2, 2021,
in the Journal of Youth and Adolescence
found that particularly for girls, a high
level of social media, television, or
video game use that increased over
time was most predictive of suicide risk
in young adulthood. That study fol-
lowed 500 adolescents who ranged in
age from 12 to 15 at baseline over 10
years to examine the link between var-
ious types of screen time to suicide risk
in emerging adulthood.
Paula Durlofsky, Ph.D., a psychol-
ogist in private practice in Bryn Mawr,
Pa., told Psychiatric News the problems
associated with teens’ screen time
“really underscore the power that
social media has to shape young
minds, minds that are still developing
and so vulnerable and impres-
sionable.” She advises clinicians to
routinely ask patients about their
social media and technology use
during initial consultations and how
they think it’s affecting them. “Keep
in mind that social media use may be
a factor in their condition.”
Durlofsky, who is the author of
Logged In and Stressed Out: How Social
Media Is Affecting Your Mental Health
and What You Can Do About It, said she
wrote her book to address concerns
expressed by many of her patients,
including that their social media use
was causing their depression and anx-
iety and that they were using it to
self-medicate or cope with dysfunc-
tional relationships. “Parents need to
be aware of what their young kids are
watching and informed about the
research findings on social media and
its potential dangers. We need to work
to control and manage our screen time
and that of young people.”
What’s her biggest concern? “Teens
are not developing interests or finding
ways to use the other parts of their
brains or minds beyond social media,”
Durlofsky said. “Spending hours in
front of a screen is going to negatively
affect our mental health because it
narrows our experiences and our world.
It definitely steals our precious time
away from activities and pursuits that
see Tics on page 47
 SPECIAL REPORT

NEWS
Special Report Illustrations by Simone Hasselmo

Prescriber, Prescribe Thyself

Psychiatrists need to create a partnership that doesn’t lean on Andrés Martin, M.D., M.P.H., is the
psychiatric jargon or an encyclopedic list of side effects, but instead Riva Ariella Ritvo Professor at the
Yale Child Study Center. Shashank
on measured candor, vulnerability, and—most importantly—time.
V. Joshi, M.D., is a professor of
BY ANDRÉS MARTIN, M.D., M.P.H., AND SHASHANK V. JOSHI, M.D.
psychiatry, pediatrics, and education
and director of training in child and
adolescent psychiatry at Stanford
University. They are the editors of
Thinking About Prescribing: The
Psychology of Psychopharmacology
With Diverse Youth and Families
from APA Publishing. APA members
may purchase the book at a
discount at https://www.appi.org/
Products/Psychopharmacology/
Thinking-About-Prescribing.

“I felt disappointed and was so angry at the psychiatrist. We waited three months for this appointment this: Surgeons don’t for a second forget that scalpels
and got a half-hour where we shared basically nothing about our son’s life, except his ‘symptoms.’ He are instruments, base metals at that. If only we psy-
has no idea who we are or who our son is. We got a prescription, a huge bill, and an appointment for a chiatrists had a similar mindset when prescribing
‘med-check’ two weeks later.”—Jennifer, parent of a 15-year-old with depression our own pills. Alas, we forget all too often that our

I
t may seem unbecoming to begin this report on
children’s mental health on a surgical note. But
there are at least two good reasons that we are
doing so. First, we ask you to consider the answer
to that old chestnut “Why did some of us become
psychiatrists?” Perhaps it was because surgery wasn’t
invasive enough. Surgery simply did not go sufficiently
deep for some of our sensibilities. Second, and to
learn from our colleagues in surgery and not just
use them as strawmen for a tired quip, let’s give them
potions are partly instruments, base salts at times.
Our remedies are only as good as the way in
which we dispense them—prescribing psychotro-
pic medications to developing children is as much
the cold facts of molecules as it is the warm way in
continued on next page

PSYCHNEWS.ORG 35
SPECIAL REPORT
continued from previous page
which we envelop them for delivery. It is a reminder
that no matter how accurate said delivery may be,
it all goes to naught—molecules be damned—if
there is no one on the receiving end; a psychotro-
pic not taken is perfectly inert and useless. But our
goal should not end at mere “compliance” (an unfor-
tunate term that reeks of power dynamics and
hierarchical paternalism); ingesting a pill and
letting its molecules fulfill their job description
are but the start of a therapeutic process.
Simple conceptualizations of depression as a
low serotonin condition or of stimulants as dopa-
mine enhancers are as incomplete today as they
are misguided. A chemical’s docking, Apollo-like,
onto a receptor’s site to right a neurotransmitter’s
tenuous balance is as romantic a throwback as a
1960s moon shot. Advances in molecular psychia-
try over recent decades have made it clear that
psychotropics are more than simple “keys” to neu-
rotransmitter “locks.” The contact of molecule and
receptor may be a start, but it is the secondary,
tertiary, and subsequent messengers where the
action truly lies. It is these elusive messengers that
get in deep, that get closer to the actual machinery
of the cell, that get the job done.
“We should not be mere prescribers, the
holders of key rings on our proverbial tool
belts. We are—or should be, or aspire to be,
or reclaim being—pharmacotherapists.”
In a similar way, we should not be mere pre-
scribers, the holders of key rings on our proverbial
tool belts. We are—or should be, or aspire to be,
or reclaim being—pharmacotherapists. Our own
job description gets started well before molecules
reach their targets; we are cognizant that the
moment of chemical bonding is but another start;
we remain humble in our commitment, recog-
nizing that to deliver on the full potential of our
Key Ingredients of the BPV (30-Minute Brief Pharmacotherapy Visit)
Topics for Discussion
1. Tend to rapport (It’s nice seeing you again. How
have things been? Since we met last time, I’ve
been thinking about what we talked about. What
do you think of _____).
2. Get updates on environmental influences
(consider a modified HEADS assessment: home,
education, eating, activities, distractions, drugs,
sleep, sex, suicidal thoughts).
3. Provide counseling re: environment.
4. Elicit/discuss obstacles to health, treatment/
adherence.
5. Discuss maintaining tx or changing course.
6. Review medicine efficacy/side effects.
7. Answer any additional questions.
Adapted from a table by Max S. Rosen, M.D., and Anne L. Glowinski, M.D., M.P.E., in Thinking About Prescribing (APA Publishing, 2022).
36 PSYCHIATRIC NEWS | JUNE 2022
treatment, we, too, must become and remain the
secondary, tertiary, and subsequent messenger
systems. The prescription, the prescriber, and the
prescribed are inherently intertwined; we ignore
such bondings (chemical or otherwise) at our own
therapeutic detriment.
Entering the Time-Frame Continuum
By focusing too narrowly on the dosing of mil-
ligrams or the number and class of psychotropic
medications, we can easily come to forget that time
is that other key aspect of our nosology. Time is
perhaps our most valuable resource, and we would
all do well to remember that “in psychiatry’s mea-
sure of time, more is more,” according to Arthur
Caye, M.D., Ph.D., a contributor to our book. For
example, in contemplating a patient who does not
get better in the way or at the speed that we would
hope for, we are comfortable—arguably too com-
fortable—increasing the milligrams or the number
of psychotropics prescribed, and often both at the
same time. We can capitulate in a similar fashion
Suggested Questions and Comments
Have you had any free time since we met last; if
so, what have you enjoyed? What are your favorite
social media platforms/TV shows? Which YouTubers
are you following? Who’s that on your t-shirt?
How’ve things been at home? How’re people getting
along? What’s your favorite/least liked part about
school these days?
Let’s discuss things you’d like to work on changing.
What are your thoughts about taking medicine to
treat _____?
How are things going in psychotherapy/family tx?
How do you think _____ is working for you?
Is there anything else we should talk about today?
when facing some of the many outside influences
that can intrude into the confines of our therapeu-
tic relationship: unrealistic expectations for quick
fixes or perverse incentives for “biological” treat-
ments, as well as the pervasive influence of the
pharmaceutical industry and the tentacular reach
of its oversized advertising budget.
We urge you to resist being pushed to, yielding
to, or (banish the thought) opting for the circum-
scribed role of “medication prescriber.” Our first
and best defense against such a misguided inter-
pretation of our role is to remember the central-
ity of time within and across clinical encounters,
to reclaim the dosing of ourselves, of the number
and frequency of our visits, of our presence and
therapeutic engagement within them. If these
words seem too idealistic and removed from the
daily realities of a child psychiatrist, we want to
move clinicians away from the term “med check”
into the reality of the “brief pharmacotherapy
visit (BPV)” to bridge the divide between what may
be aspirational for some and what is possible for
many. Milligrams dispensed are easy; time well spent
is hard.
In pediatric psychopharmacology, establishing
an appropriate frame is the yang to the yin of its
time management. At the start of our book, Kyle
Pruett, M.D., provides the pithy prescription for
the task: “How you are with your patient is as
important as what you do with your patient.” Three
very different yet complementary chapters of our
book help establish a robust frame through which
to be with our patients. Our authors have adapted
pharmacotherapy with children and adolescents
from the “Y-model” first posited by Erik Plakun,
M.D., and colleagues in the January 2009 Journal
of Psychiatric Practice. The therapeutic alliance,
as the stem of the Y, provides a common point of
entry for any clinical approach. In its original
description, that stem bifurcates into psychody-
namic and behavioral arms. As appealing as such
a neat tripartite model may sound, it only begins
to tell the story when working with children and
their families. The “stem” may instead be construed
as more akin to a tree trunk, and the two arms as
just two of the many branches in a complex canopy.
Indeed, a multitude of synergistic approaches is
what we are routinely called upon to muster as
pharmacotherapists. Other chapters include those
that apply psychodynamic principles to the context
of pediatric psychopharmacology and that utilize
cognitive-behavioral and motivational interview-
ing approaches.
There is an additional and more recent conno-
tation to the “frame” under discussion—and that
is the virtual frame through which more of our
visits are taking place these days. What started as
telepsychiatry in the 1990s, designed to reach
remote and particularly underserved locations,

has rapidly evolved and made major inroads into
routine pediatric psychopharmacology. The onset
of the COVID-19 pandemic did in just a few months
for the uptake of “virtual frames” what two decades
of telepsychiatry educational efforts could not. Jeff
Bostic, M.D., Ed.D., and David Kaye, M.D., have been
pioneers and early settlers of these erstwhile bar-
ren virtual lands. They are also effective guides,
enriching our vocabulary with terms such as
tele-alliance, protection of the virtual space, tel-
erapport, Freudian blips, screen empathy, and
webside manner.
What once was “treatment not as usual” has by
now become second nature. We should not envi-
sion a future devoid of physical visits, but rather
embrace this new and complementary way of
hitting the clinical target as an additional arrow
in our therapeutic quiver. As we embrace e-pre-
scribing over paper scripts (remember those?) and
swoon over the powers of the pixel, we should not
lose sight of the fact that many areas of the world
do not have e-prescription capabilities and that
families within even wealthy nations like ours do
not have access to the internet or adequate band-
width and may face other inequities and barriers
to care, including those entrenched through struc-
tural racism.
“Obtain informed consent, but stop
from making patients and their
families feel part of an informed
coercion process.”
At Least Three (Though It Can Still Take
Two) to Tango
Pharmacotherapy with adults is largely a dyadic
process between a patient and a prescribing clini-
cian, an approach that at times works in the pedi-
atric realm, particularly with adolescents and
transition-age youth. However, the vast majority
of time, prescribing psychotropic medications to
children and adolescents involves other parties—
at times several of them—each with competing
priorities or agendas. For starters, given the endur-
ing shortage of child and adolescent psychiatrists,
prescriptions often come from partners in a mul-
tidisciplinary team, including pediatricians and
advanced practice registered nurses.
In another common approach, treatment may
be complemented and synergized among prescrib-
ing and nonprescribing clinicians (“split treatment,”
the commonly used term for this arrangement, is
another unfortunate misnomer because it empha-
sizes the potential divide rather than the intended
partnership). The potential for cooperation and for
different vantage points on children, including their
interactions with other children, is multiplied in
schools or in congregate care settings such as inpa-
tient units and residential facilities.
In navigating what can be such tricky shoals,
we’d all do well to heed the aphoristic advice by
Srinivasa Gokarakonda, M.D., M.P.H., and Peter
Jensen, M.D., that “the messenger may be ‘wrong’
even if the message is ‘right.’ ” To be the best pos-
sible messengers and to maximize the odds of our
thoughtfully selected treatments to be consumed,
these authors emphasized the role of psychoedu-
cation and cooperation as part of a partnership
with common goals. With regard to working with
children and adolescents, this duality most com-
monly involves parents or legal guardians. Estab-
lishing a caring and trusting relationship with
them can be as critical to the success and longevity
of our treatment as making the youngster feel at
ease with us—and with our psychotropic stand-ins,
which we ask them to faithfully ingest.
The richness of our work is in no small measure
a reflection of the wide array of ethnoculturally
diverse individuals and families we get to work with
daily. And even as we respect their uniquely defining
characteristics, we have found it helpful to approach
clinical encounters—especially those involving the
initial prescription of a psychotropic—through a
framework that incorporates the perceived utility
of the treatment on the one hand and the stance
regarding treatment on the other.
Toward that end, the words we choose in pedi-
atric pharmacotherapy are every bit as critical as
the milligrams we dispense. As psychiatrists, we
cherish words, though at times we overuse them.
Prime examples of such verbal prolixity include
the explanation of arcane and outdated mecha-
nisms of action, an emphasis on encyclopedic
side-effect lists, and a penchant for the legalese of
informed consent. To make matters worse, these
words have a way of morphing into reams of elec-
tronic boilerplate.
Surely there is a way to reclaim the healing power
of pithier wordsmithing. And there is. First, go for
the object. And the object in this instance is not the
medication, but rather the child in front of you.
Second, when addressing how treatments work, real-
ize that “chemical imbalance” and the neurotrans-
mitter hi-lo index may be more helpful in binding
our own anxieties than those of our patients. Accept
SPECIAL REPORT
the fact that we don’t really know how our medicines
work and step off the podium. When talking to kids,
call the things “medicines,” not “medications” or (the
horror!) “psychotropics.” A “pill” can be “candy,” and
children do well to take neither one from a stranger.
By contrast, a “medicine” is a known entity, and one
that generally helps kids feel better.
When addressing side effects, beware of unleash-
ing terms such as “sudden death” and “suicide risk”;
these horses are hard to put back in their barns—
not that you should elide them completely; follow
instead your own advice to “start low and go slow.”
Start, in fact, at the lowest, a truism that often goes
unsaid: The most common side effect is no side
effect. Build up from there: There are relatively
common side effects that tend to be minor and well
tolerated, and there are more infrequent and seri-
ous ones. Address the ones that are more likely to
be pertinent, and remember that some things can’t
be unheard. After a few minutes, only the most
salient words are likely to stick. You don’t have to
build Rome in a day—or, by frightening your audi-
ence away, demolish it in a day either. Obtain
informed consent, but stop from making patients
and their families feel part of an informed coercion
process. And finally, did we mention going for the
object? It is right there, staring you in the face.
Placebo, Nocebo, No Dice
The placebo effect gets a bad rap, what with all
of its muddying of the clinical trials we base so
much of our evidence base on. But the placebo effect
deserves a closer look as more than methodological
noise. The nonpharmacological powers vested in a
medication, and the positive meaning and healing
expectations attributed to it, can be powerful allies
in leading to positive change. By contrast, placebo’s
younger cousin, the nocebo effect, can be a force
to reckon with because it can taint with its negative
messaging, dashed hopes, and harmful attributions.
When expectations are not only the patient’s but
those of parents or guardians, of schoolteachers or
coaches, as well as of social media–frenzied influ-
encers, we need to pause to consider the interlock-
ing effects of what David Grelotti, M.D., and Profes-
sor Ted Kaptchuk initially conceptualized for adults,
and Efrat Czerniak, M.D., and colleagues termed
“placebo by proxy” and “nocebo by proxy” effects
for children and adolescents.
We may think of our consulting rooms as a con-
fidential sanctum of privacy, but conversations
about treatment rarely end at our door; they are
more likely to only get started there, and we risk
enlarging our blind spots if we sidestep this chorus
of informative or inflammatory influences.
A self-defeating adolescent experiencing depres-
sion may resist a medication she considers herself
unworthy of taking or that may threaten to alter
distorted views deemed by then integral to her per-
continued on next page
PSYCHNEWS.ORG 37
SPECIAL REPORT
continued from previous page
sonality. Gentle yet goal-directed motivational
interviewing may permit us to close the gap and
“get to yes.” A parent or guardian may resist allow-
ing a child to take a psychotropic out of an under-
standable abundance of caution, but there are times
when untoward hesitation or repeated instances of
abandoned treatment may require the involvement
of child protective services. No one can force a child
to take a medication, and the instance of involuntary
administration (as in the case of an intramuscular
injection) should remain a (very) last resort measure
within an emergency department or inpatient set-
ting. Long-acting depot antipsychotics don’t have a
safety record in minors to warrant their regular use.
In short, protective services, the courts, and inject-
able medications do have a role in contemporary
psychiatry, but they are rarely invoked or useful
beyond an acute emergency situation in the case of
pediatric pharmacotherapy.
For many of these all-too-common scenarios,
there are concrete suggestions we have found help-
ful in our own practice. Our oversharing of details—
in the spirit of being transparent and comprehen-
sive—can corner us into a resigned stance. We do
not advocate for the outright omission of side-effect
“Side effects ... may be the manifest excuse to
turn down medication treatment, when closer
listening may reveal that the stigma of mental
illness is the more relevant latent message.”
discussions, but we do make a case for being less
meticulous and defensive. Take, for example, suicide
risk in the context of starting an antidepressant.
Time and again we hear necessary and well-mean-
ing conversations about the relative risk of emergent
suicidal ideation among children taking antidepres-
sants compared with those who are unexposed. So
far, so good. But what we all too rarely hear is the
more relevant comparison—higher rates of death
by suicide among the untreated. Our cathartic con-
fessionals scare away more often than they mean-
ingfully engage patients and their families: We
should resist snatching defeat (in the form of losing
a patient to follow up or, tragically, to suicide) out
of the jaws of victory (in the form of starting a poten-
tially lifesaving medication embedded within a
therapeutic relationship).
Our task is in no small measure one of shared
meaning-making. Magdalena Romanowicz, M.D.,
and her colleagues were direct and aphoristic in
their advice when they reminded us how the parent
and patient most often seek consultation to receive
help with their problems and not to receive a DSM
diagnosis. Our task is to assist them in creating
meaning and making sense of symptoms. In an
important article in the August 2019 issue of Psy-
chodynamic Psychiatry, David Mintz, M.D., expanded
this notion, alerting us to attend to the meaning of
medication, particularly given that “[w]hile all peo-
ple who take medications may attach pathogenic
meanings to them, children and adolescents may
be particularly vulnerable, because such effects can
38 PSYCHIATRIC NEWS | JUNE 2022
be amplified when incorporated into unfolding
developmental processes.” Moreover, “when harm
occurs at the level of meaning, the problem will be
most usefully addressed at the level of meaning. Far
too often, however, medicated children receive little or
no psychological treatment.”
A Bitter Pill to Swallow: Stigma
Side effects (for example) may be the manifest
excuse to turn down medication treatment, when
closer listening may reveal that the stigma of men-
tal illness is the more relevant latent message. To
take (or to give) a medication may be seen as tacit
endorsement of an unwelcome diagnosis, of “oth-
erness,” of frailty or fallibility we would rather
ignore. As if the stigma of mental illness was not
bad enough, the stigma on psychotropics can
increase messages of exclusion and isolation, of
being “broken” and in need of “repair.”
There is much that we can do in our daily fight
against the stigma of mental illnesses and the
medications on which we often rely to treat them. those moments, we have been pediatric pharmaco-
Psychoeducation is certainly prominent on the therapists, physicians, and humans at our very best.
to-do list. But there is something else worth con- We are not alone in this endeavor, and we
sidering. It will sound radical, provocative, or embrace the sage and insightful words of our cou-
boundary breaking to some, and we respect those rageous and pathbreaking colleague, Stephen Hin-
views. But for some others, being a bit radical, a shaw, Ph.D., in his 2017 book, Another Kind of Mad-
tad provocative, a pinch boundary breaking, and ness: A Journey Through the Stigma and Hope of
a whole lot legitimate and human can be Mental Illness. He wrote that “fostering humaniza-
game-changing. tion may be the single most important weapon in
Specifically, we have used as a tool for good the the fight against stigma for ... [m]ental disorders
careful, selective sharing of our own diagnoses, don’t afflict them—a deviant group of flawed, irra-
treatments, medicines, family struggles, and recov- tional individuals—but us: our parents, sons and
eries. Whenever we have done this with the patient’s daughters, colleagues and associates, even our-
well-being in mind, when the sharing has been selves.” Thus, though we have nothing to disclose,
genuine and caring, when we have met with patients we do have much to share. In short, we invite you,
and their families in our full shared vulnerability, at dear fellow prescriber, to prescribe thyself. 
  “The Y Model: An Integrated, Evidence-Based Approach to Teaching Psychotherapy Competencies” is posted at https://journals.lww.
com/practicalpsychiatry/Abstract/2009/01000/The_Y_Model__An_Integrated,_Evidence_Based.2.aspx. “Recovery from Childhood
Psychiatric Treatment: Addressing the Meaning of Medications” is posted at https://guilfordjournals.com/doi/10.1521/pdps.2019.47.3.235.
Author Disclosures
Andrés Martin, M.D., M.P.H., and Shashank V. Joshi, M.D., receive revenue from APA Publishing and have no
other financial conflicts to disclose.

Family Interventions Benefit People With Schizophrenia
An analysis of 90 randomized, controlled trials suggests that nearly
all types of family interventions for schizophrenia significantly
reduced relapse at 12 months. BY NICK ZAGORSKI
F
amily interventions are effective
tools to prevent relapse in
patients with schizophrenia,
according to a meta-analysis in
The Lancet Psychiatry. What’s more, the
analysis found that the simplest
approach—basic family psychoeduca-
tion (classes where families are taught
about schizophrenia and treatment
options)—was associated with the low-
est relapse rates.
This “network meta-analysis con-
firms the relevance of family inter-
ventions in preventing relapse in gen-
eral, and the efficacy of almost all
individual family intervention mod-
els,” wrote lead study author Alessan-
dro Rodolico, M.D., a researcher in the
Department of Clinical and Experi-
mental Medicine at the University of
Catania in Italy and colleagues. “These
findings should be taken into consid-
eration for future clinical guidelines.
In particular, in the context of limited
resources, family psychoeducation
alone should be offered as a simple but
highly effective tool.”
Rodolico and colleagues compiled
data from randomized clinical trials
that compared outcomes in patients
with schizophrenia who had received
family interventions along with regu-
lar clinical care with those receiving
regular care alone. Regular care typi-
cally included psychiatric consulta-
tions; antipsychotic medication; and
access to community-based services,
including employment programs. Stud-
ies involving patients experiencing
acute illness or concurrent medical or
psychiatric disorders were excluded.
The final samples included 90 clin-
ical trials with more than 10,000
patients (average duration of illness
was 6.5 years) and 11 different
approaches for family intervention.
Most of the approaches were rooted in
family psychoeducation but differed
based on whether the patient was
included in the family intervention
and what additional elements (for
example, crisis planning or skills train-
ing) were taught.
The analysis found that 9 of the 11
interventions were superior to regular
care at reducing patient relapse at 12
months. Only brief family psychoedu-
cation (just one or two sessions) and
psychoeducation focused on crisis
planning failed to reduce relapse in
comparison with regular care. Of all
the models, basic family psychoeduca-
tion that included the patient per-
formed the best; only about 10% of
patients who participated in basic fam-
ily psychoeducation relapsed after 12
CLINICAL & RESEARCH
chiatric Rehabilitation at Boston Uni- Columbia’s Division of Behavioral
versity who has extensive clinical and Health Services and Policy Research,
research experience with family inter- told Psychiatric News that the other
ventions. “We’ve known approaches tested in this analysis
for decades that educat- should not be overlooked. “The big take-
ing a patient’s family away isn’t so much that one approach
about the nature of is better than the other, but that several
schizophrenia has a pos- different strategies work.”
itive impact. Over time, Yet despite the many available
however, the education choices, “these proven therapies are
component of a family barely used,” added Dixon, who is also
inter vention has editor of the APA journal Psychiatric
become somewhat Services.
shortchanged,” he said. “There are many sound theories
This study suggests on why uptake of family interven-
“there is something to tions for schizophrenia is low, but the
be said about keeping it most practical issue is that it’s
simple,” Mueser, who nobody’s job to make sure they’re
was not involved in this provided,” Mueser said.
meta-analysis, added. Increasing the use of family inter-
In an editorial accom- ventions for patients with schizophre-
panying the meta-anal- nia may require dedicated staff at men-
ysis, Cherrie Ann Gal- tal health centers to help connect
letly, M.B.B.S., Ph.D., a families with such care, Mueser sug-
professor of psychiatry gested. A family services coordinator,
Kim Mueser, Ph.D., thinks mental health clinics at the University of Ade- he suggested, could offer family psy-
should hire staff to provide proven interventions laide in Australia, con- choeducation, serve as a liaison with
involving patients with schizophrenia and their c u r r e d . “ The met a- organizations that provide support to
families that reduce the risk of relapse.
analysis by Rodolico … families such as the National Alliance
and colleagues has pro- on Mental Illness, and help connect a
months compared with 37% of patients vided a pathway to simplify and stan- patient’s clinician and family. “We can-
receiving regular care. The second dardize family interventions in schizo- not overlook that one reason why these
most effective intervention was sys- phrenia,” she wrote. “The next step is research studies showed such a bene-
temic-oriented family intervention, to develop cost-effective educational ficial effect was because the clinicians
which focuses on strengthening the programs, adapted for local cultures and family worked closely together,”
interpersonal relationships within a and circumstances, so that many more he said. “Maintaining a close relation-
family. About 16% of patients whose people with schizophrenia and their ship with the family improves treat-
families had participated in system- families have access to an evi- ment monitoring, which can further
ic-oriented family intervention had dence-based treatment that will reduce reduce the risk of relapse.”
relapsed at 12 months. relapse rates.” Dixon added that greater use and
“This analysis provides important Lisa Dixon, M.D., M.P.H., a professor acceptance of family interventions is
and welcome news,” said Kim Mueser, of psychiatry at Columbia University best achieved when patients are given
Ph.D., a professor at the Center for Psy- Medical Center and the director of some control over the decision-mak-
ing process. “An invitation to a family
intervention should start by asking
Family Interventions for Schizophrenia Reduce Relapse Risk patients what they think their family
Intervention Type 12-Month Relapse Rate is doing to help them, and what their-
family is doing that is not helpful.
Family psychoeducation 9.7%
That conversation can help decide
Systemic family-oriented intervention 16.3% what approach might be suitable,” she
Family psychoeducation combined with behavioral or said. “The patient should also have
17.1%
skills training and mutual skills training support input as to which family [members]
Family psychoeducation combined with family can attend the interventions. If [the
17.9%
behavioral or skills training patient] can contribute to setting the
Family psychoeducation combined with crisis-oriented terms, the odds of engagement are
20% greater. It doesn’t have to be an all-
behavioral or skills training
Family psychoeducation combined with patient or-nothing proposition.”
21.5% The meta-analysis was funded by a
behavioral or skills training
grant from the German Ministry for
Relatives psychoeducation (no patient involvement) 21.8%
Education and Research. 
Family psychoeducation combined with behavioral or 22.4%
skills training and emotional climate focused intervention
  “Family Interventions for Relapse Preven-
Relatives psychoeducation and patient psychoeducation tion in Schizophrenia: A Systematic Review and
23.2%
(done separately) Network Meta-analysis” is posted at https://
Community-based care intervention 27% www.thelancet.com/journals/lanpsy/article/
Brief family psychoeducation (1-2 sessions) 32.8% PIIS2215-0366(21)00437-5/fulltext. The editorial
“Effective Family Interventions for People with
Usual clinical care 37% Schizophrenia” is posted at https://www.the
Source: Alessandro Rodolico, M.D., et al., Lancet Psychiatry, March 2022. lancet.com/journals/lanpsy/article/PIIS2215-
0366(21)00502-2/fulltext.
PSYCHNEWS.ORG 39
 CLINICAL & RESEARCH
Mood Symptoms in Pregnant Women
May Not Be Fully Resolved by SSRIs
iStock/RyanKing999
A study tracking pregnant women’s mood symptoms month
to month found that generally symptoms were well controlled,
but about one-third of women experienced subthreshold
levels of depression and/or anxiety, particularly in the final
weeks of pregnancy. BY NICK ZAGORSKI
M
any studies have explored
the risks of antidepressants
during pregnancy, but few
have tracked how well anti-
depressants manage a mother’s
mood symptoms over the course of
pregnancy.
CLIMATE CHANGE & MENTAL HEALTH
What Every Psychiatrist Should Know About the Climate Crisis
BY DAVID POLLACK, M.D., AND ELIZABETH HAASE, M.D.
T
he APA Committee on Climate
Change and Mental Health is
identifying the key components
of curricula on climate-related
issues. The following list describes the
broad scope of mental health concerns
related to climate change, organized by
the following:
• The neuropsychiatric conse-
quences of exposure to various
climate vectors, such as heat, air
pollution, and neurotoxicant
exposure.
• The array of anxiety and mood
symptoms/conditions that arise
from acute disasters and long-
term exposure due to repeated
climate harms.
• The indirect effects of the ever-in-
creasing sense of foreboding, fear,
anxiety, and hopelessness that derive
from growing climate awareness
within the general population, with
special emphasis on the impacts on
children and youth.
This list should be considered and
40 PSYCHIATRIC NEWS | JUNE 2022
“If we are going to ask our patients
to use a medication during pregnancy,
we have to be confident that the disease
is riskier than the medicine,” said Kath-
erine Wisner, M.D., the Norman and
Helen Asher Professor of Psychiatry
and Behavioral Sciences and a professor
David Pollack, M.D., is
professor emeritus for
public policy in the
Department of Psy-
chiatry and Division of
Management at Oregon
Health and Science
University. He is also a
member of the Climate
Psychiatry Alliance.
Elizabeth Haase, M.D.,
is medical director of
behavioral health at the
Carson Tahoe Regional
Medical Center and
chair of APA’s Commit-
tee on Climate Change and Mental Health.
included in any climate and mental
health–related curriculum program
for professional trainees at the grad-
uate medical education and continu-
ing medical education levels, for
example, psychiatry residents and
practicing psychiatrists. The content
may need to be simplified for under-
graduate medical curriculum inclu-
sion. A more detailed list of curricu-
lar content is posted at https://files.
const a nt cont ac t .com /ad f 62 2bd
of obstetrics and gynecology at North-
western University Feinberg School of
Medicine. Wisner recently co-wrote a
paper in Psychiatric Research & Clinical
Practice that describes how she and her
team prospectively monitored the tra-
jectory of depression and anxiety
symptoms in women taking antide-
pressants during pregnancy and the
postpartum period.
“Currently in depression care, we
often make our calculations on the
assumption that women’s symptoms
will be well controlled throughout
pregnancy,” she said. As Wisner’s study
uncovered, that is not the case for
many women.
The study involved 88 pregnant
women from one of three academic
medical centers (Northwestern Uni-
versity, University of Texas-Galveston,
and University of Pittsburgh) or a rural
health center (Marshfield Clinic Health
System in Wisconsin). All the partici-
pants were 18 weeks pregnant or less
with a singleton pregnancy; had at least
one prior episode of major depressive
disorder; and were taking sertraline,
6 01/1e 2 f 0 2 f 2 - a c 3 4 - 417 0 - 8 a 0 4 -
746ca2186a1b.pdf.
1. Heat
• The impact of high temperatures
on violence, suicide, and depression.
• The relationship between
neurotransmitters and heat
regulation and how psychotro-
pic medications increase heat
stroke risk.
• Safety measures during heat
waves.
• Policy measures that can be
enacted to promote resilience to
mounting temperatures.
2. Air pollution
• The psychiatric impacts of ozone
and particulate air pollution on
children’s developmental cognitive
health, on dementia, and on depres-
sion and suicide.
• The relationship between clean air
policies and improved population
health.
3. Habitat change and neurobiology
• Climate impacts on infectious
disease vectors, waterborne disease,
and the nutritional value/availability
of food.
fluoxetine, citalopram, or escitalopram
with the intent of maintaining treat-
ment throughout pregnancy.
Wisner noted that the women’s deci-
sion to continue treatment was made
along with their clinicians before being
approached for this study, and their
clinicians continued to monitor the
women’s medications during the study.
The women were assessed for depres-
sion and anxiety every four weeks until
delivery and again at six and 14 weeks
postpartum using such scales as the
Edinburgh Postnatal Depression Scale
(EPDS) and the Generalized Anxiety
Disorder Scale, 7-item (GAD-7). Women
who scored 15 or more on the EPDS
screen and 10 or more on the GAD-7
were considered to have probable
depression or anxiety.
The longitudinal assessments
revealed three trajectories of depres-
sive symptoms among the women: 18%
of women experienced consistently low
EPDS scores (below 5) during preg-
nancy, 50% experienced mild symp-
toms (EPDS scores around 8) early in
pregnancy that dropped slightly at the
end of the first trimester, and 32% had
subthreshold symptoms (EPDS scores
around 11) in early pregnancy that
dropped after delivery but then rose
again during the postpartum period.
see Pregnancy on page 42
• Connection of nutritional changes
to common mental disorders.
• How waterborne toxins result
from changes or diversions of
water supply.
4. Habitat change and psychological
effects
• Climate impacts on loss of culture
and livelihood due to geophysical
changes and forced migration.
• The psychic demands and emo-
tional impacts of habitat change.
• The role of mental health profes-
sionals in facilitating the emotional
process of adaptation and focusing
on the psychological processes that
support social cohesion.
5. Existential and general psychology
• How climate change affects
people emotionally.
• How to address existential
distress, resistance to change,
cognitive biases, denialism, and
the overwhelming complexity of
climate solutions.
6. Eco-anxiety
• Description of eco-anxiety and
psychiatric models for
continued on facing page

Psilocybin-Assisted Therapy Found
To Improve Depression, Offer Other Benefits
A small study involving 24 participants found that psilocybin
therapy was safe and effective up to one year following
administration. More research using larger sample sizes is
needed to further clarify efficacy and safety. BY RICHARD KAREL
A
study on the safety and efficacy
of psilocybin-assisted therapy in
a therapeutic setting in 24 par-
ticipants with major depressive
disorder found that the hallucinogen
provided rapid and substantial antide-
pressant effects lasting up to one year
with no serious adverse effects. The long-
term efficacy and safety of such treat-
ment, however, are not known.
The study, conducted by researchers
at the Johns Hopkins Center for Psy-
chedelic and Consciousness Research
(CPCR) in the Department of Psychiatry
and Behavioral Sciences in Baltimore,
was published in February in the Jour-
nal of Psychopharmacology and aug-
ments research previously published
in JAMA Psychiatry.
The 24 participants were randomized
to either an immediate or eight-week
delayed treatment protocol, involving
a combination of psilocybin sessions
continued from facing page
understanding it, emphasizing that
eco-anxiety is often nonpathologi-
cal and different from clinical
anxiety disorders.
7. Ecological grief
• The impacts on indigenous commu-
nities, women’s reproductive decisions,
farmers/ranchers, and others whose
lives depend upon the land.
• Our larger collective grief and
sense of human failure.
• The work of planetary mourning
and how our love of what we lose can
stimulate positive action.
8. Behavioral change for climate
change
• Change theory and the neurobiol-
ogy of habits.
• Habits of thought that deter
climate responsiveness at individual
and societal levels.
• Re-imagining, telling new stories,
being creative, being authentic, and
showing moral courage to facilitate
sustained change in the face of the
climate crisis.
9. Communicating about climate
change
• Effective strategies for educating/
and supportive psychotherapy. Each
participant received two doses of psilo-
cybin and were followed for up to a year.
Lead author Natalie Gukasyan, M.D.,
an assistant professor of psychiatry and
behavioral sciences at Hopkins and
medical director of the CPCR, and col-
leagues reported “large decreases from
baseline using the standardized Ham-
ilton Depression Rating Scale (GRID-
HAMD) scores at one, three, six, and
12-month follow-up.” The principal
investigator was Roland Griffiths, Ph.D.,
director of the CPCR.
At 12 months, 75% of the 24 partic-
ipants achieved “treatment response”—
defined as a reduction of 50% or greater
in GRID-HAMD score from baseline;
58% of the participants achieved remis-
sion—defined as a GRID-HAMD score
less than or equal to 7. Self-reported
measures, including the Quick Inven-
tory of Depressive Symptomatology
motivating health professionals.
• The best approaches for clinical
encounters, public presentations,
and policy discussions.
10. Group approaches to climate
distress
• Community groups for processing
climate distress.
• Methods for living sustainably
through conscious community.
11. Community approaches to climate
resilience
• What communities can and
should do to prepare for the health
and mental health impacts of
climate change.
• Engagement with environmental
justice and just transition initiatives.
• Transformational resilience–
derived public health interven-
tions at the community level to
promote psychosocial resilience
and social cohesion.
12. Climate disasters
• The psychological impacts of
acute and repeated weather and
climate disasters.
• Understanding how “we are all in
or between disasters” to support
sustained humanitarian and emo-
tional disaster responses.  bin-assisted therapy—including those
The types of features that the
researchers asked about in their
study on psilocybin-assisted thera-
py, such as personal meaning and
spiritual significance, did not predict
patients’ magnitude of depression,
says Natalie Gukasyan, M.D.
(QIDS) and the Beck Depression Inven-
tory II (BDI-II), were consistent with
the GRID-HAMD outcomes.
One intriguing finding was that “par-
ticipant ratings of personal meaning,
spiritual experience, and mystical expe-
rience after sessions predicted increased
well-being at 12 months but did not
predict improvement in depression.”
The researchers employed the
30-item revised Mystical Experience
Questionnaire (MEQ30) to evaluate spir-
itual and mystical experience. The
instrument was developed from a survey
of mystical-type experiences associated
with the use of psilocybin. In a study
explaining the MEQ30 published in 2015
in the Journal of Psychopharmacology,
mystical experiences were defined as
having a number of dimensions, includ-
ing unity, sacredness, noetic quality (in
this context, a sense of revelation hard
to verbalize), ineffability, positive mood,
and transcendence of time and space—
with the authors emphasizing that a
totality of these dimensions must occur
to qualify as a complete mystical expe-
rience. The authors of that study further
noted that “mystical experience is not
conceptually limited to religious expe-
rience or practice. ...”
The finding of a divergence between
remission or improvement in major
depression and self-reported well-being
“is a somewhat counterintuitive part
of our results,” Gukasyan commented.
The research team was focused on
determining which acute drug effects
were helpful in predicting depression,
she noted. Many studies of psilocy-
CLINICAL & RESEARCH
whose participants had symptoms of
anxiety and depression secondary to a
terminal cancer diagnosis—have found
that subjective ratings such as mystical
experience were correlated with lon-
ger-term changes from baseline in
depressive symptoms, Gukasyan said.
“The important thing to understand
about well-being scores is that they are
not changes from baseline, but rather
absolute scores taken at follow-up time
points derived from a questionnaire
that asks where participants continue
to experience persisting changes in
their well-being that they attribute to
the psilocybin therapy,” Gukasyan
added. “Taken together, these results
suggest that the types of features we
asked about—personal meaning, spir-
itual significance, mystical experience,
and so on—did not help us predict mag-
nitude of depression.”
The finding may indicate that there
are quality of life elements that are
improved in people with major depres-
sion after psilocybin therapy that are
not captured by depression severity
scores in the GRID-HAMD and similar
measures, she observed. This is an area
that needs further exploration using
instruments that better measure how
well-being changes from baseline fol-
lowing psilocybin therapy, she said.
Psychiatrist Charles Grob, M.D., a
professor of psychiatry and biobehav-
ioral sciences and pediatrics at the
David Geffen School of Medicine at
UCLA, has studied the therapeutic util-
ity of psychedelic drugs for decades.
The new Hopkins study “furthers the
growing interest in the potential safety
and utility of the psychedelic treatment
model as an alternative—albeit novel—
psycho-spiritual therapy and will likely
catalyze future studies that examine
even longer post-treatment time spans
in order to measure the full durability
of psilocybin treatment,” Grob told Psy-
chiatric News.
The divergence between self-re-
ported findings of enhanced personal
meaning and spirituality versus anti-
depressant measures requires further
study to better understand the signif-
icance of the data, Grob said. 
  “Efficacy and Safety of Psilocybin-Assisted
Treatment for Major Depressive Disorder: Pro-
spective 12-Month Follow-Up” is posted at https://
journals.sagepub.com/doi/10.1177/02698811211073759.
“Psilocybin Treatment for Major Depression Effec-
tive for Up to a Year for Most Patients, Study Shows”
is posted at https://www.hopkinsmedicine.
org/news/newsroom/news-releases/psilocybin-
treatment-for-major-depression-effective-
for-up-to-a-year-for-most-patients-study-shows.
”Effects of Psilocybin-Assisted Therapy on Ma-
jor Depressive Disorder” is posted at https://
jamanetwork.com/journals/jamapsychiatry/
fullarticle/2772630. “Validation of the Revised Mys-
tical Experience Questionnaire in Experimental Ses-
sions With Psilocybin” is posted at https://journals.
sagepub.com/doi/10.1177/0269881115609019/.
PSYCHNEWS.ORG 41
 JOURNAL DIGEST
BY NICK ZAGORSKI
iStock/ljubaphoto
Study Questions Link
Between Inflammation,
Late-Life Depression
L
ate-life depression alone does not
lead to elevated inflammation, sug-
gests a report published in Trans-
lational Psychiatry.
Though previous studies have
pointed to a link between late-life
depression and inflammation, few of
these studies controlled for comorbid
medical conditions also associated
with inflammation.
Investigators at the University of
Pennsylvania and colleagues recruited
66 adults aged 50 or older who had
major depression but no other medical
conditions associated with systemic
inflammation (for example, an auto-
immune disease). This sample was
matched with 26 older adults without
depression or inflammatory condi-
tions. The adults with depression were
randomized to receive escitalopram,
escitalopram plus celecoxib (an
anti-inflammatory drug), or placebo
for eight weeks.
The investigators analyzed the con-
centration of 29 different inflammatory
molecules in the blood of the partici-
pants at baseline and found no differ-
ences between the adults with and
without depression. After eight weeks,
average levels of inflammatory mole-
Pregnancy
continued from page 40
The analysis also identified four tra-
jectories for anxiety symptoms, three of
which were similar to the patterns seen
for depression: 7% of women had no anx-
iety (GAD-7 scores of 0) consistently
through pregnancy, 53% had minimal
anxiety (GAD-7 scores around 2) through-
out pregnancy, and 23% had mild symp-
toms (GAD-7 scores around 8) at the start
of pregnancy that gradually dropped
around the time of delivery before rising
slightly during the postpartum period.
However, 18% of the women experienced
breakthrough anxiety, in which their
GAD-7 scores were low at the start of
pregnancy but then rose almost to 10
starting at the end of pregnancy and to
about eight weeks postpartum.
42 PSYCHIATRIC NEWS | JUNE 2022
cules among all participants remained small study in the Journal of Affective
unchanged, despite significant Disorders now suggests that repeated
improvements in depressive symptoms doses of ketamine do not signifi-
among the adults with depression. cantly worsen cognitive function in
Though adults who took escitalopram veterans with comorbid depression
alone or escitalopram in combination and PTSD.
with celecoxib had statistically better Researchers at the University of
improvements in depressive symptoms Minnesota Medical School and col-
than those taking placebo, there were leagues provided six ketamine infu-
no differences between the two medi- sions to 15 veterans with comorbid
cation groups. depression and PTSD over 12 days. The
“Our findings … make the import- participants’ PTSD and depression
ant point that inflammation is not symptoms were assessed before and
an intrinsic component of depression after each infusion, while cognitive
and [should] prompt further consid- assessments were conducted at the
eration of personalized therapeutic start of the study and one week after
approaches for [major depression] in the last ketamine infusion.
which both inf lammation and Compared with baseline assess-
depression are addressed,” the inves- ments, the participants demonstrated
tigators wrote. a significant improvement in working
memory after ketamine infusions. The
 No Increase in Inflammation in Late-Life researchers also found that veterans
Major Depression Screened to Exclude Physical with lower scores on working memory
Illness. Luning Prak ET, Brooks T, Makhoul W, or processing speed at baseline showed
et al. Transl Psychiatry. 2022; 12(1): 118. https:// greater improvements in both depres-
www.nature.com/articles/s41398-022-01883-4 sion and PTSD symptoms following
ketamine treatment.
The researchers noted that deficits
in working memory and processing
speed seen in patients with PTSD may
result from overactivation of the amyg-
iStock/Amornrat Phuchom
dala, which directs the brain’s resources
toward threat detection and other emo-
tional processes.
“Ketamine infusions may promote
recovery from PTSD symptoms by
enabling appropriate allocation of cog-
Veterans With PTSD Report nitive resources to non-threat related
Memory Improvements tasks,” they wrote.
Following Ketamine   Albott CS, Lim KO, Erbes C, et al. Neurocog-
K
etamine can help to alleviate nitive Effects of Repeated Ketamine Infusions
symptoms of comorbid depres- in Comorbid Posttraumatic Stress Disorder
sion and posttraumatic stress and Major Depressive Disorder. J Affect Disord.
disorder (PTSD), but some have ques- April 13, 2022. Online ahead of print. https://
tioned whether such treatment may www.sciencedirect.com/science/article/pii/
result in neurocognitive problems. A S0165032722004037
“Nearly 1 in 3 women had clinically
meaningful depression symptoms,
Virginia. She explained that while phy-
sicians typically augment treatment if
while 40% had difficulties with anxi- a pregnant woman has problems con-
ety,” Wisner said. “Many of these trolling diabetes or hypertension, they
women were not doing well, and this tend to be more hesitant when it comes
is from a group who had a history of to increasing a pregnant woman’s anti-
responding to medication. These depressant dose.
results show how risky depression can “They try to limit exposure [of the
be during pregnancy.” fetus to the antidepressant] rather than
Wisner suggested that clinicians treat the illness,” said Payne, who was
should monitor patients regularly for not involved in this study. She and col-
any emerging depression or anxiety leagues recently did an analysis that
and encourage patients to use online found women with depression are far
tools to help monitor their symptoms. more likely to receive a medication
“These findings show that there is dose adjustment during the postpar-
still a problem of undertreating depres- tum period compared with during
sion during pregnancy,” said Jennifer pregnancy. In this study, just 18 of the
Payne, M.D., a professor of psychiatry 88 participants were given a dose
and neurobehavioral sciences and increase during pregnancy.
director of the Reproductive Psychiatry “The main message is do not assume
Research Program at the University of your patients will stay well during preg-
iStock/dolgachov
Alcohol Prevention
Programs Found to Have
Lasting Effects
A
seven-year follow-up of high
school students enrolled in a
study on alcohol prevention pro-
grams found that both a Web-based
program for all students or an in-per-
son program for high-risk youth can
offer lasting benefits. As noted in the
Journal of the American Academy of Child
and Adolescent Psychiatry, however,
providing both alcohol prevention pro-
grams in the same school offered no
additional benefit.
These findings were from the Cli-
mate and Preventure trial, a study
initiated in Australia in 2012 among
eighth graders (average age, 13 years)
at 26 Australian secondary schools.
The schools were randomized to one
of four groups: (1) offered students
twelve 40-minute lessons of Climate,
a universal Web-based alcohol use pre-
vention program; (2) offered students
two 90-minute group sessions of Pre-
venture, a prevention program tai-
lored to youth who met personality
criteria for high-risk of substance use;
(3) offered students both Climate and
Preventure; or (4) offered students the
school’s usual health education. The
study and follow-up were conducted
by researchers at the University of
Sydney and colleagues.
continued on facing page
nancy, even if they have up to that
point,” Wisner said. “Pregnancy is a
very stressful time, and many women
require additional interventions as the
birth gets closer.”
This study was supported by grants
from The Eunice Kennedy Shriver
National Institute of Child Health and
Human Development, the Obstetric-
Fetal Pharmacology Research Centers,
the Asher Center for the Study and
Treatment of Depressive Disorders, the
Center for Pharmacogenomics, and the
Northwestern University Feinberg
School of Medicine. 
 “Trajectories of Depressive and Anxiety
Symptoms Across Pregnancy and Postpartum
in Selective Serotonin Reuptake Inhibitor‐Treat-
ed Women” is posted at https://prcp.psychiatry
online.org/doi/10.1176/appi.prcp.20210034.
 MED CHECK
BY TERRI D’ARRIGO
New Caplyta Dosing
Approved
T
he Food and Drug Administration
(FDA) approved two additional dos-
age strengths of the atypical anti-
psychotic Caplyta (lumateperone) for
two specific patient populations,
Intra-Cellular Therapies announced in
April. The two populations affected are
patients who take CYP3A4 inhibitors
and patients with moderate (Child-Pugh
class B) and severe (Child-Pugh class C)
liver impairment. Caplyta is approved
for the treatment of adults with schizo-
phrenia and depressive episodes asso-
ciated with bipolar I or II disorder as
monotherapy and as adjunctive therapy
with lithium or valproate.
The new recommended dosage for
patients who take strong CYP3A4 inhib-
itors is 10.5 mg once daily, and the new
recommended dosage for patients who
take moderate CYP3A4 inhibitors is 21
mg once daily. These dosages are a
reduction from the previous dosages
because taking CYP3A4 inhibitors
increases exposure to lumateperone.
The new recommended dosage for
patients with moderate or severe liver
impairment is 21 mg once daily. This
continued from facing page
About half of the original partici-
pants, who were now of legal drinking
age in Australia, completed the sev-
en-year follow up assessments. After
seven years, the participants in each
of the three prevention groups reported
similar lower odds of alcohol-related
problems (for example, went to work
or school drunk and/or got in fights
when drinking) compared with those
receiving usual health education.
Youth in the Climate or Preventure
groups (but not the combined group)
were also less likely to report hazardous
drinking after seven years.
“The durability of alcohol preven-
tion effects over a seven-year period
speaks to the value of school-based
prevention initiatives, which, for a rel-
atively modest investment of time and
resources, continue to deliver benefits
long after implementation,” the
researchers wrote.
  Newton NC, Stapinski LA, Slade T, et al. The
7-Year Effectiveness of School-Based Alcohol Use
Prevention From Adolescence to Early Adult-
hood: A Randomized Controlled Trial of Univer-
sal, Selective, and Combined Interventions. J Am
Acad Child Adolesc Psychiatry. 2022; 61(4): 520-
532. https://www.sciencedirect.com/science/
article/pii/S0890856721019997#bib28
dosage is a reduction from the previous
dosage because patients with impaired
liver function were found to have
higher exposure to lumateperone than
patients with normal liver function.
The new dosage strengths are
expected to be available in pharmacies
later this year.
FDA, DEA Warn Online
Pharmacies Against
Illegally Selling Adderall
I
n April the FDA and the Drug Enforce-
ment Administration (DEA) issued
joint warning letters to two online
pharmacies, kubapharm.com and pre-
miumlightssupplier.com for illegally
selling Schedule II stimulants, includ-
ing amphetamine drug products mar-
keted as Adderall (amphetamine/dex-
troamphetamine). These websites sell
Adderall online without a prescription.
In a statement, the FDA said that peo-
ple should dispose of unused medi-
cine from these websites and not pur-
chase or use prescription drugs sold from
these websites without a prescription.
“Illegally marketed prescription
drugs pose significant risks to consumers
who purchase those products. Consum-
ers who buy prescription drugs from
unsafe online pharmacies may put their
iStock/kupicoo
Study Highlights Factors
Key to Well-being
In Adults With ADHD
O
ver 40% of adults with atten-
tion-deficit/hyperactivity disor-
der (ADHD) living in Canada
reported feelings of life satisfaction
and psychological well-being when
surveyed by researchers at the Univer-
sity of Toronto. The results, published
in the International Journal of Applied
Positive Psychology, also identified fac-
tors that may promote these positive
outcomes.
This study “makes a significant con-
tribution to the literature on adults
with ADHD by identifying factors asso-
ciated with flourishing in this popula-
tion, shifting away from the deficit-fo-
cused perspective that is frequently
used in ADHD research,” the research-
ers wrote.
health at risk because the products, while
being marketed as authentic, may be
counterfeit, contaminated, expired or
otherwise harmful,” the agencies wrote.
CMS Finalizes Medicare
Coverage Policy for Aduhelm
T
he Centers for Medicare & Medic-
aid Services (CMS) in April
released a national policy for cov-
erage of Biogen’s Alzheimer’s medica-
tion Aduhelm (aducanumab) and any
future monoclonal antibodies directed
against amyloid approved by the FDA
with an indication for use in treating
Alzheimer’s disease. The guidance
restricts reimbursement for Aduhelm
only if it is used in a clinical trial.
Aduhelm was approved last year to
treat Alzheimer’s disease via the FDA’s
accelerated approval pathway, which
is designed to speed up the approval
of medications for serious or
life-threatening illnesses by allowing
companies to provide a surrogate end-
point that reasonably predicts future
clinical benefit.  The surrogate end-
point for Aduhelm was evidence that
people who took the medication had
significantly greater reduction of amy-
loid beta plaques in their brains after
78 weeks than those who took placebo.
The findings were drawn from 21,099
respondents to the 2012 Canadian Com-
munity Health Survey-Mental Health,
a nationally representative survey
assessing the mental health status and
related factors of Canadian adults; the
sample included 480 adults with diag-
nosed ADHD.
The researchers first calculated how
many adults achieved complete mental
health, which they defined as the
absence of any other mental illness or
substance use disorder (other than
ADHD) in the past year and presence
of consistent emotional and social
well-being over the past month. Over-
all, 42% of adults with ADHD reported
complete mental health, compared
with 74% of adults without ADHD.
Among adults with ADHD, those
who were married, physically active,
and/or used spirituality to cope with
challenges were more likely to expe-
rience complete mental health. In
contrast, adults who experienced
childhood abuse, debilitating pain, or
had a history of depression or anxiety
were less likely to achieve complete
mental health.
“This [study] can help guide clini-
cians towards modifiable factors for
improving mental health among those
with ADHD, such as improving physical
activity and social support, and treat-
These plaques are a hallmark of Alz-
heimer’s disease.
FDA Seeks Comments on
Mail-Back Envelopes for
Opioid Disposal
T
he FDA is seeking comments
through June 21 on a proposed mail-
back envelope requirement that
would provide patients who receive opi-
oids on an outpatient basis with an option
to mail back their unused medications
and with education on the safe disposal
of opioid medications. If implemented,
this proposal would be incorporated into
the existing Opioid Analgesic Risk Eval-
uation and Mitigation Strategy.
“Such a requirement could reduce
the amount of unused opioid analgesics
in patients’ homes, thereby reducing
opportunities for nonmedical use, acci-
dental exposure, and overdose, and
possibly reducing the development of
new opioid addiction,” the agency wrote
in an article in the Federal Register. The
article and instructions on how to sub-
mit comments is posted at https://www.
federa lreg ister.gov/document s/
2022/04/21/2022-08372/providing-
mail-back-envelopes-and-education-
on-safe-disposal-with-opioid-analgesics-
dispensed-in-an. 
ing symptoms of comorbidities, such
as chronic pain, depression, and anx-
iety,” the researchers concluded.
  Fuller-Thomson E, Ko BK, Carrique l, Mac-
Neil A. Flourishing Despite Attention-Deficit
Hyperactivity Disorder (ADHD): A Population
Based Study of Mental Well-Being. Int. J. Appl.
Posit. Psychol. April 12, 2022. Online ahead of
print. https://link.springer.com/article/10.1007/
s41042-022-00062-6
iStock/franckreporter
Movement Tracking May
Identify Severity of Negative
Schizophrenia Symptoms
P
assively tracking the movements
of people with schizophrenia (via
their smartphone and/or smart
bands) may offer some clues about the
negative symptoms they are experienc-
ing, reports a study in Schizophrenia.
Researchers at the University of
see Journal Digest on page 47
PSYCHNEWS.ORG 43
 LETTERS TO THE EDITOR
More Beds Desperately Needed for People With Serious Mental Illness
I
am a psychiatrist working on both
the Assertive Community Treatment
Team and the Forensic Services Pro-
gram of Penndel Mental Health Center
in Bucks County, Pa. We work with
Letters to the Editor
Readers are invited to submit
letters of not more than 350 words
for possible publication. Psychiat-
ric News reserves the right to edit
letters and publish them in any
of its formats. Letters should be
emailed to cbrown@psych.org.
MIPS
continued from page 5
ple, psychiatrists performed more
poorly on measures such as participa-
tion in health information exchanges;
documentation of patient medica-
tions; and preventive measures that
are not related to psychiatry, such as
cancer screening.
“The fact that just as many psychi-
atrists in our exploratory analysis
reported on quality measures for can-
cer screening and flu shots as for
depression care suggests that MIPS
performance reflects multispecialty
group performance as opposed to
quality of psychiatric care,” the
researchers wrote.
Yet psychiatrists are often not part
of multispecialty group practices,
instead choosing to go into solo prac-
tice. This can make it more difficult for
them to benefit from MIPS, Johnston
told Psychiatric News.
“It’s a system that disadvantages solo
practitioners because they don’t have
the infrastructure and management
to report performance in a way that
Claims
continued from page 1
‘biologically based’ but provides far less
coverage for other diagnoses. ... In real-
ity, all mental illnesses are partially
based on a person’s biology.”
In addition, one national insurer in
her area began cutting payments for
telepsychiatry visits as of April 1 to the
significantly lower “hospital facilities”
rate. Unlike hospitals, however, prac-
tices such as Neill’s cannot bill a sepa-
rate facilities fee to make up the differ-
ence. She said she’s heard rumblings
that other insurers she participates with
will follow suit.
Neill said one national carrier is
44 PSYCHIATRIC NEWS | JUNE 2022
patients with severe and persistent
mental illness, mostly schizophrenia,
and see them wherever they live. Even
with our supports, many of our
patients struggle to remain stable in
the community, and many cannot
obtain or lose their housing due to
psychotic behaviors, inability to care
for self, lack of funds, and criminal
record or charges.
As I write this, it is my understand-
ing that there are upward of 250 home-
less mentally ill people in the com-
munity where I work. That’s 250
people who may not be able to care
for themselves, manage their psychi-
gets the biggest possible returns,” John-
ston explained.
Psychiatrists in the study were much
more likely than other physicians to see
patients who had dual enrollment in
Medicaid and Medicare: 56.6% of psychi-
atrists saw patients in this population
compared with 26.7% of other physicians.
“This is a marker that they are treat-
ing a higher percentage of patients who
are socially at risk,” Johnston said. He
added that lower payments and greater
penalties for psychiatrists may com-
pound the barriers to access these
patients already face.
“If Medicare and Medicaid are not
paying high enough rates, psychia-
trists have to offset that somehow,”
Johnston said. “It puts psychiatrists
between a rock and a hard place,
because even though they may want
to treat patients insured by Medicare
or Medicaid, they have to limit the
number of those patients to balance
out their panel with patients who pay
higher rates.”
Measures included in the mental/
behavioral health specialty set, includ-
ing measures related to depression,
paying her only 50% to 60% of the Medi-
care rate in her jurisdiction. “I earned
more than double that [rate] while
moonlighting as a psychiatric resident,
and I didn’t have the overhead,” she
said. “We’re a tiny practice so plans
won’t negotiate. … We have no choice
but to leave that network. I have a lot
of patients with that insurance, so I feel
horrible about it, but we also want to
keep our doors open.”
Psychiatrist Kamala Adury, M.D.,
founder of the Center for Behavioral
Health and Sleep Disorders in Medina,
Ohio, told Psychiatric News she has sim-
ilar challenges. Insurance problems
are “a universal issue that no one talks
about. Scores of private practices have
atric and medical illnesses, protect
themselves from predation, obtain
food and clothing and a safe place to
sleep, and more.
We need beds! WE NEED BEDS! On
every level from locked to unlocked
facilities, we need beds. The shelters
are full! The wait list for community
residential rehabilitation and extended
acute units and long-term structured
residences is months to years.
Some of our society’s most vulner-
able people, who need the highest level
of professional, compassionate mental
and physical health care, are being
denied, left to sleep in old cars in park-
were rarely reported throughout the
study. In an accompanying commen-
tary, Marcela Horvitz-Lennon, M.D.,
M.P.H., senior physician scientist at the
RAND Corporation and a professor at
the Pardee RAND Graduate School in
Boston, and colleagues wrote that this
finding points to a need to develop and
encourage the use of measures relevant
to psychiatric care in MIPS. To that end,
they offered two strategies for policy-
makers to consider.
“First, critically review and restruc-
ture the mental/behavioral health
specialty set, which should include
measures relevant to the patient pop-
ulations most commonly served by
Medicare psychiatrists,” they wrote.
“Second, use a different perfor-
mance assessment method for psychi-
atrists, depending on the health and
social complexity of their caseloads,”
they added. They wrote that such
changes may include fewer or no per-
formance requirements for the
interoperability, improvement activ-
ities, and cost domains for psychia-
trists working in low-resource set-
tings; addressing psychiatrists’ more
become extinct or have been extermi-
nated. The income of small practices
has fallen drastically, which could lead
to cramming more patients per hour
to stay afloat—clearly compromising
patient care,” she said.
Some national insurers in Adury’s
area pay her only about two-thirds of
the Medicare rate. “They say ‘Take it or
leave it.’ I want to accept insurance,
and I keep getting calls from patients
who I have to turn down; otherwise, I
cannot stay in business.” One insurer
paid Adury and then later billed her for
hundreds of dollars, saying she had
been overpaid and that she needed to
return the money or face consequences.
APA’s Jaffe said Medicare rates are
ing lots, tents in the woods, on the side-
walks, or in abandoned buildings—or
a jail cell. We got it right when the focus
shifted from institutionalization to
patients’ rights, freedom, choices, well-
ness, and recovery. But we clearly failed
in preparing enough welcoming beds
for those who truly need more super-
vision. Spread the word: WE NEED
MORE BEDS! 
BONNIE WRIGHT, M.D.
Langhorne, Pa.
Editor’s note: APA released a detailed
report assessing the need for psychiatric
beds as this issue went to press. Coverage
of the report will appear in a future issue.
socially complex caseloads by com-
paring performance between clini-
cians treating patients of similar
social risk; and making psychiatrists’
participation voluntary.
However, Johnston feels that
increased access to mental health care
needs to come first.
“It would be great to have relevant
performance measures, but we don’t
have the luxury of grilling psychia-
trists on quality of care when we hav-
en’t met the first step of having enough
psychiatrists in the first place,” John-
ston said.
This study was supported by the
National Institute of Mental Health. 
 “Comparison of Performance of Psychi-
atrists vs Other Outpatient Physicians in the
2020 U.S. Medicare Merit-Based Incentive
Payment System” is posted at https://jama-
network.com/journals/jama-health-forum/
fullarticle/2790543. “Association Between the
Merit-Based Incentive Payment System and Ac-
cess to Specialized Behavioral Health Care for
Medicare Beneficiaries” is posted at https://
jamanetwork.com/journals/jama-health-forum/
fullarticle/2790545.
considered to be the floor for physician
reimbursement to allow practices to
operate. Lower payments do appear to
be outside the norm, according to a lit-
erature review by the Kaiser Family Foun-
dation in 2020. That review found that
private insurers’ payments to physicians
for office-based care were 43% higher
than Medicare’s, on average (with a range
of 18% to 79% higher, across studies).
Two psychiatrists in private practice
in California said that carriers with
whom they participate have made it
difficult or impossible to reach their
provider relations departments, com-
pounding all the problems, John S.
Smolowe, M.D., and Joellen Werne,
continued on facing page
continued from facing page
M.D., told Psychiatric News in a joint
interview. “There are many issues that
claims reps cannot answer,” Smolowe
said. Examples include requesting a
reimbursement schedule, reporting a
payment check missing, and needing
to change an address. “Now these types
of issues often drag on for months or
go unanswered and unresolved.”
Smolowe said another concern is car-
riers’ increasing use of subcontractors
to manage behavioral health claims,
which erects an additional barrier
between the psychiatrist and the claims
departments. “The patient is unaware
of these subcontractors, and by design
their contact information does not
appear on patients’ insurance cards. Yet
if we send the claim to the wrong entity,
they disregard it,” he said. Oftentimes,
determining who is managing a given
patient’s claims takes longer than 90
days, at which time the bills are denied
due to lack of timely filing.
Psychiatrists in New York have also
reported a significant increase in claims
and administrative problems with insur-
ers, Rachel A. Fernbach, J.D., deputy
director and assistant general counsel
of the New York State Psychiatric Asso-
ciation, told Psychiatric News. For exam-
ple, several members have reported car-
riers declining to pay for the E/M portion
of a bill. Rather, plans told these physi-
cians they should be billing only for psy-
chotherapy for most visits, Fernbach said.
This is in direct conflict with the 2010
guidance issued by the Department of
Financial Services (formerly the New
York State Insurance Department)
requiring all carriers to accept E/M
claims submitted by all physicians,
including psychiatrists, she added.
Fernbach said she has found other
problematic administrative barriers.
Insurers request additional claims doc-
umentation for audits or prepayment
reviews, and once the psychiatrists sub-
mit it, some carriers don’t acknowledge
it. In some cases, members have faxed,
emailed, and even overnighted the infor-
mation—but insurers do not respond.
Role of Billing Rule Changes
The rise in psychiatric claims prob-
lems appears to have coincided with
a major overhaul of E/M coding rules
for office-based outpatient care that
took effect in January 2021. There is
now an entirely new framework for
code selection and documentation of
medical decision-making, which
sometimes results in higher-level cod-
ing and more costly care for psychiat-
ric patients, depending on their level
of complexity and acuity presented.
For example, during office visits when
psychiatrists are treating unstable
patients with at least one chronic ill-
ness and also managing medications
during that same visit, it is now billed
and how best to document their ser-
vices. For example, Jaffe said it is
important for members to note that
unstable patients are only those defined
as “with exacerbation, progression, or
side effects of treatment.”
Budgets Driving Decisions
“So much of what we’re reacting to is
anecdotal and not data driven,” Robert
L. Trestman, Ph.D., M.D., told Psychiatric
News. He is chair of APA’s Council on
Healthcare Systems and Financing and
chair of Psychiatry and Behavioral Med-
icine at Virginia Tech School of Medi-
cine. However, such data are hard to
come by because insurers are typically
Kamala Adury, M.D., says she wants the ones who hold it. “Even if one could
to accept insurance, but some amass all the claims data from a given
national insurers pay her only about state, one could see which claims were
two-thirds of the Medicare rate. denied, but not the reasons why.”
“I want to accept insurance, and I Trestman said insurers’ administra-
keep getting calls from patients who
I have to turn down; otherwise, I tive staff in billing and claims, who are
cannot stay in business.” focused on keeping within their bud-
as a level four/moderate complexity
visit versus a level three.
“The New York State Psychiatric Asso-
ciation is working with the Department
of Financial Services and carriers doing
business in New York to ensure that
insurers and health plans are aware of
these recent changes in the coding rules
and are appropriately adopting this new
framework in their utilization review
efforts,” Fernbach said.
Rebecca Yowell, APA’s director of
Amy Joehlin-Price, M.D.
reimbursement policy, said the orga-
nization is in the process of further
revising its educational materials about
the coding changes, to add more clar-
ity and provide additional psychia- Marnie Neill, M.D., says admin-
try-specific examples. The revisions istrative burdens, coupled with
are aimed at helping members deter- poor reimbursement, are making it
increasingly difficult for psychiatrists
mine appropriate E/M billing levels to participate in insurance networks.
gets, are more likely to be making the
day-to-day decisions than are the chief
psychiatrists, who are focused on
improving the quality of care. “So
there’s a predictable disconnect.”
Although the exact numbers are not
known, it is estimated that as many as
one-third of psychiatrists are already
not accepting insurance. “What we would
want, given this new pandemic of men-
tal illness that is growing out of a con-
Rouse Photography Group LLC
sequence of the SarsCoV2 pandemic, is
for insurers to do everything they can
to expand access, reduce administrative
burden, and encourage psychiatrists to
join networks. Insurance companies
could then track the data. They could
Robert Trestman, M.D. says, “What see that our patients were getting better
we would want, given this new and that the investment was worth it.”
pandemic of mental illness that is
growing out of a consequence of the
SarsCoV2 pandemic, is for insurers Mental Health Parity Enforcement
to do everything they can to expand Disparities in claims processing or
access, reduce administrative bur- payments for psychiatrists may con-
den, and encourage psychiatrists to stitute a violation of mental health
join networks.”
parity laws, particularly if the process
is more stringent than for other phy-
sicians, according to Ellen Weber, J.D.,
senior vice president for health initia-
tives with the Legal Action Center.
“Reimbursement for psychiatrists at
levels significantly below Medicare
rates is a red flag, particularly if the
reimbursement for other physicians is
higher than the Medicare rate for the
same codes,” she told Psychiatric News.
Weber added that prepayment
claims reviews could also be a parity
law violation if insurers are not requir-
ing that same process for medical and
surgical office visits. “The level of
administrative work required to pro-
vide the information is an indication
that is suggestive of a more stringent
application, such as when practitioners
must spend an inordinate amount of
time responding to questions.”
In 2021, Congress amended the Men-
tal Health Parity and Addiction Equity
Act to allow federal officials to put a
greater emphasis on proactive enforce-
ment. Now plans are required to begin
providing detailed analyses of their
non-quantitative treatment limitations
(NQTLs). NQTLs are strategies used by
health plans to limit benefits, such as
prior authorizations, fail-first policies/
step therapy protocols, and insurance
network admission standards.
A review by the departments of Trea-
sury, Labor, and Health and Human
Services in January of analyses of their
behavioral health NQTLs submitted by
health plans found that not a single
plan complied with the law (Psychiatric
News, https://psychnews.psychiatry
on line.org /doi /10.1176/appi.pn.
2022.03.3.32). Officials issued dozens
of enforcement letters to health plans
identifying plans’ mental health parity
violations as well as deficiencies in
plans’ reporting transparency. The
report also recommended that Con-
gress amend federal parity laws to
ensure that MH/SUD benefits are
defined in an objective and uniform
manner, for example, using the most
recent Diagnostic and Statistical Manual
of Mental Disorders. 
  APA members are encouraged to contact
the Practice Management Helpline for assistance
with claims issues at practicemanagement@
psych.org and 800-343-4671. The Kaiser Family
Foundation’s “How Much More Than Medicare Do
Private Insurers Pay? A Review of the Literature”
is posted at https://www.kff.org/medicare/
issue-brief/how-much-more-than-medicare-do-
private-insurers-pay-a-review-of-the-literature.
The Government Accountability Office report
“Behavioral Health: Patient Access, Provider
Claims Payment, and the Effects of the COVID-19
Pandemic” is posted at https://www.gao.gov/
products/gao-21-437r. The 2022 MHPAEA Report
to Congress is posted at https://www.dol.gov/
sites/dolgov/files/EBSA/laws-and-regulations/
laws/mental-health-parity/report-to-congress-
202 2-realizing-parit y-reducing-stigma-
and-raising-awareness.pdf.
PSYCHNEWS.ORG 45
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continued from page 43
Georgia and colleagues collected accel-
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The participants with schizophre-
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https://www.nature.com/articles/s41537-022-
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Hormone Therapy
continued from page 26
Byne added that psychiatrists should
have resources at hand to make appro-
priate referrals.
“Psychiatrists who are not experi-
enced in gender-affirming care need
to know when, where, and to whom to
refer youth and their parents or care-
givers for appropriate gender-focused
care and support that ameliorates
rather than exacerbates anxiety and
dysphoria,” he said.
A Call to Action
The experts agree that these data
illuminate a need to ensure that trans-
gender youth receive gender-affirming
care, including gender-affirming hor-
mone therapy, if they desire it.
“Legislation should not prohibit
gender-affirming care or penalize pro-
fessionals who provide it,” said Byne.
Green emphasized the importance
practices, anything that creates a feel-
ing of  ‘flow.’ ”
ping caregivers.
Mainstays of treatment for TS are
of advocacy. antipsychotic medication and cogni-
“From a social justice perspective, Tourette Syndrome or Tics? tive-behavioral therapy. However, for
these data should serve as a call to For physicians who haven’t seen TLB-SM, “management includes psy-
action to stand up for laws and policies many cases, Münchau said that distin- choeducation about functional symp-
that increase access to gender-affirm- guishing functional tic-like behaviors toms and tic-like attacks. This expla-
ing care and to stand against the wave after social media (TLB-SM) from nation in itself can result in a dramatic
of anti-transgender health care bans Tourette syndrome (TS) can be chal- resolution of symptoms. It is important
we are seeing introduced in states lenging. He said he has seen many to note that these young people show
across the U.S.,” she said. patients who were misdiagnosed with little or no response to the usual med-
Turban noted that all major medical TS who have “had to go through a dif- ications for tics, and we would not rec-
associations, including APA, oppose ficult re-diagnosing and acceptance ommend prescription,” wrote Hedderly
legislation that would outlaw gen- process.” However, several clear-cut and colleagues in the May 21, 2021,
der-affirming care for transgender differences have emerged: age of onset Arhives of Disease in Childhood. 
youth, but added a caveat. (5 years on average with TS vs. 15 years
“Unfortunately, physicians have with TLB-SM); symptom onset (over   “Rapid Onset Functional Tic-Like Behaviors
historically not been very involved in months or years with TS vs. hours or in Young Females During the COVID-19 Pandemic”
state legislative processes,” Turban said. days with TLB-SM). Boys are diagnosed is posted at https://movementdisorders.online
“I am hopeful that psychiatrists will with TS at four times the rate of girls, library.wiley.com/doi/10.1002/mds.28778. “Pan-
contact their state legislatures to edu- whereas most adolescents afflicted with demic Tic-like Behaviors Following Social Media
cate them about the mental health TLB-SM are girls. Consumption” is posted at https://movement
needs of transgender youth, share rel- The movements themselves are dif- disorder s .onlinelibrar y.wiley.c om/doi/
evant peer-reviewed research, and ferent, too: TS is characterized by full/10.1002/mds.28800. “Suicide Risk in Emerg-
encourage them to implement evi- abnormal simple motor movements ing Adulthood: Associations With Screen Time
dence-based public policies that will often involving the head, face, and Over 10 years” is posted at https://link.springer.
best promote the mental health of neck. In TLB-SM, abnormal move- com/article/10.1007%2Fs10964-020-01389-6.
young people.” ments typically involve the trunk and “Screen Time Use Among U.S. Adolescents During
Green and colleagues reported no extremities, are complex and variable, the COVID-19 Pandemic” is posted at https://
outside funding for their study. The and worsen over time and in the pres- jamanetwork.com/journals/jamapediatrics/
study by Turban and colleagues ence of others. The movements also article-abstract/2785686. “COVID-19–Related In-
reported funding from the American decline when patients were alone and crease in Childhood Tics and Tic-Like Attacks”
Academy of Child & Adolescent Psy- tended to be “goal-directed,” or is posted at https://adc.bmj.com/content/
chiatry (as supported by Arbor Phar- directed toward others, such as slap- 106/5/420.
maceuticals LLC and Pfizer), the
National Institute of Mental Health,
The Sorensen Foundation, and the
Health Resources and Ser vices
Administration Bureau of Primary
Health Care. 
  “Association of Gender-Affirming Hormone
Therapy With Depression, Thoughts of Suicide,
and Attempted Suicide Among Transgender and
Nonbinary Youth” is posted at https://www.
jahonline.org/article/S1054-139X(21)00568-1/
fulltext. “Access to Gender-Affirming Hormones
During Adolescence and Mental Health Outcomes
Among Transgender Adults” is posted at https://
journals.plos.org/plosone/article?id=10.1371/
journal.pone.0261039. APA’s Position Statement
on Treatment of Transgender (Trans) and Gen-
der Diverse Youth is posted at https://www.
psychiatry.org/File%20Library/About-APA/
Organization-Documents-Policies/Policies/
Advertisement
Position-Transgender-Gender-Diverse-Youth.
pdf.
Tics
continued from page 34
nourish our bodies and minds, such as
exercising, connecting with nature,
pursuing creative outlets, and nurtur-
ing our relationships with the people
we care most about.”
Durlofsky advises adults and teens
alike to “give themselves permission
to step away from technology, includ-
ing all screens. That is an act of self-
love and self-protection. Take a break
and commit to nondigital self-care
PSYCHNEWS.ORG 47