Remembering Jimmie Holland, a Founder of Psycho-Oncology

Source: Memorial Sloan Kettering - On Cancer
Date: 01/09/2018
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On Christmas Eve, Memorial Sloan Kettering and the wider cancer community lost a beloved and brilliant doctor, Jimmie Holland, who died of cardiovascular disease at 89. Dr. Holland was a tireless advocate for supporting the emotional and psychological needs of people with cancer. She also made huge strides in reducing the stigma surrounding the disease.

Dr. Holland was considered a founder of the field of psycho-oncology, which combines oncology and psychiatry. It is increasingly considered a vital part of comprehensive cancer care, largely thanks to her work.

In 1977, Dr. Holland joined MSK as the inaugural Chief of the Psychiatry Service, the first such service at a cancer center anywhere in the world. She was then named Chair of MSK’s Department of Psychiatry and Behavioral Sciences when it was created in 1996. The department was also the first of its kind, and Dr. Holland remained in her role there until 2003. At the time of her death, she held the Wayne E. Chapman Chair in Psychiatric Oncology.

“Jimmie’s death is a profound loss to us all,” says MSK Physician-in-Chief José Baselga. “Through her visionary work she has forever changed the landscape of cancer care.”

Changing World, Changing Needs

Dr. Holland grew up in a tiny town in north Texas, the only child of a cotton farmer and his wife, neither of whom had finished high school. When she earned her medical degree from Baylor College of Medicine in the early 1950s, “cancer”was a word that most people wouldn’t say out loud. Many newspapers and magazines wouldn’t print it, and patients often were not even told of their diagnosis.

That began to change in the 1970s. Better treatments became available and people with once-fatal cancers starting living longer and even being cured. As the wife of James Holland — a leading oncologist and one of the pioneers of chemotherapy combinations — Dr. Holland had a front-row seat from which to witness the medical revolution that was taking place. While her husband and his colleagues focused on curing people of their cancer, Dr. Holland asked a question that none of them were able to answer: How do the patients feel about it?

As a psychiatrist, she had long been interested in studying how people with otherwise good mental health responded emotionally and psychologically to life-threatening illnesses. She called this focus “psychological care of the medically ill.” She began encouraging oncologists who were conducting clinical trials to include questions about patients’ quality of life in their data collection and research.

The Science of Caring

But measuring things like anxiety, depression, and fatigue was not always straightforward. Dr. Holland met this challenge by developing ways to gauge what patients were feeling that went beyond what doctors and nurses could just observe. She worked to create objective scales to evaluate aspects of people’s experience that were once considered immeasurable. This in turn could validate whether psychological treatments were working. Her research brought the emerging field of psycho-oncology into the realm of evidence-based science, which allowed it to become a recognized subspecialty.

During her years at MSK, Dr. Holland created the nation’s largest training and research program in psycho-oncology. In 1984, she produced for MSK the first-ever syllabus on psycho-oncology. In 1989, she was senior editor of the first textbook on the subject. She also shared her knowledge with the world. She co-founded the International Psycho-Oncology Society in 1984 and founded the American Psychosocial Oncology Society in 1986. She is credited with putting psychosocial and behavioral research on the agenda of the American Cancer Society in the early 1980s. She was also a founder and co-editor-in-chief of the journal Psycho-Oncology.

Dr. Holland recognized that people’s psychological distress could linger even after they were considered cured of their cancer. To address this, she advocated for the formation of a program at MSK that today is called Resources for Life After Cancer. It became a model for other similar initiatives around the world.

“Jimmie was a cancer pioneer, a remarkable woman, and a once-in-a-generation influencer,” says William Breitbart, the current Chair of Psychiatry and Behavioral Sciences and the Jimmie C. Holland Chair. “Her death is a profound loss for all of oncology.”

The Sixth Vital Sign

Dr. Holland pushed to recognize patient distress as the sixth vital sign in medicine. (The others are temperature, pulse, blood pressure, respiration, and pain.) She played a key role in the development of the National Comprehensive Cancer Network’s distress thermometer. This enables people to report their levels of anxiety and depression on a scale of zero to ten, similar to the way they rate their pain.

Other topics that were important to her included survivor guilt, diminishing the stigma of a cancer diagnosis, and evaluating ways to lessen cancer side effects like depression, anxiety, and fatigue with medication and other treatments.

In her later years, she also became particularly interested in supporting the psychosocial needs of elderly patients. As part of that effort, she founded the Vintage Readers Book Club, an offshoot of a support group she led on aging and cancer. The participants talked about classic works by writers including Cicero and Benjamin Franklin, and used their discussions as a springboard for talking about wider-ranging topics that were important to them.

“Jimmie was an inspiration on multiple levels, not least of which was her appreciation of the fact that we are more than our careers,” says psychologist and author Mindy Greenstein, who first came to know Dr. Holland when she conducted her fellowship in MSK’s Department of Psychiatry and Behavioral Sciences. The two later worked together and coauthored the book Lighter as We Go: Virtues, Character Strengths, and Aging. “While raising her own family as well as comforting patients and their family members with her Texas warmth and sound insights, she still found the time to accomplish so much in her work. Hers was a life of unique and dedicated service.”

Dr. Holland, who died at home surrounded by family, was still seeing patients up until two days before she died. She is survived by her husband; six children; nine grandchildren; and countless friends, colleagues, and collaborators.

“Jimmie was a true pioneer in the field of psycho-oncology, and her passion for her patients and her research was evident,” says MSK President and CEO Craig Thompson. “She will be dearly missed by the MSK community and by the world.”

Proactive Psychiatric Consultations Benefit MICU Patients

Source: Brigham and Women's Hospital - On a Mission
Date: 01/03/2019
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Preexisting mental illness and substance abuse disorders are common in patients being treated in intensive care units (ICUs), as is delirium. There is increasing appreciation for the impact of these conditions on overall health outcomes, length of hospital stay and mortality.

Proactive psychiatric consultation has demonstrated improved outcomes in the general hospital setting. Accordingly, Brigham and Women’s Hospital has launched and studied an innovative proactive psychiatric consultation model in the intensive care setting. In this model, a psychiatrist is embedded with the medical ICU (MICU) team and participates in daily walk rounds, rather than the standard approach of having psychiatric consultations conducted only when called by the primary care team.

“These are patients who are critically ill and at their most vulnerable,” said Nomi Levy-Carrick, MD, MPHIL, an associate psychiatrist in the Brigham’s Department of Psychiatry. “The idea is that if you can identify any psychiatric conditions or delirium early in the course of their treatment, you are more likely to be able to bring an informed approach to managing those issues. In that way, you can help to support patients as they navigate this critical period.”

A 2018 study published in Psychosomatics by Dr. Levy-Carrick and her colleagues at the Brigham found that including proactive psychiatric consultation for patients in the ICU led to shorter hospital stays, particularly for those who needed to be on ventilators as part of their care. In the study, two MICUs at the Brigham were randomized to either proactive or conventional psychiatric consultation models.

Due to the study’s positive results, this program remains active at the Brigham. It is managed in cooperation with the critical care medicine and nursing staffs in the ICU.

Beyond what was shown in the study, there are many other ways that patients can benefit from proactive psychiatric consultation. One situation is in the case of delirium, which is common in the ICU setting.

“We’re able to help alleviate their agitation, including through the use of medication, to minimize distress,” Dr. Levy-Carrick said. “Many people come to the ICU already taking a variety of psychotropic medications. We can help manage these medications in the context of the broader medical complexity. We make sure that these drugs are either continued or discontinued in ways that can improve the patient’s overall outcome.”

One built-in component of this model is that it takes into account the possible role of trauma in psychiatric health and recovery. “We’ve recognized that someone’s prior exposure to trauma impacts their ability to tolerate hospitalizations,” Dr. Levy-Carrick said. “At the same time, medical procedures themselves can be potentially traumatic. It’s important that we find ways to mitigate that to prevent the progression of any kind of pathology related to their experience of hospitals.”

Another important part of this program is that members of the psychiatry team continue to follow patients after they are moved to a regular medical floor, and even beyond.

“We follow these patients longitudinally from the point of critical illness through medical stabilization. We also have the opportunity to see them again after they’ve gone home through our Critical Illness Recovery Program,” Dr. Levy-Carrick said. “It provides us with an increased opportunity to be able to help these patients, many of whom may have longer-term psychiatric and other medical needs.”

Longitudinal Walk-In Urgent Care Psychiatric Clinic Offers a New Model of Care

Source: Brigham and Women's Hospital - On a Mission
Date: 11/12/2019
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Arranging psychiatric care can be a logistical challenge. Appointments usually need to be scheduled months in advance, and missed visits may result in removal from patient rolls. This situation is often a critical obstacle to care, especially because people who require psychiatric care are likely to struggle to deal with these sorts of challenges.

The Challenge of Access to Care

This situation was the impetus for the creation of the urgent care clinic for psychiatry at Brigham and Women’s Hospital. It was launched in 2017 to make it easier for people to get care when they need it.

“Access to psychiatry is difficult pretty much everywhere you go,” said David S. Kroll, MD, of Brigham and Women’s Department of Psychiatry, who leads the program. “There are parts of the country where there literally is no psychiatrist within hundreds of miles. Even in Boston, where we have a relatively high concentration of psychiatrists, it can be difficult for patients to see them, in part because psychiatric care is just very time-intensive.”

Dr. Kroll explained that although historically the Brigham has been well-equipped to provide excellent psychiatric care to patients who are able to adhere to the basic expectations of the clinic, too many people were being kept out of psychiatry because of the difficulty in keeping appointments. He and his colleagues decided that a walk-in clinic would be an innovative way to address this challenge.

The Longitudinal Urgent Care Psychiatry (LUCY) clinic is currently open three afternoons a week for walk-in visits. A handful of psychiatrists share in clinical duties. Anyone who gets primary care through another Brigham doctor is eligible to participate; having a previous relationship with the Department of Psychiatry is not required. The clinic also has social workers on staff who can manage crises, help patients schedule regular follow-ups and provide limited therapy when needed.

“When we opened our doors to walk-ins, we basically told people, ‘You can come in for anything you need,’” Dr. Kroll said. “If it’s an urgent care visit, that’s fine. If there’s an expectation that you will continue to get your care primarily on a walk-in basis, that’s fine too.” He added that although a consistent structure to appointments is ideal, when the alternative is no care at all, the walk-in clinic provides a valuable service.

A Major Innovation for the Field of Psychiatry

In the two years that the clinic has been open, it has seen 350 patients—250 of whom previously did not have any access to psychiatric care. Additionally, 60 percent of those patients sought follow-up, either through another urgent care visit or through a scheduled appointment with another psychiatrist in the clinic.

“We’re still working on a formal outcomes study, but anecdotally the clinic appears to have reduced the way that some patient groups have traditionally used emergency rooms,” Dr. Kroll said. He added that while the clinic sees a disproportionate number of Medicare and Medicaid patients, the psychiatrists working in the clinic tend to be more productive, in part because many appointments are shorter than average. “From a fee-per-service perspective, it works out pretty well,” he said.

Plans are in place to expand social work and therapy services and to increase the number of doctors who are available during clinic hours.

“Other programs have tried different kinds of walk-in clinics,” Dr. Kroll concluded. “But ours is unique in that we’re planning for long-term management of patients within this urgent care framework.”

Using MRI to Decode the Brain’s Inner Workings

Source: Brigham and Women's Hospital - On a Mission
Date: 11/12/2019
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Thanks to imaging technologies like CT, MRI and PET, researchers who study the brain are able to peer inside its “black box” to learn how different parts of the brain interact and how those interactions change in response to disease or injury.

The Psychiatry Neuroimaging Laboratory at Brigham and Women’s Hospital, directed by Martha E. Shenton, PhD, was established to understand more about brain abnormalities and their role in neuropsychiatric disorders. The lab makes use of state-of-the-art neuroimaging techniques.

“From the beginning, my research has been focused on developing and refining new technology to study schizophrenia and traumatic brain injury [TBI] in living brains,” said Dr. Shenton, who founded the laboratory in 2005. “We are excited to be taking this research into the clinic.”

Visualizing Brain Changes Across the Lifespan

Much of Dr. Shenton’s work has concentrated on MRI. Unlike types of imaging that provide far less detail, MRI enables researchers to distinguish between the gray matter (which contains the cell bodies, dendrites and axon terminals of neurons, as well as the synapses) and the white matter (which is made of the axons that connect different areas of gray matter to each other). They can also use it to analyze the flow of fluid between different parts of the brain.

One of the major goals of the laboratory is to build an atlas of what normal brains look like across the entire human lifespan. This will enable both researchers and clinicians to better understand changes over time and changes in response to damage.

“When you test someone’s cholesterol levels in the blood, you need to know the normative range to test it against,” Dr. Shenton explained. “It’s the same with brain scans. If you are looking at someone who is 30 years old and has a concussion, you want to know what to expect in a healthy brain that’s been matched for age, gender and other factors. That gives you a better understanding of how severe the injury is and how it may be affecting brain function.”

Improved Predictive Modeling

Dr. Shenton believes the tools she’s developing will eventually lead to better diagnostic and predictive models for schizophrenia and other neurological disorders. “By identifying individuals who are at high risk for developing schizophrenia and studying them over time, we can determine how measures like inflammation in the brain may affect the onset and progression of the disease as well as how it responds to therapy,” she said.

She added that this research may lead to better clinical trials for schizophrenia by enabling better classification of patients by the particular features of their disease. “Schizophrenia is a very heterogeneous disease, and not everyone is going to respond to the same drug in the same way,” she said. “If we can figure out how to group people into smaller, more homogeneous groups based on the characteristics of their disease, we’ll be able to match them better to the right clinical trial.”

Dr. Shenton is also participating in research on TBI and chronic traumatic encephalopathy (CTE) funded in part by the National Institute of Neurological Diseases and Stroke. She along with other researchers on the team are looking at levels of tau and amyloid-beta proteins in the brain to understand how changes here may lead to complications later in life, as CTE is currently a diagnosis only at post-mortem. Being able to track brain changes over time will thus provide more information that may assist in detecting those most vulnerable to CTE and other neurodegenerative diseases.

“We hope to eventually collect enough data to help football players understand their risk for future brain complications,” she concluded.

Neuropsychiatry Focuses on Bringing Two Fields Together

Source: Brigham and Women's Hospital - On a Mission
Date: 11/12/2019
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It’s not uncommon for people who have neurological disorders to experience behavioral and emotional symptoms. The field of neuropsychiatry is dedicated to addressing this issue and bringing a neurobiological understanding to the field of psychiatry.

“We focus on the intersection between neurology and psychiatry and on understanding the full range of cognitive, emotional and behavioral manifestations that can present with different neurological disorders,” said Gaston C. Baslet, MD, chief of the Neuropsychiatry Division in the Brigham and Women’s Hospital Department of Psychiatry and co-director of the Center for Brain/Mind Medicine. “There’s a lot of overlap, and it’s important for these two specialties to work together to understand the emotional disorders that can arise from alterations in the function of the brain.”

At the Intersection of Psychiatry and Neurology

Psychiatric conditions are common in people with neurological diseases, including Alzheimer’s disease and other forms of dementia, multiple sclerosis and epilepsy. They also can occur in people with brain tumors and those who have experienced traumatic brain injuries, strokes or infectious diseases of the nervous system, among other conditions. “We want to understand how a brain affected by neurological illness can also have all sorts of impact on emotional and cognitive function,” Dr. Baslet said.

“The Brigham has a large group of professionals interested in brain and behavior. This puts us in a unique position to better understand and offer help to address these disorders,” he added. “We have a number of experts in neuropsychiatry in our group. Additionally, as part of the Center for Brain/Mind Medicine, we work closely and collaborate with the behavioral neurology group and the neuropsychology group.”

As a tertiary care center, the Brigham sees people with both common and rare neurologic and psychiatric disorders. Because of the large volume of inpatients who are in more acute stages of neurological disease—which frequently has a psychiatric component—inpatient consultations are also a growing area of specialization.

Clinical research is an important element of the work done by the Brigham’s neuropsychiatrists. “We are really expanding our research as a way to grow our division,” Dr. Baslet said. “We are developing clinical trials that are at the cutting edge of research to try to better treat functional neurological disorders.” He is particularly excited about one trial that is looking at the role of inflammation in severe depression and targeting that inflammation as a treatment strategy.

The Future of Neuropsychiatry

Training the next generation of leaders in the field is another key component of the Brigham’s neuropsychiatry program. The Fellowship in Behavioral Neurology/Neuropsychiatry is available to those who have completed residencies in either neurology or psychiatry. It allows trainees to gain experience in both behavioral neurology, which focuses on cognitive impairment, and neuropsychiatry, which focuses on psychiatric and emotional disorders arising from neurological disease. Fellows spend two years learning to diagnose and treat a broad range of neuropsychiatric disorders. They also have the opportunity to pursue various areas of research.

Through Harvard Medical School, the Brigham is also involved in continuing medical education classes for those who are already practicing medicine and want a greater understanding of the depth and breadth of neuropsychiatry.

Bridge Clinic Connects People Struggling with Addiction to Much-Needed Services

Source: Brigham and Women's Hospital - On a Mission
Date: 01/16/2020
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The opioid epidemic in the United States is entering its third decade, and Brigham and Women’s Hospital has had a longstanding commitment to deliver care to those facing addiction to opioids as well as alcohol and other drugs. The Brigham’s Bridge Clinic, established in 2018, is the latest program aimed at reducing barriers to treatment. The clinic provides urgent, on-demand care while also helping patients transition to other, longer-term programs.

“If you look around the country, the vast majority of people who have substance-use disorders are not receiving any treatment whatsoever—about 90 percent are unable to access care,” said Joji Suzuki, MD, director of the Division of Addiction Psychiatry in the Brigham’s Department of Psychiatry. “This is in contrast to conditions like diabetes or heart disease, where most people are receiving treatment.”

Over the past decade, the Brigham has undertaken many efforts to expand access to substance use-disorder treatment for people who need it. These include launching a comprehensive outpatient clinic, establishing addiction treatment programs in primary care settings and assisting hospital teams in managing patients with substance-use disorders hospitalized for acute medical reasons.

“What we began to realize pretty quickly is that when we offer treatment for substance-use disorders to hospitalized patients who have come to the Brigham for another condition, they’re very willing to start addiction treatment,” Dr. Suzuki said. “But addiction treatment is relatively scarce, and patients often needed to wait weeks or even months to begin treatment. This was the primary motivation for the creation of the Bridge Clinic.”

A Walk-In Clinic With Several Paths of Referral

The Bridge Clinic, which is open during regular daytime hours as well as Tuesday evenings, is designed as a walk-in clinic. Although patients are asked to make appointments, it is set up to offer care whenever people show up. One reason the clinic can operate this way is that it is funded primarily by philanthropic support, rather than a fee-for-service model. Plans call for the clinic to expand its evening hours and open on weekends in the future.

“Our goal is to be flexible and to keep access as open as possible. This really flies in the face of how most hospitals have done addiction treatment in the past and all the barriers that have existed,” Dr. Suzuki said. “People are used to being given a list of phone numbers to call and then sent on their way. We are focused on retaining them in our clinic until we can help them get somewhere else.”

Patients are referred to the Bridge Clinic in many different ways. They may come through the emergency department, inpatient units, an outpatient clinic or one of the Brigham’s outpatient addiction programs.

A distinguishing feature of the Bridge Clinic is that it provides basic medical and psychiatric care in addition to addiction treatment. “The clinic includes primary care physicians, addiction psychiatrists, a nurse practitioner, a women’s health specialist, a peer recovery coach and a resource specialist,” Dr. Suzuki said. “We also have the ability to manage infectious disease complications, such as HIV, hepatitis C and bacterial infections, which are somewhat common in this population.”

The clinic staff also features recovery coaches who are in recovery themselves and help motivate and inspire patients.

Early Success in a Challenging Patient Population

Dr. Suzuki said that in the first year of the program, close to 200 patients were referred to the Bridge Clinic, and just under 90 percent showed up. The team is continuing to collect patient outcomes and plans to report on these soon, but the early signs indicate the program has been very successful in bridging patients to community programs for longer-term treatment.

“We’ve been very surprised at how good these outcomes are because this is a very challenging population to treat,” he concluded. “Many are homeless, and many have other medical comorbidities. The staff has done a tremendous amount of work to retain patients and to bridge them to other programs. I’m very proud of what we’ve accomplished so far.”

Care Model Has a Critical Impact on Patient Care in Psychiatry

Source: Brigham and Women's Hospital - On a Mission
Date: 01/30/2020
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For over 20 years, the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model has offered improved care for patients in need of psychiatric care in the primary care setting. At Brigham and Women’s Hospital, a collaborative care paradigm modeled on IMPACT is in the final stages of being rolled out to primary care practices throughout the system.

“This approach can also be valuable because it can facilitate more frequent clinical contacts with an interdisciplinary team around the assessment of a treatment response,” said Jane L. Erb, MD, psychiatric director, behavioral health integration into primary care. “We know that when PCPs have the proper tools, this practice can work well for many patients, like those with mild cases of depression or anxiety. At the same time, when a patient has greater needs, it’s important to have a system in place to ensure they get the specialized care they need.”

David S. Kroll, MD, associate vice chair for program development in the Department of Psychiatry, noted that depression is the leading cause of disability in the United States and suicide is the 10th leading cause of death. Even in a large metropolitan area like Greater Boston, however, patients can struggle to access psychiatric care services.

“The IMPACT model organizes the management of depression screening and referrals into a more systematic approach,” Dr. Kroll said. “Patients who just need first-line treatments can get them right away through primary care, while those who don’t respond or have more complex problems can be prioritized for referral to a psychiatry clinic.”

Making Depression Screening Central to Care

At the Brigham, depression screening has become a central part of care, in the same way that patients are screened for conditions like cardiovascular disease or diabetes. Questionnaires to screen for depression are given to patients to fill out in the waiting room, and PCPs can follow up with anyone who screens positive during their appointment.

Primary care offices have depression care specialists on staff to guide patients and later check in with them about issues like prescription fulfillment, side effects and the effectiveness of medications and counseling. At the Brigham, social workers collaborate with support specialists who proactively help patients with this treatment as well as other health conditions like diabetes and high blood pressure.

“The goal of this program is to administer first-line treatments to patients with straightforward cases of depression. This applies to the majority of the cases we see,” Dr. Kroll said. “First-line care may be medication or psychotherapy, or a combination of the two. This system works well because patients don’t have to wait to get an appointment with a psychiatrist who will ultimately give them the same treatment.”

Comprehensive Care for Complicated Health Issues

Dr. Erb noted that because many of the Brigham’s patients have complicated health issues requiring multiple medications, a primary care doctor should be taking the lead in managing all the prescriptions.

“The PCPs have a consulting psychiatrist to advise them on specific medications,” she said. “But because so many classes of drugs and conditions have side effects that affect patients psychologically or can interact with one another, it’s important to have someone with a comprehensive view who can put all the pieces together.”

According to Dr. Kroll, this approach can also be valuable because most patients see their PCPs more frequently than they would see a psychiatrist. As a result, if the treatment is not working or adjustments need to be made, the problem will be recognized sooner.

“The backbone of collaborative care is a treatment approach called measurement-based care,” Dr. Kroll explained. “This is a systematic way for us to map out each patient’s trajectory. It gives us a very good view of how they’re doing. The Brigham is bringing this kind of care into our routine practice throughout psychiatry.”

How the Brigham Meets the Psychiatric Needs of Patients in the Emergency Department

Source: Brigham and Women's Hospital - On a Mission
Date: 01/29/2020
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For many people, their first interaction with Brigham and Women’s Hospital is through the Emergency Department (ED). Usually, they are in a desperate state. As such, the ED is a critical place for patients who need acute psychiatric care.

At the EDs at Brigham and Women’s Hospital’s main campus in Boston’s Longwood/Harvard Medical School neighborhood and at the Brigham and Women’s Faulkner Hospital (BWFH) campus in Boston’s Jamaica Plain neighborhood, psychiatric care is woven into the fabric of emergency observation, diagnosis and care.

“Many other hospitals have a separate psychiatry emergency room, often called Psychiatric Emergency Services,” said Sejal B. Shah, MD, director of the Brigham’s Division of Medical Psychiatry. “But we work in conjunction with the ED to care for the patients. Any time someone comes into the ED and those caring for them think psychiatry could be helpful, someone from our psychiatry consultation service is called in. This may be a fellow, a resident or an attending, who then makes recommendations for psychiatric care to the ED clinicians.” This model keeps the patients under the direct care of the emergency department and avoids a feeling of separate mental health care and lack of emergency physician and nurse “ownership,” while providing close, expert specialty consultation and management.

Psychiatric Consults Lead to a Range of Care Approaches

A psychiatry consult may be needed for any number of reasons. A patient may come in after a suicide attempt or drug overdose. They may exhibit signs of psychosis. Or they may be experiencing delirium or hallucinations due to a medical illness like heart disease or a neurocognitive disorder.

For patients who ultimately are admitted to the hospital for their medical condition, members of the psychiatry consultation team continue to follow them on the medical and surgical floors. The Brigham psychiatry service is the most consulted service in the hospital, and has won awards from among all the services, year after year. For other patients, psychiatry consultants may recommend an inpatient psychiatric unit or outpatient intensive care, also called a partial hospitalization program. Consulting psychiatrists work collaboratively with team members across the ED and the rest of the hospital, including social workers, who may meet with family members or help patients access needed services.

“Many of the patients we treat are brought in because they’re experiencing some kind of psychiatric crisis,” said Naomi A. Schmelzer, MD, MPH, director of medical psychiatry at BWFH’s campus. “Many people lack access to the services they need, so the emergency room becomes their safety net when they’re in crisis.” She added that these patients may come in on their own or may be brought in by a concerned family member or another caregiver.

Getting Patients the Level of Care They Need

According to Dr. Shah, behavioral health issues represent about 8 percent of total ED visits nationally.

“BWFH’s campus is located near many nursing homes and group homes,” Dr. Shah noted. “When people who live in these facilities have a medical problem, whether it’s related to their psychiatric illness or not, they are often brought there.”

Dr. Schmelzer emphasized that the emergency medicine physicians at both hospitals are supportive of patients’ psychiatric needs and work to reduce any stigma patients may feel. “We collaborate well with them.” she said. “At BWFH, many of the ED patients are there for psychiatric reasons. The Psychiatry Consultation-Liaison service and the ED have instituted daily interdisciplinary rounds to review the care of all psychiatric patients in the ED.”

However, Dr. Shah cautioned, the best place to treat psychiatric illnesses is not in the ED.

“Our job is to stabilize patients and then help to figure out where they can get the level of care they need,” she said. “But as part of that, we may go ahead and start patients on an antidepressant or antipsychotic while they’re still in the emergency room. Or we make sure they get medication for substance withdrawal, if that’s what’s needed.”

“The emergency room doctors are our partners in making sure that these patients are treated appropriately and don’t fall through the cracks,” Dr. Shah concluded.

How to Cope with Stress and Anxiety during COVID-19

Source: Memorial Sloan Kettering
Date: 05/08/2020
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The COVID-19 pandemic is taking an emotional toll on people all over the world. Feelings of worry may seem overwhelming, especially if you were already coping with the stress and anxiety of a cancer diagnosis or cancer treatment. 

As a psycho-oncologist, Memorial Sloan Kettering’s Christian Nelson is dedicated to safeguarding the mental health and well-being of people with cancer both during and after treatment. “Feelings of uncertainty and a loss of control are some of the biggest sources of anxiety for people with cancer,” he says. “When you add COVID-19 into the mix, it makes the loss of control feel that much stronger.”

Dr. Nelson, who is Chief of the Psychiatry Service in the Department of Psychiatry and Behavioral Sciences, adds, “COVID-19 causes such intense feelings of uncertainty because we don’t know how long the pandemic will last or when we’re going to get back to our normal lives. Until that happens, the most important message for people with cancer is that MSK is here to help.”

Dr. Nelson provides some strategies to help people with cancer cope with anxiety and gain a sense of control over their lives during the COVID-19 pandemic.

1. Acknowledge your feelings.

Accept that this is a stressful time. There will be many emotional ups and downs. Many studies have shown that recognizing the sources of stress can help relieve it. “Acknowledging that others are experiencing the same stresses also normalizes the experience and can help you know you’re not alone,” Dr. Nelson says.

2. Create structure.

People going through cancer treatment are already knocked off their typical daily rhythms, and COVID-19 multiplies that. But having structure in your day can help lessen feelings of anxiety. Try to get up at the same time every morning. Take a shower and get dressed. Make a plan for what you want to do every day and schedule activities to help provide that sense of structure. “These things can help you feel more like yourself,” Dr. Nelson says.

3. Make connections.

Stay in touch with friends and family, whether on the phone or with video calls. It’s not the same as spending time with them in person, but it’s better than being isolated. Many community groups have created ways for people to engage with others online. Most religious organizations are running meetings and services by video. “My patients who connect with their friends through video calls tell me that it’s really helpful to not only hear people’s voices but to see their smiling faces,” Dr. Nelson says. (Devices are available to both inpatients and outpatients at MSK who would like to video chat with friends and family during an appointment or hospital stay.)

4. Engage in activities.

Brainstorm interesting, enjoyable, and meaningful activities that you can do at home, either alone or with others. This may be spending time with family, playing board games, reading, gardening, cooking, or some other hobby. Consider how you can give back to your community, too.

5. Focus on ways to destress.

Because of COVID-19, most people can’t do the things they normally do to relieve stress. Think about new or different ways to help reduce feelings of worry. It’s not one size fits all — it’s whatever works for you to relieve yourstress. If you like to exercise but can’t go to the gym like you usually do, try online classes or go on walks. “One of my patients started journaling, and he found it helpful to write every day about his life,” Dr. Nelson says. “Meditation is also good for many people, and you can easily do it at home.”

6. Trust your cancer care team.

A common concern among people with cancer is that treatment has changed because of the pandemic. Maybe it’s been delayed or the time increments have changed — for example, a therapy might be given every four or five weeks instead of every three weeks. It’s important that people speak with their cancer care team about these worries. “I assure my patients that MSK’s oncologists are managing all treatments exactly the way that they should be and always have our patients’ best interests and safety in mind,” Dr. Nelson notes.

7. Take advantage of virtual resources.

MSK is making many channels of online support available for people with cancer and their families during social distancing.

  • The MSK Counseling Center is providing care though telemedicine. Our counselors provide therapy to help individuals, couples, families, and caregivers cope with stress, anxiety, and other issues. Our psychiatrists can also prescribe medications to help with many mental health problems.
  • MSK’s Social Work staff is providing virtual support groups. Our regular social work programs remain available for patients.
  • Our Resources for Life After Cancer program offers virtual counseling and support groups for people who have completed their cancer treatment.
  • Our Integrative Medicine Service is providing online classes in yoga and other types of exercise. We also have mindfulness classes and offer a number of online meditation programs that people can do anytime to help relax, sleep, or cope with the side effects of treatment.
  • Connections, MSK’s online community, allows patients, caregivers, survivors, and friends to exchange support, information, and inspiration.

Revisiting the potential of using psychedelic drugs in psychiatry

Source: Cell Press
Date: 04/02/2020
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Before they were banned about a half century ago, psychedelic drugs like LSD and psilocybin showed promise for treating conditions including alcoholism and some psychiatric disorders. In a commentary publishing April 2 in the journal Cell, part of a special issue on medicine, researchers say it’s time for regulators, scientists, and the public to “revisit drugs that were once used but fell out of use because of political machinations, especially the war on drugs.”

Brain imaging over the past 20 years has taught scientists a lot about how these drugs act on different areas of the brain, says first author David Nutt (@ProfDavidNutt), a professor and neuropharmacologist at Imperial College London. “There’s mechanistic evidence in humans of how these drugs affect the brain,” he says. “By back-translating from humans to rodent models, we can see how these drugs produce the powerful neuroplastic changes that explain the long-term alterations we see in humans.”

Nutt is a prominent proponent of conducting controlled trials to examine the potential benefits of psychedelics. He is also chair of the scientific advisory board for COMPASS Pathways, a for-profit company that is leading clinical research to test the safety and efficacy of psilocybin-assisted therapy for treatment-resistant depression. The treatment has been granted breakthrough therapy designation from the US Food and Drug Administration. The group also plans to launch a similar study for obsessive-compulsive disorder.

In the Cell commentary, Nutt and his colleagues write about the “psychedelic revolution in psychiatry.” They explore specific questions in research, including what is known about the receptors in the brain affected by these drugs and how stimulating them might alter mental health. They also address what’s been learned so far about so-called microdosing, the value of the psychedelic “trip,” and what researchers know about why the effects of these trips are so long-lasting.

Brain imaging has shown that the activity of psychedelic drugs is mediated through a receptor in brain cells called 5-HT2A. There is a high density of these receptors in the “thinking parts of the brain,” Nutt explains.

The key part of the brain that appears to be disrupted by the use of psychedelics is the default mode network. This area is active during thought processes like daydreaming, recalling memories, and thinking about the future–when the mind is wandering, essentially. It’s also an area that is overactive in people with disorders like depression and anxiety. Psychedelics appear to have long-term effects on the brain by activating 5-HT2A receptors in this part of the brain. More research is needed to understand why these effects last so long, both from a psychological perspective and in terms of altered brain functioning and anatomy.

The authors note the challenges in obtaining materials and funding for this type of research. “Before LSD was banned, the US NIH funded over 130 studies exploring its clinical utility,” they write. “Since the ban, it has funded none.”

Nutt highlights the early potential of psychedelic drugs for treating alcoholism, which the World Health Organization estimates to be the cause of about one in 20 deaths worldwide every year. “If we changed the regulations, we would have an explosion in this kind of research,” Nutt says. “An enormous opportunity has been lost, and we want to resurrect it. It’s an outrageous insult to humanity that these drugs were abandoned for research just to stop people from having fun with them. The sooner we get these drugs into proper clinical evaluation, the sooner we will know how best to use them and be able to save lives.”

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The Beckley Foundation and the Alexander Mosley Charitable Trust supported much of the imaging and clinical work respectively. This research is also funded by the UK Medical Research Council. David Nutt is a scientific advisor to COMPASS Pathways. Co-author Robin Carhart-Harris is a scientific advisor to COMPASS Pathways and USONA.

Cell, Nutt et al. “Psychedelic psychiatry’s brave new world” https://www.cell.com/cell/fulltext/S0092-8674(20)30282-8