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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.

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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.

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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