Social Determinants of Mental Health and Clinical Updates Featured at Meeting

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CONFERENCE INSIDER

In its first year back in-person since the COVID-19 pandemic, the American Psychiatric Association 2022 Annual Meeting featured more than 300 sessions and 1000 posters discussing clinical updates, diversity and health equity, and technological issues. The meeting’s theme, “Social Determinants of Mental Health,” attracted leaders in the field from across the globe. Here you will find selected highlights. Additional coverage can be found at www.psychiatrictimes.com.conferences/apa.

More Than a Knockout: Structural Brain Effects in MMA Sparring

Heidi Anne Duerr, MPH

In a first-of-its-kind study, researchers examined the practice sparring’s effects of mixed martial arts (MMA) fighters and resulting brain changes.

Although previous studies have looked at other sports that involve repetitive brain injury, the real risk for MMA fighters occur during practice sessions, explained study co-author Aaron I. Esagoff, a medical student at Johns Hopkins University School of Medicine. While fights and matches only happen a few times per year, individuals can spend hundreds of hours sparring and practicing. MMA is a hybrid combat sport that includes moves from boxing, wrestling, karate, judo, and jujitsu.

“With MMA and a lot of combat sports, you are going to get hit in the head a good amount. And when you get hit a lot of times, that can lead to damage and disease,” Esagoff told attendees. The increasing awareness of repetitive brain trauma and its relationship to neuropsychiatric sequela inspired Esagoff and colleagues to conduct the study of MMA fighters.

To better understand the effects of the repetitive head impacts, the investigators conducted a cross-sectional study of 92 active professional MMA fighters, looking at the relationship between customary sparring practice rounds per week on white matter hyperintensity volume and regional brain volumes.

In doing so, Esagoff and colleagues found customary sparring practice rounds per week were significantly associated with increased white matter hyperintensity volume, which he noted may be indicative of damage (eg, axonal injury, vascular damage, etc). However, the investigators also found that customary sparring practice rounds per week were associated with increased relative size of the left and right caudate nucleus. The authors hypothesized that practice may help protect from injuries during official fights that damage the caudate.

“The one takeaway would be that sparring and practice is not all good or all bad, as there are some good effects, some not-as-good effects,” concluded Esagoff. “But it’s all an association for now; we’re not able to conclude anything with confidence.”

Esagoff’s co-authors included Michael J.C. Bray, MS; Andres A. Pasuizaca; Matthew E. Peters, MD; Bharat R. Narapareddy, MD; and Charles B. Bernick, MD.

Artificial Intelligence Revolution Holds Enormous Potential for Psychiatry

Erin O'Brien

Artificial intelligence (AI) is here to stay, and it’s really very important for the psychiatric field to take a leading role in developing it,” said P. Murali Doraiswamy, MBBS, FRCP, of the Duke University School of Medicine in Durham, North Carolina.

Doraiswamy was joined in a panel discussion by Robert M. Califf, MD, MACC, commissioner of food and drugs for the FDA, and moderator Samantha Boardman, MD, psychiatrist and author of Everyday Vitality: Turning Stress Into Strength.

“If I [were] a computer programmer describing the unmet needs in the mental health field, I would use a formula…something like this: 40, 40, 30, 0. This means only 40% of [individuals] who need care get access to the care they want; of those, only 40% get optimal care; of those, only 30% achieve remission; and 0%...get preventive care in terms of resilience,” Doraiswamy said. “That’s the problem in this field—and the hope and promise is that AI and technology can help with some of this.”

Doraiswamy noted that $4 billion has been invested in AI, which has been doubling every 3 months for the past few years and transforming multiple fields. In psychiatry, digital health coaching, stigma reduction, triage and suicide prediction, clinical decision support, and therapeutic apps have already had an impact, with therapeutic wearables, robots and virtual reality avatars, protocol standardization, quality control and practice management, and population forecasting on the horizon.

Mental health and wellness apps are particularly lucrative, with more than 5000 currently on the market and around 250 million individuals having accessed them in the past 2.5 years. Although some of these apps are FDA-approved—such as EndeavorRx for the treatment of pediatric attention-deficit/hyperactivity disorder and Somryst for chronic insomnia—it is important to note that many are neither approved nor overseen by the FDA unless they make a disease claim. In addition, many of these digital tools also provide inaccurate information, send data to third parties, and are based on “black box” algorithms rather than randomized controlled trials. However, recent data show that 82% of individuals believe robots can support their mental health better than humans can, because robots are unbiased, judgment free, and able to provide quick answers.

Clinicians have cited potential harms of AI, including diagnostic and treatment errors; a loss in creative clinical thinking; greater risks of dehumanization and jeopardization of the therapeutic process due to lack of empathy; and less privacy and more fatalism in general. Clinicians also worry that the machine’s reaching a diagnosis could become a “black box” process and that, if time saved is used by administrators to increase patient loads, it might increase clinician burnout.

Another potential concern for clinicians is job security given the fully automated psychiatrist, which is another form of AI in development. Doraiswamy emphasized that a development like this should be regarded as an enhancement of psychiatric practice. “This is not going to replace you,” said Doraiswamy. “This is a personal assistant that’s going to be sitting in the waiting room doing the initial interview intake, get all the intake ready, and then summarize this information and have it ready for you so that you can make a diagnostic assessment.”

Clinicians have also cited benefits of AI, including better outcomes through more standardized protocols and elimination of human error; less bias in regard to race or gender; and scalability of treatment. They say AI can encourage patients to answer truthfully and accept support more objectively, use big data more efficiently than humans, provide practical guidance for trainees, and help elucidate etiologies of diseases that are not well understood.

The evidence for the predictive benefits of AI for psychiatry is also growing. Recent research has found support that AI may be able to detect Alzheimer disease 5 years before diagnosis and predict depressive episodes and risk of suicide. In addition, it is possible that machine learning may be able to anticipate a mental health crisis using only data from electronic health records. “By and large, this shows you the promise,” noted Doraiswamy. Because DeepMind—owned by Google—recently released a general-purpose AI agent, “it’s probable that you could have one AI program that could help with all 159 diseases in the DSM-5,” Doraiswamy told attendees.

To maximize the potential benefits of AI and ensure that psychiatry leads this revolution, Doraiswamy recommended that the field develop clinical practice guidelines; provide proper education and training; ensure that cases are relevant and human centered; advocate for equitable, accountable AI; implement quality improvement methods into workflow; create benchmarks for “trusted and safe” apps; and work with payers to develop appropriate reimbursement.

“We need to step back and acknowledge that digitization in our society and broad access to the internet are having profound effects that we don’t yet understand—and that as we develop technologies with the plasticity that these technologies have, as opposed to traditional medical devices, you can change the software very quickly,” Califf said. “It’s a tremendous potential benefit, but it also carries very specific risks that we need to be aware of.”

“Some very reasonable [individuals] might argue that AI and psychiatry don’t belong even in the same sentence—that AI should play no role whatsoever in mental health care, and that the psychotherapeutic relationship is sacrosanct,” Boardman concluded. “But in a world where there are so many unmet mental health needs, I think there’s a very good argument that AI can not only improve care and diagnostics and increase access, but also reduce stigma and even flag potential issues and symptoms before they appear and reduce burnout among professionals.”

New Weapon in the Fight Against Opioid Use Disorders

Heidi Anne Duerr, MPH

The opioid epidemic has raged on despite the development of evidence-based treatment for opioid use disorders,” explained Kimberly Hu, MD. “About 70% of the nearly 71,000 drug overdose deaths in 8 states involved opioids. That’s a huge, staggering number.”

Recognizing the role that insufficient access to medications plays in this epidemic, Hu and colleagues at the Ohio State University Wexner Medical Center designed and implemented an opioid use disorder (OUD) curriculum for third-year medical students. In the study, the students (n=405) were provided with in-person or virtual buprenorphine waiver training and in-person clinical experiences between January 2019 and April 2021. Pre- and post-intervention tests, along with self-reported clinical management surveys, assessed the students’ ability to screen patients with OUD and manage acute and chronic pain. Paired sample t-tests were estimated to assess improvement in knowledge and approach to clinical management principles.

Hu, a resident at the Ohio State University Wexner Medical Center, and colleagues found a statistically significant increase in both their knowledge as seen in the pre- and post-test scores as well as their self-reported understanding of management principles. A follow-up study at the end of the year also provided positive feedback. Hu reported: “83% [of the participants] said that they felt they knew how to manage acute pain, about 62% felt that they knew how to manage chronic pain, and about 77% said that they knew how to screen the patient for opioid use disorder.”

This is important no matter which specialty the students pursue, as these students will be able to “link patients with resources early and make sure that there aren’t patients slipping through the cracks,” Hu explained.

She noted that educating third-year medical students gives them—and their future patients—an advantage. “They’re a little over halfway through medical school, and then they’ll go into residency in a number of different specialties. So giving them this knowledge early helps them to incorporate [the information and skills] as they continue their training.”

Hu noted that the educational program is ongoing and supported by the Substance Abuse and Mental Health Services Administration. Her study co-authors included Julie Niedermier, MD; Amanda Start, PhD; Casia Horseman, MD; and Julie Teater, MD.

“If we can educate the next generation physicians and increase access to care, this is one way we can combat the opioid crisis,” Hu concluded.

New Data Shows Trauma’s Ripple Effects

Heidi Anne Duerr, MPH

In a disaster, we naturally tend to pay attention toward the most immediate victims, so people who are impacted physically and with physical injuries and damages,” Gaëlle Rached, MD, MSc, told attendees during a new research presentation at the APA annual meeting. But what about the family members who live thousands of miles away?

Rached, a research postdoctoral fellow at Northwestern University, shared details about the events of August 4, 2020, when the residents of Beirut experienced a massive explosion as a result of improperly stored ammonium nitrate at the city’s port. More than 200 individuals were killed, and many more were injured and left homeless. Although Rached was in the city and saw firsthand the devastation and trauma, she found herself taken aback by the reports from expat friends and colleagues.

“They heard about the blast from social media, and they tried reaching out to their families, but they weren’t able to reach them,” she told attendees. “The lines weren’t connecting. They spent hours trying to reach them and thinking and imagining the worst… Can you imagine sitting at home looking at these headlines and wondering what your family is going through? Can you imagine seeing these videos shared over on social media and being stuck abroad due to COVID, not being able to help?”

As she talked with her colleagues about these experiences, she realized that the traumatic experiences were similar, “but somehow a little bit different.”

In general, expatriates are exposed to stressful living conditions, which makes them more susceptible to developing mental health problems, Rached noted. Yet their general mental health is not well studied, and even less is known about such in the context of traumatic events. Thus, Rached and colleagues conducted a 7-month study to examine the impact of the Beirut explosion on expats.

The study consisted of 670 Lebanese citizens or first generation from Lebanese descent who were residing abroad (not in Lebanon) and at least 18 years old. Of that population, 268 experienced the explosion and/or had close family members physically impacted by it. The median age was 31, and the majority (62.2%) were female. Participants came from all over the world, with the highest percentages coming from the United States and France. Study co-authors included Muriel Slim; Dimitri Fiani, MD; Margarita Abi Zeid Daou, MD; and Souraya Torbey, MD.

Participants were screened using the Hopkins Symptoms Checklist and the PTSD Checklist for DSM-5. Preliminary analysis found almost 60% of the 268 who had more personal experience had scores on the PTSD Checklist indicative of PTSD. Furthermore, about 41% of participants screened higher than the threshold for anxiety and depression on the Hopkins Symptom Checklist. Both younger age and female sex were associated with higher scores, even months after the event occurred.

Rached explained their results show expatriates’ mental health are negatively affected by traumatic events in their home countries:

Months following the traumatic event

Regardless of how long the expat has been away from their home country

Regardless of if they experienced the event or witnessed it firsthand

“My simple message would be that there are 200 million expats around the world right now. Look out for expats in your life—your friends, your coworkers, your colleagues—especially when the country is going through traumatic events,” Rached concluded.

Clearing the “Brain Fog” in Long COVID

Erin O'Brien

How can we “clear the fog” surrounding brain fog? Experts addressed the cognitive dysfunction, or brain fog, observed in patients with long COVID—as well as patients with fibromyalgia or chronic fatigue syndrome or those undergoing chemotherapy treatment.

Maria Tiamson-Kassab, MD, of the Moores Cancer Center at UC San Diego Health in California, introduced the session, which was delivered on behalf of the Academy of Consultation-Liaison Psychiatry. Durga Roy, MD, FACLP, of Johns Hopkins Bayview Neuropsychiatry Clinic and Johns Hopkins University School of Medicine in Baltimore, Maryland, discussed symptoms and pathophysiology of brain fog in long COVID, as well as some ways clinicians can help patients with brain fog after long COVID. Additional speakers included Jon Levenson, MD, of Columbia University Irving Medical Center, and Susan Abbey, MD, FRCPC, of the University of Toronto.

Tiamson-Kassab explained that brain fog is a nonmedical term used to describe what patients feel in any condition that causes confusion, memory loss, inability to concentrate or focus, and difficulty with word finding or multitasking. It is a symptom in many conditions, including long COVID, fibromyalgia, chronic fatigue syndrome, pregnancy, multiple sclerosis, and systemic lupus erythematosus, as well as in cancer treatments and certain medications. Neurocognitive domains affected in brain fog include planning; decision-making; processing speed; complex, divided, and selective sustained attention; free and cued recall; and working, procedural, and autobiographical memory.

Cognitive dysfunction is a particular concern in long COVID, as many patients have reported symptoms such as brain fog weeks or months after SARS-CoV-2 infection, Roy explained. Current definitions of long COVID differ. The National institute for Health and Care Excellence defines it as a constellation of symptoms that develop during or following SARS-CoV-2 infection that persist for 12 weeks or more; the World Health Organization defines it as persistent symptoms occurring 3 months from onset in individuals with past confirmed or probable SARS-CoV-2 infection and persisting for at least 2 months; and the CDC defines it as a range of symptoms that can last weeks or months after initial SARS-CoV-2 infection and can appear weeks after infection. In all cases, the symptoms cannot be sufficiently explained by any alternative diagnosis, and they can present even if the initial SARS-CoV-2 infection was mild or asymptomatic.

Although a range of symptoms may present, “fatigue and cognitive impairment appear to be the most debilitating symptoms of long COVID,” Roy explained. However, the exact cause of brain fog and other symptoms in long COVID is not yet clear. “We have to be cognizant of the fact that, potentially, anxiety and depression could be factors that are driving the fatigue and cognitive impairment,” Roy said. “And pathophysiology can stem from numerous hypotheses, neuroinflammation, or neurotropism, but the idea is that the frontal limbic pathway seems to consistently be something that we’re hearing about when it comes to cognitive problems in long COVID.”

In terms of treatment, Roy recommended both pharmacologic and nonpharmacologic interventions targeting mental fatigue and cognition. Pharmacologic interventions may include medications such as methylphenidate, donepezil, modafinil, luteolin, nicotinamide riboside, vitamin C or probiotic supplementation, monoclonal antibodies, or adaptogens. Suggested nonpharmacologic interventions include cognitive behavioral therapy, graded exercise therapy, pacing, and rehabilitation.

With studies on brain fog in long COVID still new and in development, Roy emphasized a need for more research to improve treatment and patient quality of life. “This is definitely a syndrome that we don’t know very much about,” Roy said. “It’s something that we really need to study more in order to get a better grasp on what’s going on.”