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class="text-sm text-gray-500"><div class="blockText_blockContent__TbCXh"></div><div class="clear-both"></div></div><div class="relative w-full py-4"><div class="flex items-center space-x-4 border-0 border-b border-secondary select-none py-1"><h2 class="text-3xl text-primary">Latest News</h2></div><div class="grid grid-cols-1 gap-4 md:grid-cols-2"><div class="col-span-1 md:col-span-2 relative pt-4"><div><div><div class="text-[8px] text-center text-gray-500 hidden"> </div><div id="div-gpt-ad-infeed-top"></div></div></div></div><div class="grid grid-cols-4 gap-3 mt-3 md:col-span-2"><a href="/view/psychiatric-times-through-the-years-the-last-5-years-in-january-covers"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%] md:rounded-bl-none md:rounded-tl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="Psychiatric Times Through the Years: the Last 5 Years in January Covers" title="Psychiatric Times Through the Years: the Last 5 Years in January Covers" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:cover"/><noscript><img alt="Psychiatric Times Through the Years: the Last 5 Years in January Covers" title="Psychiatric Times Through the Years: the Last 5 Years in January Covers" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3319a64a7a8d614c5625e47376bd495e5c2ed8c6-1920x1080.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3319a64a7a8d614c5625e47376bd495e5c2ed8c6-1920x1080.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3319a64a7a8d614c5625e47376bd495e5c2ed8c6-1920x1080.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:cover" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/psychiatric-times-through-the-years-the-last-5-years-in-january-covers">Psychiatric Times Through the Years: the Last 5 Years in January Covers</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/megan-mcsweeney">Megan McSweeney</a></span></div><p class="text-sm text-gray-500">January 31st 2025</p><p class="text-md block">Celebrate Psychiatric Times’ 40th anniversary with a look back at some of our previous covers. </p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/rural-realities-resilience-and-revelations-from-a-year-in-psychiatry"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="fotoworld/Adobe Stock" title="fotoworld/Adobe Stock" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="fotoworld/Adobe Stock" title="fotoworld/Adobe Stock" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff38dbdeea021e755403c76eb7e14cb26d2f4dd26-3674x2449.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff38dbdeea021e755403c76eb7e14cb26d2f4dd26-3674x2449.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff38dbdeea021e755403c76eb7e14cb26d2f4dd26-3674x2449.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/rural-realities-resilience-and-revelations-from-a-year-in-psychiatry">Rural Realities: Resilience and Revelations From a Year in Psychiatry</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/grace-lehnerdt-md">Grace Lehnerdt, MD</a></span></div><p class="text-sm text-gray-500">January 21st 2025</p><p class="text-md hidden">Facing limited resources, cultural barriers, and complex mental health cases, A newly qualified doctor’s year in rural South Africa offers a deep dive into psychiatry in underserved areas.</p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/breaking-down-barriers-to-quality-care-for-patients-with-schizophrenia"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="digital brain" title="digital brain" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="digital brain" title="digital brain" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7523aa9e92c5455af5ef1d6f1f97d247472e1097-4500x3000.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7523aa9e92c5455af5ef1d6f1f97d247472e1097-4500x3000.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7523aa9e92c5455af5ef1d6f1f97d247472e1097-4500x3000.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/breaking-down-barriers-to-quality-care-for-patients-with-schizophrenia">Breaking Down Barriers to Quality Care for Patients With Schizophrenia </a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/leah-kuntz">Leah Kuntz</a></span></div><p class="text-sm text-gray-500">January 17th 2025</p><p class="text-md hidden">Digital therapeutics may help improve negative symptoms associated with schizophrenia. </p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/disappointing-data-from-phase-iii-connex-for-iclepertin-in-addressing-cognition-impairment-in-schizophrenia"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="Disappointing Data From Phase III CONNEX for Iclepertin in Addressing Cognition Impairment in Schizophrenia" title="Disappointing Data From Phase III CONNEX for Iclepertin in Addressing Cognition Impairment in Schizophrenia" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="Disappointing Data From Phase III CONNEX for Iclepertin in Addressing Cognition Impairment in Schizophrenia" title="Disappointing Data From Phase III CONNEX for Iclepertin in Addressing Cognition Impairment in Schizophrenia" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/disappointing-data-from-phase-iii-connex-for-iclepertin-in-addressing-cognition-impairment-in-schizophrenia">Disappointing Data From Phase III CONNEX for Iclepertin in Addressing Cognition Impairment in Schizophrenia</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/heidi-anne-duerr-mph">Heidi Anne Duerr, MPH</a></span></div><p class="text-sm text-gray-500">January 16th 2025</p><p class="text-md hidden">Although iclepertin was found to be well tolerated, the agent did not meet endpoints. </p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/discontinuing-antipsychotics"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img 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AI Has Its Say" title="How ‘Real’ Are Psychiatric Disorders? AI Has Its Say" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="How ‘Real’ Are Psychiatric Disorders? AI Has Its Say" title="How ‘Real’ Are Psychiatric Disorders? 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AI Has Its Say</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/ronald-w-pies-md">Ronald W. Pies, MD</a></div><a href="/view/how-real-are-psychiatric-disorders-ai-has-its-say"><span class="text-sm text-gray-500 pl-4">December 27th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Perhaps, in our modern arguments over the reality of mental illness, we are merely reinventing the wheel—or maybe, just spinning our wheels.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/how-real-are-psychiatric-disorders-ai-has-its-say"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="flex md:hidden justify-center items-center"></div><div class="w-full h-full"><div 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src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F873006aedf137fcbcd042fe3c520c7a0f6d0df74-4896x3264.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/a-conversation-about-the-clozapine-rems">A Conversation About the Clozapine REMS</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/michael-asbach-dmsc-pa-c-psych-caq">Michael Asbach, DMSc, PA-C, Psych-CAQ</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/autumn-roque-dnp-aprn-pmhnp-bc">Autumn Roque, DNP, APRN, PMHNP-BC</a></div><a href="/view/a-conversation-about-the-clozapine-rems"><span class="text-sm text-gray-500 pl-4">December 23rd 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">An FDA committee recently decided the clozapine REMS protocol was no longer necessary. How will this impact clinicians?</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/a-conversation-about-the-clozapine-rems"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" 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title="antipsychotics" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdf8a0d9c55930cc286d385f6a4d7004bb2944806-5472x3648.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdf8a0d9c55930cc286d385f6a4d7004bb2944806-5472x3648.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdf8a0d9c55930cc286d385f6a4d7004bb2944806-5472x3648.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdf8a0d9c55930cc286d385f6a4d7004bb2944806-5472x3648.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdf8a0d9c55930cc286d385f6a4d7004bb2944806-5472x3648.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, 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ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">A recent longitudinal, retrospective study aimed to examine antipsychotic prescribing and rehospitalization rates in a forensic psychiatric sample.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/antipsychotic-prescriptions-and-rehospitalizations-in-a-forensic-psychiatry-sample"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " 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Dysfunction in Psychosis Explored at ACNP Meeting</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/heidi-anne-duerr-mph">Heidi Anne Duerr, MPH</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/m-belen-blasco">M Belén Blasco, MD</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/romina-mizrahi-md-phd">Romina Mizrahi, MD, PhD</a></div><a href="/view/synaptic-dysfunction-in-psychosis-explored-at-acnp-meeting"><span class="text-sm text-gray-500 pl-4">December 10th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">New research links reduced synaptic density,early psychosis, and cannabis use, offering insights into negative symptoms and potential interventions.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/synaptic-dysfunction-in-psychosis-explored-at-acnp-meeting"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="flex md:hidden justify-center items-center"></div><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/from-stupor-to-success-managing-catatonia-in-rural-south-africa"><div class=""><span 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gap-2"></div><p class=" mt-4 text-gray-800 pl-4">The presentation of catatonia can vary, making its management challenging, particularly in resource-limited settings in South Africa.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/from-stupor-to-success-managing-catatonia-in-rural-south-africa"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " 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style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/clinical-pearls-treating-trauma-and-psychosis"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:56.25%"></span><img alt="Clinical Pearls: Treating Trauma and Psychosis" title="Clinical Pearls: Treating Trauma and Psychosis" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" 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Treating Trauma and Psychosis</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/sripriya-chari-phd">Sripriya Chari, PhD</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/grace-eun-lee-phd">Grace Eun Lee, PhD</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/nichole-d-olson-phd">Nichole D. Olson, PhD</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/kate-v-hardy-psyd">Kate V. Hardy, PsyD</a></div><a href="/view/clinical-pearls-treating-trauma-and-psychosis"><span class="text-sm text-gray-500 pl-4">November 28th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Learn more about best practices when treating comorbid trauma and psychosis.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/clinical-pearls-treating-trauma-and-psychosis"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/study-finds-childhood-trauma-impacts-effectiveness-of-antipsychotic-medications"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:57.67307692307693%"></span><img alt="Schizophrenia" title="Schizophrenia" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="Schizophrenia" title="Schizophrenia" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1920&q=75 1920w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=2048&q=75 2048w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F045c74ea570b54030d94afb93fc1ed3c8904189c-5200x2999.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/study-finds-childhood-trauma-impacts-effectiveness-of-antipsychotic-medications">Study Finds Childhood Trauma Impacts Effectiveness of Antipsychotic Medications </a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/megan-mcsweeney">Megan McSweeney</a></div><a href="/view/study-finds-childhood-trauma-impacts-effectiveness-of-antipsychotic-medications"><span class="text-sm text-gray-500 pl-4">November 28th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">In a new study, researchers found the subtype of childhood trauma impacts the effectiveness of antipsychotic medications.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/study-finds-childhood-trauma-impacts-effectiveness-of-antipsychotic-medications"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/weiden-discusses-clozapine-rems-and-advisory-committees-recommendations"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:100%"></span><img alt="Peter J. 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Weiden, MD, Discusses Clozapine REMS Challenges and Advisory Committees' Recommendations</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/peter-j-weiden-md">Peter J. Weiden, MD</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/heidi-anne-duerr-mph">Heidi Anne Duerr, MPH</a></div><a href="/view/weiden-discusses-clozapine-rems-and-advisory-committees-recommendations"><span class="text-sm text-gray-500 pl-4">November 27th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">What does the clozapine REMS recommendations from the FDA Advisory Committees mean for clinical care? </p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/weiden-discusses-clozapine-rems-and-advisory-committees-recommendations"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/advocacy-group-applaud-joint-fda-committee-proposed-changes-to-clozapine-rems-requirements"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:125.12820512820512%"></span><img alt="Advocacy Group Applaud Joint FDA Committee Proposed Changes to Clozapine REMS Requirements" title="Advocacy Group Applaud Joint FDA Committee Proposed Changes to Clozapine REMS Requirements" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="Advocacy Group Applaud Joint FDA Committee Proposed Changes to Clozapine REMS Requirements" title="Advocacy Group Applaud Joint FDA Committee Proposed Changes to Clozapine REMS Requirements" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff547ece1e84a270217c6a3c18c4ef0686e058e8f-195x244.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff547ece1e84a270217c6a3c18c4ef0686e058e8f-195x244.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff547ece1e84a270217c6a3c18c4ef0686e058e8f-195x244.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff547ece1e84a270217c6a3c18c4ef0686e058e8f-195x244.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff547ece1e84a270217c6a3c18c4ef0686e058e8f-195x244.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, 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style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/advocacy-group-applaud-joint-fda-committee-proposed-changes-to-clozapine-rems-requirements">Advocacy Group Applaud Joint FDA Committee Proposed Changes to Clozapine REMS Requirements</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/heidi-anne-duerr-mph">Heidi Anne Duerr, MPH</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/gordon-lavigne-med">Gordon Lavigne, MEd</a></div><a href="/view/advocacy-group-applaud-joint-fda-committee-proposed-changes-to-clozapine-rems-requirements"><span class="text-sm text-gray-500 pl-4">November 26th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Gordon Lavigne, MEd, CEO of the Schizophrenia & Psychosis Action Alliance, talk about the joint FDA committee's vote on clozapine REMS.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/advocacy-group-applaud-joint-fda-committee-proposed-changes-to-clozapine-rems-requirements"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full 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","contentCategory":{"_createdAt":"2020-02-25T09:31:48Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Podcasts","_id":"93d57b69-2d72-45fe-8b8a-d18e7e7e5f20","_updatedAt":"2020-02-25T09:31:48Z"},"published":"2021-05-11T16:31:51.296Z","taxonomyMapping":[{"_ref":"pst_taxonomy_641_depression","_type":"reference","_key":"5908f4bfc3e7"},{"_ref":"pst_taxonomy_362_schizophreniapsychosis","_type":"reference","_key":"96c1fd1870c9"},{"_key":"51932eeaf6d4","_ref":"pst_taxonomy_394_substanceusedisorder","_type":"reference"}],"_id":"343e6eed-b436-4392-be9d-79296a0512eb"},{"is_visible":true,"url":{"current":"recognize-treat-traumatic-brain-injury","_type":"slug"},"contentCategory":{"_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Podcasts","_id":"93d57b69-2d72-45fe-8b8a-d18e7e7e5f20","_updatedAt":"2020-02-25T09:31:48Z","_createdAt":"2020-02-25T09:31:48Z"},"_id":"df456d96-2873-469e-aadc-99175b205c87","thumbnail":{"_type":"mainImage","asset":{"_ref":"image-882c03d79aad20809abba7ed419641756c66f364-3000x3000-jpg","_type":"reference"}},"_type":"article","title":"Recognize and Treat Traumatic Brain Injury","seoTag":["traumatic brain injury","depression","psychosis","suicide"],"summary":"Millions of Americans will suffer brain injuries this year, and many of them will need a psychiatrist’s help. ","body":[{"markDefs":[],"children":[{"marks":[],"text":"","_key":"c61811477d4e","_type":"span"}],"_type":"block","style":"normal","_key":"d244bf263a86"},{"_type":"iframe","_key":"a12836b39ec5","url":"https://embeds.audioboom.com/posts/7808025/embed/v4"},{"_key":"f8ad89658019","markDefs":[],"children":[{"text":"PSYCHPEARLS PODCAST","_key":"bbcc43bd52420","_type":"span","marks":["strong"]}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"March is brain injury awareness month. According to a study by the Centers for Disease Control, nearly 3 million individuals a year suffer a traumatic brain injury (TBI), and psychiatric disturbances are the most-common ","_key":"ccc580f571c20"},{"text":"long-term effects of these injuries","_key":"ccc580f571c21","_type":"span","marks":["d9d669c0713e"]},{"_type":"span","marks":[],"text":".","_key":"ccc580f571c22"}],"_type":"block","style":"normal","_key":"75d2e345d84a","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/pharmacological-management-psychiatric-aspects-traumatic-brain-injury","_key":"d9d669c0713e"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"In this edition of ","_key":"da09fe455c830"},{"_type":"span","marks":["em"],"text":"Psych Pearls","_key":"da09fe455c831"},{"_type":"span","marks":[],"text":", we speak to David Arciniegas, MD, about how to spot TBI and its psychiatric sequalae—and how to give effective treatment.","_key":"da09fe455c832"}],"_type":"block","style":"normal","_key":"3e40a478d77f"},{"_type":"block","style":"normal","_key":"03da52bb0c8e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"bb0f4b4c04720"}]},{"_type":"block","style":"normal","_key":"b0ce2d244426","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Arciniegas ","_key":"fcaf8ad96b870"},{"_type":"span","marks":["em"],"text":"is professor and senior research neuropsychiatrist in the Department of Psychiatry and Behavioral Sciences at the University of New Mexico School of Medicine. He is director of research at the Marcus Institute for Brain health and editor of the ","_key":"fcaf8ad96b871"},{"marks":[],"text":"Journal of Neuropsychiatry and Clinical Neurosciences.","_key":"fcaf8ad96b872","_type":"span"}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"9295895cde530"}],"_type":"block","style":"normal","_key":"6b230f00ac54","markDefs":[]}],"published":"2021-02-23T22:27:51.516Z","_rev":"lcksSrK6MQ8IAMSXDurZd6","authorMapping":[{"_ref":"pst_author_625280","_type":"reference","_key":"348f0dd93e08"}],"documentGroup":null,"_updatedAt":"2021-02-23T22:29:32Z","link":"/view/recognize-treat-traumatic-brain-injury","updatedOn":null,"_createdAt":"2021-02-23T22:29:32Z","taxonomyMapping":[{"_type":"reference","_key":"a31a2c371e57","_ref":"pst_taxonomy_351_psychosomatics"},{"_type":"reference","_key":"efbe05e3115e","_ref":"pst_taxonomy_641_depression"},{"_ref":"pst_taxonomy_362_schizophreniapsychosis","_type":"reference","_key":"4c0524d14fb8"},{"_ref":"pst_taxonomy_35_neuropsychiatry","_type":"reference","_key":"f0cdbd94d692"}]},{"summary":"Although the diagnostic criteria used in children are the same as adults, there are some key differences in clinical presentation of psychotic features. More in this podcast about childhood schizophrenia.","documentGroup":null,"_type":"article","link":"/view/realities-childhood-schizophrenia","updatedOn":null,"taxonomyMapping":[{"_ref":"pst_taxonomy_362_schizophreniapsychosis","_type":"reference","_key":"908c363f4ece"}],"is_visible":true,"_id":"9034e4eb-4a35-4477-9e0c-9a268a6e7aab","_updatedAt":"2020-08-16T18:28:48Z","authorMapping":[{"_ref":"pst_author_695235","_type":"reference","_key":"e4d5ff5367a3"}],"thumbnail":{"_type":"mainImage","asset":{"_ref":"image-882c03d79aad20809abba7ed419641756c66f364-3000x3000-jpg","_type":"reference"}},"_createdAt":"2020-07-21T13:15:32Z","url":{"current":"realities-childhood-schizophrenia","_type":"slug"},"contentCategory":{"_createdAt":"2020-02-25T09:31:48Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Podcasts","_id":"93d57b69-2d72-45fe-8b8a-d18e7e7e5f20","_updatedAt":"2020-02-25T09:31:48Z"},"title":"The Realities of Childhood Schizophrenia","seoTag":["schizophrenia"],"published":"2020-07-21T04:00:00.000Z","body":[{"_type":"iframe","_key":"ba7428b477c5","url":"https://embeds.audioboom.com/posts/7637016/embed/v4"},{"_type":"block","style":"normal","_key":"a6befa297bdd","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"PSYCHPEARLS PODCAST","_key":"a6befa297bdd0"}]},{"style":"normal","_key":"51b30bce5666","markDefs":[{"blank":true,"_type":"link","href":"https://www.communitypsychiatry.com/locations/sacramento/","_key":"b22b4d466f7e"}],"children":[{"_key":"51b30bce56660","_type":"span","marks":[],"text":"Child and adolescent psychiatrist Abhijit Ramanujam, MD, discusses clinically relevant issues in childhood schizophrenia. Dr Ramanujam is Regional Director of "},{"text":"Community Psychiatry, Sacramento, CA","_key":"51b30bce56661","_type":"span","marks":["b22b4d466f7e"]},{"_type":"span","marks":[],"text":".","_key":"51b30bce56662"}],"_type":"block"},{"children":[{"_type":"span","marks":["em"],"text":"Transcript edited for clarity. -Ed","_key":"7559f5ab1ae50"}],"_type":"block","style":"normal","_key":"7559f5ab1ae5","markDefs":[]},{"children":[{"_type":"span","marks":["strong"],"text":"Laurie Martin (LEM): How common is schizophrenia in children under the age of 18?","_key":"f6967af2965a0"}],"_type":"block","style":"normal","_key":"f6967af2965a","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Abhijit Ramanujam, MD:","_key":"756131ea7a670"},{"text":" The worldwide prevalence of early onset schizophrenia,that is symptoms prior to the age of 18yrs is estimated to be about 0.5% of the population,whereas childhood onset or very early onset schizophrenia which begins prior to the age of 13, has been estimated to be around 0.04% in the United States.Much less is known about the prevalence of childhood onset schizophrenia internationally.","_key":"756131ea7a671","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"756131ea7a67"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: Is there an age in which a child is too young to consider a diagnosis of schizophrenia? What do we know about early detection of schizophrenia and how soon can it be diagnosed?","_key":"f2c3053c836b0"}],"_type":"block","style":"normal","_key":"f2c3053c836b"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Abhijit Ramanujam, MD:","_key":"89f7ae083b860"},{"marks":[],"text":" Although there is no official age considered too young for a diagnosis of schizophrenia, we have to keep in mind that childhood-onset schizophrenia that starts before aged 13 years is extremely rare.","_key":"89f7ae083b861","_type":"span"}],"_type":"block","style":"normal","_key":"89f7ae083b86"},{"_key":"b60200adf212","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Whenever a child is suspected of having schizophrenia, the clinical assessment should include a thorough personal, medication, psychosocial and family history as well as physical examination, neurological work-up, laboratory evaluation, and collateral information from family and schools.","_key":"b60200adf2120"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"39ea0c5dd3c3","markDefs":[],"children":[{"_key":"39ea0c5dd3c30","_type":"span","marks":[],"text":"In terms of diagnosis, DSM-5 diagnostic criteria for schizophrenia in childhood and adolescence are the same as those used for adult disorders. They include the presence of significant positive and negative symptoms during a 1-month period (such as delusions or hallucinations, disorganized speech, catatonic behavior, and negative symptoms such as lack of motivation and lack of socialization). Disturbance of functioning in 1 or more major areas and continued signs of disturbance for at least 6 months, as well as the exclusion of other psychiatric or medical diagnoses."}]},{"markDefs":[],"children":[{"text":"Although the diagnostic criteria used in children are the same as those for adults, there are some key differences in clinical presentation:","_key":"955c8fa6803e0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"955c8fa6803e"},{"children":[{"text":"• Usually hallucinations are much more common than delusions in youth with schizophrenia as compared to adults. The most common hallucinations are auditory with comments or commands. These are often accompanied by visual and tactile hallucinations.","_key":"9ad3d4404e950","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"9ad3d4404e95","markDefs":[]},{"markDefs":[],"children":[{"text":"• Although hallucinations are more common, they are least likely to reported. Many youths may not disclose auditory hallucinations since they are scared that the voices may harm them.There may also be delusions associated with it such as \"The voices tell me that they will kill me if I talk about them to anyone.\"","_key":"69bc4ad3c8560","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"69bc4ad3c856"},{"style":"normal","_key":"4c58480ffe65","markDefs":[],"children":[{"_type":"span","marks":[],"text":"• Children and adolescents are more likely to exhibit negative symptoms such as being socially aloof or having a flat affect which can sometimes be mistaken for depression or lack of motivation for plain laziness as I have actually heard some of the parents describe it.","_key":"4c58480ffe650"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"• Cognitive decline, in particular verbal memory, attention, and concentration, is significantly affected. Delay in language, motor, and social development, and delay or deviation in developmental milestones may be pronounced as well in childhood-onset schizophrenia; although these delays are not diagnostic, they are commonly observed.","_key":"0e5073852edc0"}],"_type":"block","style":"normal","_key":"0e5073852edc"},{"style":"normal","_key":"8ab354fa08d8","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: What are the most commonly confused causes of schizophrenia-like behaviors?","_key":"8ab354fa08d80"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Abhijit Ramanujam, MD:","_key":"280868028cd10"},{"_type":"span","marks":[],"text":" There are many other disorders that can be confused with schizophrenia-like behaviors.","_key":"280868028cd11"}],"_type":"block","style":"normal","_key":"280868028cd1"},{"children":[{"_type":"span","marks":[],"text":"The most common one I see is PTSD. PTSD symptoms can include flashbacks which some patients may describe as auditory hallucinations. Hypervigilance and flashbacks together can often be misinterpreted as paranoia and hallucinations. However, you will notice less disorganized thinking and usually symptoms begin after a traumatic event.","_key":"2564f2f73d6b0"}],"_type":"block","style":"normal","_key":"2564f2f73d6b","markDefs":[]},{"style":"normal","_key":"8a6869d45559","markDefs":[],"children":[{"marks":[],"text":"Another area is autism spectrum disorders. Misdiagnosis of autism spectrum disorders as a psychotic disorder also occurs very commonly. Common features such as impairment in social communication can be misinterpreted as negative symptoms of psychosis. Stereotyped use of language seen in autism can be confused with disorganized speech.","_key":"8a6869d455590","_type":"span"}],"_type":"block"},{"style":"normal","_key":"0b22389f5975","markDefs":[],"children":[{"_key":"0b22389f59750","_type":"span","marks":[],"text":"It is very important to obtain a thorough developmental history and a baseline thought processes which helps distinguish these 2 diagnoses."}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"Some patients may have a comorbid diagnosis of autism spectrum disorder and schizophrenia. In these cases, you will see a new onset delusion or hallucination lasting longer than 1 month. Disordered or delusional thinking will be distinctly different from the baseline. We usually notice a significant deterioration of social and general functioning with comorbid diagnoses. I sometimes noticed this in children who have been through multiple foster homes. A baseline thought process is difficult to establish in this case since past history is not readily available. These children are more likely to be wrongly diagnosed as having a disorganized thinking process as opposed to a social communication issue.","_key":"451e5179f80f0"}],"_type":"block","style":"normal","_key":"451e5179f80f","markDefs":[]},{"_key":"cd28b8ab9c4b","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Schizoaffective disorder can be a difficult one to differentiate since a psychotic syndrome continues to evolve as a child progresses through the developmental process. Again, a thorough longitudinal symptom assessment would help distinguish the 2.","_key":"cd28b8ab9c4b0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"e778633db639","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Major depressive disorders with psychotic features or bipolar disorder with psychosis should also be considered very carefully. Usually in depression with psychotic features, the psychosis is generally seen when the depressive disorder has significantly worsened. Guilt dominates in depressive psychosis. In case of bipolar disorder with psychotic features, you generally see psychosis during severe episodes of mood and not during lucid intervals.","_key":"e778633db6390"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Another area that is very important to remember is that in very young children before the age of 6, anxiety can itself present as hallucinations. Many children with symptoms of anxiety report, \"Someone called my name;\" they may also report visual hallucinations such as \"Mama, I see a shadow every night passing by.\" Most of these children are healthy and nonpsychotic.","_key":"b486a28dbf1e0"}],"_type":"block","style":"normal","_key":"b486a28dbf1e"},{"_type":"block","style":"normal","_key":"efa06877fdb9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Anxiety-related visual hallucinations are very common in preschool children. Usually in the history, you will notice that there will be a precipitating event such as watching a scary movie or video game that triggered such reactions. Whereas in early-onset schizophrenia, you will notice a decline in cognitive function, attention, and concentration, as well as the presence of negative symptoms which indicate psychosis.","_key":"efa06877fdb90"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Sometimes, substance-induced psychosis that is secondary to steroid use can present very similarly to a primary psychotic disorder. Urine toxicology screens are very important. It is also important to remember that many of the newer recreational drugs may not be detected in current screens; hence a thorough history will help us distinguish between the 2.","_key":"cdae79f31dcd0"}],"_type":"block","style":"normal","_key":"cdae79f31dcd"},{"style":"normal","_key":"0b25fc36a219","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In case of delirium, look for waxing and waning of symptoms or evidence of ingestion of substance or any other metabolic abnormalities, since these are usually seen in delirium and not a psychotic illness.","_key":"0b25fc36a2190"}],"_type":"block"},{"_type":"block","style":"normal","_key":"0d460c30baea","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Other medical conditions may also mimic psychotic symptoms. Those include:","_key":"0d460c30baea0"}]},{"_key":"7b308cbee88a","markDefs":[],"children":[{"marks":[],"text":"• Seizure disorder","_key":"7b308cbee88a0","_type":"span"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"3fba26f72de9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"• Medication induced","_key":"3fba26f72de90"}]},{"_type":"block","style":"normal","_key":"6ce16adc8fb6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"• Encephalitis","_key":"6ce16adc8fb60"}]},{"_key":"c560689e5c67","markDefs":[],"children":[{"_type":"span","marks":[],"text":"• Autoimmune disorder, such as systemic lupus erythematosus","_key":"c560689e5c670"}],"_type":"block","style":"normal"},{"_key":"722263f7c728","markDefs":[],"children":[{"_type":"span","marks":[],"text":"• Metabolic disorder, such as Wilson disease","_key":"722263f7c7280"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"061b9049a992","markDefs":[],"children":[{"text":"CASE VIGNETTES","_key":"061b9049a9920","_type":"span","marks":["strong"]}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"I am only mentioning the positive pertinent factors in each of the following 3 cases for the sake of brevity. All names and identifying factors have been changed. This is for clinical purposes only.","_key":"d68f5de30f980"}],"_type":"block","style":"normal","_key":"d68f5de30f98"},{"children":[{"_key":"96c09da6f1b30","_type":"span","marks":["strong","em"],"text":"Case presentation 1: Oppositional or something else?"}],"_type":"block","style":"normal","_key":"96c09da6f1b3","markDefs":[]},{"_key":"b6c24f6c71a2","markDefs":[],"children":[{"marks":[],"text":"PR is a 17-year-old boy who initially brought in by his father with chief complaints of “very oppositional, up to something, secretive, and angry.”","_key":"b6c24f6c71a20","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"text":"The father appeared remorseful due to his \"busy schedule\" for the last 3 to 4 years. His being away also coincided with a gradual deterioration of his son.","_key":"6efed57930530","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"6efed5793053"},{"children":[{"text":"PR refused to talk other than state, \"I hate them\" [my parents].","_key":"da26a1ec8f100","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"da26a1ec8f10","markDefs":[]},{"_key":"5af9d1182be8","markDefs":[],"children":[{"_key":"5af9d1182be80","_type":"span","marks":[],"text":"Neuropsychological tests, detailed medical examinations, laboratory tests, and a urine drug screen came back negative; the clinical picture became clearer as we obtained collateral information."}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"870119493e0d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The mother described her son demonstrated bizarre behavior. She also hesitatingly disclosed family psychiatric issues (many relatives with schizophrenia), which was initially minimized. “It is a taboo and we do not talk about it,” she said.","_key":"870119493e0d0"}]},{"style":"normal","_key":"9ff322a81435","markDefs":[],"children":[{"_type":"span","marks":[],"text":"His siblings disclosed they are fearful of him \"Since he stays up all night and talks to himself. He does not seem like our brother anymore.\"","_key":"9ff322a814350"}],"_type":"block"},{"_key":"9683ce627feb","markDefs":[],"children":[{"text":"School reported he was growing increasingly isolative and suspicious of other kids. His grades kept falling. Teachers also responded behavior that was indicative of PR being internally preoccupied.","_key":"9683ce627feb0","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The approach of the parents changed from “the boy just needs good disciplining” to a gradual understanding and compliance with the treatment plan.","_key":"205d91e91c0d0"}],"_type":"block","style":"normal","_key":"205d91e91c0d"},{"_key":"75bf6f4b1cad","markDefs":[],"children":[{"_type":"span","marks":[],"text":"I will discuss the treatment plan further below. But before that I would like to say that PR is doing much better than he was 3 years ago.","_key":"75bf6f4b1cad0"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Case presentation 2: “The adopted boy who was ‘psychotic.’”","_key":"692ec87b59db0"}],"_type":"block","style":"normal","_key":"692ec87b59db"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"A was adopted at age 3 and was brought in for an evaluation by his adoptive mother at age 9. The adoptive mother insisted he was “psychotic” and fearful of ingesting food because he thought his mother had poisoned it.","_key":"026296128a090"}],"_type":"block","style":"normal","_key":"026296128a09"},{"_key":"82671d9ab6a6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"On examination, the boy was found to have significant anxiety, ADHD symptoms, and social communication disorder.","_key":"82671d9ab6a60"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"His fear of contamination was misinterpreted as paranoia and delusional. He had also watched a “cold cases” forensic science documentary along with his brother a few months ago which was the precipitating factor. Further information revealed he had a family history of anxiety disorder but no family history of schizophrenia.","_key":"e603d8f8657c0","_type":"span"}],"_type":"block","style":"normal","_key":"e603d8f8657c"},{"_key":"58d7220654d0","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Case presentation 3: “My daughter is hearing voices.”","_key":"58d7220654d00"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"SK is a 7-year-old girl who was brought in for auditory hallucinations. A detailed history revealed a traumatic past (she had witnessed domestic violence). Although currently she lives in a safe environment, she continued to experience flashbacks in the form of auditory hallucinations. There was no family history of psychotic disorders.","_key":"5f67bd28cb280"}],"_type":"block","style":"normal","_key":"5f67bd28cb28"},{"_type":"block","style":"normal","_key":"8bc7fdc7bf46","markDefs":[],"children":[{"_type":"span","marks":[],"text":"After 6 months of cognitive behavioral therapy and trauma-related behavioral therapy, the patient is doing significantly better.","_key":"8bc7fdc7bf460"}]},{"_key":"80b4469f31c9","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: What are some of the common therapeutic approaches in the treatment of childhood schizophrenia?","_key":"80b4469f31c90"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"b01dca8d6504","markDefs":[],"children":[{"_key":"b01dca8d65040","_type":"span","marks":["strong"],"text":"Abhijit Ramanujam, MD: "},{"_type":"span","marks":[],"text":"We can divide this into 2 sections.","_key":"b01dca8d65041"}]},{"_type":"block","style":"normal","_key":"afa21fcaca38","markDefs":[],"children":[{"_type":"span","marks":["em","strong"],"text":"Treatment during the prodromal stage.","_key":"afa21fcaca380"},{"_key":"afa21fcaca381","_type":"span","marks":["strong"],"text":" "},{"_type":"span","marks":[],"text":"In this stage, medications are aimed at delaying or stopping progression to psychotic disorder amongst children who are considered high risk or those that have prodromal symptoms, such as disorganized behavior, paranoia or suspicion, or any unusual thought content that is below the threshold of a full-blown psychotic disorder.","_key":"afa21fcaca382"}]},{"markDefs":[],"children":[{"_key":"a662cb5829a50","_type":"span","marks":[],"text":"Several medications have been tested in clinical trials. Trials of omega-3 fatty acids have shown mixed results. However, although clinical trials are mixed given the positive potential effects as well as the limited adverse effects of omega-3 fatty acids make it a good choice to consider."}],"_type":"block","style":"normal","_key":"a662cb5829a5"},{"markDefs":[],"children":[{"marks":[],"text":"Selective serotonin reuptake inhibitor antidepressants have been shown to be helpful in two naturalistic studies but have not been tested in a clinical trial. Initiating SSRIs along with omega-3 fatty acids is a grade 2 recommendation which basically means this is a suggestion, but clinicians could choose a reasonable alternative.","_key":"fc29384884480","_type":"span"}],"_type":"block","style":"normal","_key":"fc2938488448"},{"_type":"block","style":"normal","_key":"14c5bbfdaeb6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Clinical trials have not found antipsychotics to be efficacious in terms of delaying or preventing progression to psychosis.","_key":"14c5bbfdaeb60"}]},{"style":"normal","_key":"7b533fdf9b79","markDefs":[],"children":[{"text":"Treatment of schizophrenia in youth. ","_key":"7b533fdf9b790","_type":"span","marks":["em","strong"]},{"_key":"7b533fdf9b791","_type":"span","marks":[],"text":"Antipsychotics are first-line treatment for confirmed schizophrenia. Several randomized trials have shown that antipsychotics reduce positive symptoms of schizophrenia, such as hallucinations and delusions. Antipsychotics eliminate or reduce the symptoms to a tolerable level in about 70% of the patients with schizophrenia."}],"_type":"block"},{"style":"normal","_key":"203a51aa3a31","markDefs":[],"children":[{"marks":[],"text":"Negative symptoms of schizophrenia, such as diminished emotional expression or lack of motivation is a little more difficult to treat.","_key":"203a51aa3a310","_type":"span"}],"_type":"block"},{"markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/view/clozapine-ages","_key":"25c30ecb8e59","blank":true}],"children":[{"marks":[],"text":"We generally follow the age guidelines from the indications approved by the FDA in the United States which were based on the age of enrollees in the efficacy trials of antipsychotics in children with schizophrenia. These medications are aripiprazole, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ","_key":"d48f5c2ff0120","_type":"span"},{"_type":"span","marks":["25c30ecb8e59"],"text":"clozapine","_key":"d48f5c2ff0121"},{"marks":[],"text":", and the first-generation agents, chlorpromazine, haloperidol, and perphenazine.","_key":"d48f5c2ff0122","_type":"span"}],"_type":"block","style":"normal","_key":"d48f5c2ff012"},{"_type":"block","style":"normal","_key":"a726f933801f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The current recommendation is to start with a second-generation antipsychotic with lower sedation and fewer problems with metabolic syndrome.","_key":"a726f933801f0"}]},{"children":[{"_type":"span","marks":[],"text":"Clinical trials have not consistently found any one antipsychotic more effective than the others except clozapine, but due to adverse effects, it is reserved for use in treatment-resistant schizophrenia.","_key":"8b5ac6e6ec030"}],"_type":"block","style":"normal","_key":"8b5ac6e6ec03","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"Hence, clinicians can select 1 amongst the above medications, based on patient age and medication adverse effect profile.","_key":"b2e995e4b5be0"}],"_type":"block","style":"normal","_key":"b2e995e4b5be","markDefs":[]},{"style":"normal","_key":"4c41df225531","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: Can you talk about cardiometabolic risks or any other risks of treatment with antipsychotics, and do they outweigh clinical benefits?","_key":"4c41df2255310"}],"_type":"block"},{"_type":"block","style":"normal","_key":"768c140b60e0","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Abhijit Ramanujam, MD: ","_key":"768c140b60e00"},{"_type":"span","marks":[],"text":"The adverse effect profiles of individual antipsychotic drugs vary widely. Children and adolescents compared with adults are at a high risk of many of the adverse effects associated with antipsychotic use","_key":"768c140b60e01"}]},{"markDefs":[],"children":[{"text":"Common adverse effects associated with second-generation antipsychotics include weight gain and related metabolic effects, sedation, anticholinergic symptoms, elevated prolactin levels and extrapyramidal symptoms, cardiac effects, and sexual dysfunction.","_key":"aef668be86370","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"aef668be8637"},{"_key":"b2441a9d1b95","markDefs":[],"children":[{"marks":[],"text":"Many of these drugs increase appetite and alter metabolic control. Children who are more vulnerable to these adverse effects are those with pre-existing conditions, such as obesity, diabetes, or elevated cholesterol. Clozapine and olanzapine carry significantly higher risk than other antipsychotics, whereas lurasidone and to an extent aripiprazole are associated with the lowest risk.","_key":"b2441a9d1b950","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Clinicians should conduct routine short and long-term monitoring of weight, waist circumference, blood pressure, fasting glucose, and lipid profile of patients taking any of the antipsychotic drugs. For patients in whom weight gain is a concern, we tend to prescribe lurasidone. Whenever possible, we tend to avoid medication such as olanzapine which has a higher rate of metabolic abnormality.","_key":"5129619e45fd0"}],"_type":"block","style":"normal","_key":"5129619e45fd"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Tardive dyskinesia is characterized by involuntary movements of the mouth, tongue, face, extremities, or trunk (including lip-smacking, tongue, and jaw movements, and facial grimacing). The symptoms are often initially mild; however, they can progress and become disfiguring or disabling. Tardive dyskinesia risk increases with age, time of exposure to medications, and prior development of extrapyramidal symptoms (EPS).","_key":"c3d7e324defb0"}],"_type":"block","style":"normal","_key":"c3d7e324defb"},{"style":"normal","_key":"5b2746301e78","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/advances-tardive-dyskinesia-review-recent-literature","_key":"dc35bd8a0bcb"}],"children":[{"_key":"5b2746301e780","_type":"span","marks":[],"text":"However "},{"text":"tardive dyskinesia","_key":"5b2746301e781","_type":"span","marks":["dc35bd8a0bcb"]},{"_type":"span","marks":[],"text":" is less common in youth compared with adult and older adult populations—0.4% versus 6.8%.","_key":"5b2746301e782"},{"_key":"5b2746301e783","_type":"span","marks":["superscript"],"text":"1,2"}],"_type":"block"},{"markDefs":[],"children":[{"marks":[],"text":"The risk of tardive dyskinesia in children appears to be the greatest with first-generation antipsychotics with minimal or no risk seen with second-generation antipsychotics.","_key":"8ef22db6506f0","_type":"span"},{"_key":"8ef22db6506f1","_type":"span","marks":["superscript"],"text":"3"},{"_key":"8ef22db6506f2","_type":"span","marks":[],"text":" Clozapine has not shown to cause tardive dyskinesia. Patients on these medications should be formally assessed for tardive dyskinesia at least annually. Older adults should be assessed every 6 months."}],"_type":"block","style":"normal","_key":"8ef22db6506f"},{"markDefs":[],"children":[{"marks":[],"text":"Nausea and sedation are common adverse effects of antipsychotic treatment in all patients, but they often remit over time and should not be considered a reason to terminate treatment. As mentioned earlier although no one antipsychotic is better than the other, for patients with prominent insomnia we tend to use quetiapine.","_key":"b64f88485ec60","_type":"span"}],"_type":"block","style":"normal","_key":"b64f88485ec6"},{"style":"normal","_key":"e77ec2c81d0e","markDefs":[],"children":[{"text":"Clinicians should routinely assess for fall risks in vulnerable population, given that many of these medications cause sedation as well as orthostatic hypotension. Anticholinergic effect, such as constipation, dry mouth, blurry vision, and urinary retention are fairly common. In the case of clozapine sialorrhea rather than dry mouth is common.","_key":"e77ec2c81d0e0","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["em","strong"],"text":"Extrapyramidal adverse effects.","_key":"cac2bda5d1930"},{"_type":"span","marks":[],"text":" Second-generation antipsychotics have reduced incidence of akathisia, rigidity, bradykinesia, dysphagia, tremor, and acute dystonic reactions that constitute EPS. Among the second-generation antipsychotics, risperidone carries the highest risk, especially at doses greater than 4 mg/day; elevated risk is also noted with aripiprazole, asenapine, and lurasidone. Quetiapine and clozapine are preferred agents in patients with high risk for EPS. Patients on second-generation agents should be asked about restlessness, slow movements, shaking, and rigidity at baseline and weekly during dose increases.","_key":"cac2bda5d1931"}],"_type":"block","style":"normal","_key":"cac2bda5d193"},{"_key":"86542769e26a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"We usually start with a second-generation antipsychotics because of their lower rates of extrapyramidal symptoms and tardive dyskinesia compared with the first-generation antipsychotics.","_key":"86542769e26a0"}],"_type":"block","style":"normal"},{"children":[{"marks":[],"text":"Prolactin elevation can occur in both men and women. Accordingly, patients may experience gynecomastia, galacturia, menstrual disturbance sexual dysfunction and infertility. Risperidone and paliperidone are more strongly associated with elevated prolactin. Olanzapine and aripiprazole, clozapine and quetiapine show little or no change in prolactin levels.","_key":"c0af4c43fc1b0","_type":"span"}],"_type":"block","style":"normal","_key":"c0af4c43fc1b","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"Patients on risperidone and paliperidone should be asked about changes in sexual function and abnormal lactation at each visit for 12-week and annually thereafter. A serum prolactin level is indicated if the patient develops signs of sexual dysfunction or galacturia.","_key":"449a92af14cf0","_type":"span"}],"_type":"block","style":"normal","_key":"449a92af14cf"},{"style":"normal","_key":"2e3d49580282","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Sexual adverse effects that cause dysfunction in all phases of sexual activity are quite common. It seems to be highest on patients who are prescribed risperidone and least amount patients were on aripiprazole. Clinicians are encouraged to ask about sexual functioning initially and at least annually thereafter.","_key":"2e3d495802820"}],"_type":"block"},{"_key":"33a7fa5d0d8d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"QT prolongation can happen with many of the medications. A corrected QT interval greater than 500 or an increase in QT of 60 or more during antipsychotic treatment indicates significant risk. Ziprasidone appears to have a somewhat greater risk of QT prolongation. Olanzapine and risperidone have been associated with mild QT prolongation but neither carries a specific caution on this issue. Lurasidone and Abilify are the least likely to cause cardiac arrhythmias.","_key":"33a7fa5d0d8d0"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"Routine monitoring of ECG with antipsychotics is not usually required in patients without cardiac risk factors. Rarely, cases of myocarditis and cardiomyopathy have been reported with quetiapine, Risperdal, and ziprasidone.","_key":"fcd5c2bb676b0","_type":"span"}],"_type":"block","style":"normal","_key":"fcd5c2bb676b"},{"children":[{"_type":"span","marks":[],"text":"Orthostatic hypotension is frequently observed with clozapine, quetiapine, iloperidone, and paliperidone. This is somewhat less so with olanzapine, risperidone, and ziprasidone. It very rarely occurs with aripiprazole. The symptoms are generally benign and self-limiting but, in some cases, may necessitate a slowing in the rate of dose titration. Seizures have been associated with several second-generation antipsychotics and is dose dependent. Clozapine carries the ","_key":"3eea4600ab150"},{"_type":"span","marks":["cc4a25aca4d5"],"text":"highest risk","_key":"3eea4600ab151"},{"marks":[],"text":" among the second-generation antipsychotics.","_key":"3eea4600ab152","_type":"span"},{"_key":"3eea4600ab153","_type":"span","marks":["superscript"],"text":"4"}],"_type":"block","style":"normal","_key":"3eea4600ab15","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/27249081/","_key":"cc4a25aca4d5"}]},{"markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/view/duty-care-and-informed-consent","_key":"288249495a96","blank":true}],"children":[{"_type":"span","marks":[],"text":"Some of the less common adverse effects include ","_key":"a85386f492100"},{"text":"neuroleptic malignant syndrome","_key":"a85386f492101","_type":"span","marks":["288249495a96"]},{"_type":"span","marks":[],"text":", cardiomyopathies, and cataracts. The use of antipsychotics in children should always be started with extreme caution at a low dose and titrated slowly.","_key":"a85386f492102"}],"_type":"block","style":"normal","_key":"a85386f49210"},{"_key":"4c7bca57972c","markDefs":[],"children":[{"_key":"4c7bca57972c0","_type":"span","marks":["strong"],"text":"LEM: Are there family or genetic factors to consider? What about trauma, sexual abuse, or domestic violence? Do these factors have any effect on children’s propensity to develop early-onset psychosis or psychotic symptoms?"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"4d889b566da5","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Abhijit Ramanujam, MD:","_key":"4d889b566da50"},{"text":" In terms of predisposing factors, genetic vulnerability, environmental factors, obstetric complications, trauma, social adversities, and substance use can all contribute to the risk for acquiring a primary psychotic disorder. Studies have shown the presence of a substance use disorder and co-occurring psychotic symptoms indicate an increased risk for developing a primary psychotic disorder.","_key":"4d889b566da51","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"_key":"5d0b8c7cdbd00","_type":"span","marks":[],"text":"Cannabis in particular has the potential to cause psychotic symptoms, although the studies are limited. However, the body of evidence is consistently increasing."}],"_type":"block","style":"normal","_key":"5d0b8c7cdbd0"},{"markDefs":[],"children":[{"marks":[],"text":"The birth cohort study of patients with schizophrenia reported an association between hypoxia during birth complications and early onset schizophrenia but not of adult-onset schizophrenia. Prematurity was found in 17% of early-onset psychosis in a schizophrenia spectrum disorder study.","_key":"b74a1d7155b90","_type":"span"},{"_type":"span","marks":["superscript"],"text":"5","_key":"b74a1d7155b91"}],"_type":"block","style":"normal","_key":"b74a1d7155b9"},{"children":[{"text":"Two large systematic studies demonstrate that 30% to 50% of patients with childhood onset schizophrenia had premorbid features of autism or had comorbid diagnoses of pervasive developmental disorders.","_key":"554ae901870b0","_type":"span","marks":[]},{"marks":["superscript"],"text":"6","_key":"554ae901870b1","_type":"span"},{"_type":"span","marks":[],"text":" However, youth with early-onset schizophrenia frequently showed greater premorbid deficits in attention, learning, and socialization compared with their counterparts with adult-onset schizophrenia.","_key":"554ae901870b2"}],"_type":"block","style":"normal","_key":"554ae901870b","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"A meta-analysis reported strong evidence that childhood adversity was associated with an increased risk for psychosis in adults, although psychotic symptoms may also be present in PTSD.","_key":"57d47e809ab70","_type":"span"},{"_type":"span","marks":["superscript"],"text":"7,8","_key":"57d47e809ab71"},{"text":" Twin studies suggest that childhood-onset of schizophrenia may have a substantial genetic component.","_key":"57d47e809ab72","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"9","_key":"57d47e809ab73"},{"_type":"span","marks":[],"text":" A number of psychiatric disorders occur in higher frequency amongst first-degree relatives of children with schizophrenia.","_key":"57d47e809ab74"}],"_type":"block","style":"normal","_key":"57d47e809ab7"},{"style":"normal","_key":"c2be3c13b1f8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"For example, bipolar disorder prevalence is 6% in first degree relatives versus 2.4% in the general population. The same can be said for schizophrenia spectrum disorder: 10% in first-degree relatives versus 3.5% in general population. Anxiety disorders prevalence is 15% in first degree relatives versus 7.3% in the general population.","_key":"c2be3c13b1f80"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: Is it too early to talk about long-acting injectable antipsychotic agents, or LAI, treatments?","_key":"c339731f18330"}],"_type":"block","style":"normal","_key":"c339731f1833"},{"style":"normal","_key":"9eb80a194e84","markDefs":[],"children":[{"marks":["strong"],"text":"Abhijit Ramanujam, MD:","_key":"9eb80a194e840","_type":"span"},{"_type":"span","marks":[],"text":" In terms of long-acting injectable antipsychotics, they have not been sufficiently studied in younger children to recommend their use.","_key":"9eb80a194e841"}],"_type":"block"},{"_type":"block","style":"normal","_key":"e1e7a5fd2699","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: From a child’s perspective, how do we build a daily routine of taking oral medications? What can one expect when there is a patient stops treatment abruptly?","_key":"e1e7a5fd26990"}]},{"style":"normal","_key":"7b63e0e91ad1","markDefs":[],"children":[{"marks":["strong"],"text":"Abhijit Ramanujam, MD:","_key":"7b63e0e91ad10","_type":"span"},{"_type":"span","marks":[],"text":" I strongly recommended a multimodal instead of medication-alone approach for a better outcome. First psychoeducation is key and is best provided early in treatment and frequently reviewed, provide children and their parents or guardian information about the illness, medications, and other interventions. It is highly useful to integrate family members and educate them to better support youth.","_key":"7b63e0e91ad11"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"There are a few variables in terms of our approach based on the clinical presentation of the patient.","_key":"6dedcfd53f270"}],"_type":"block","style":"normal","_key":"6dedcfd53f27"},{"markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"1. Family intervention. ","_key":"52168ce488fd0"},{"_type":"span","marks":[],"text":"For patients with schizophrenia who have had a recent psychotic episode and have significant ongoing contact with family members, we recommend patients and family members receive a family intervention for at least 6 to 9 months. During family intervention, patient's family members receive education about the nature course treatment of schizophrenia.","_key":"52168ce488fd1"}],"_type":"block","style":"normal","_key":"52168ce488fd"},{"style":"normal","_key":"4663fdb34152","markDefs":[],"children":[{"_type":"span","marks":[],"text":"It also involves correcting the erroneous notion that poor parenting was the cause of schizophrenia. Many parents are left to wonder what they could have done wrong to cause the illness and need help transitioning from the guilt and blame to acceptance and support.","_key":"4663fdb341520"}],"_type":"block"},{"markDefs":[],"children":[{"marks":[],"text":"Many times, family members may perceive the negative symptoms of schizophrenia, such as lack of motivation and asociality, as laziness. Furthermore, the clinician should teach early warning signs and explain the importance of medication adherence.","_key":"055f8670f8530","_type":"span"}],"_type":"block","style":"normal","_key":"055f8670f853"},{"markDefs":[],"children":[{"text":"2. If the patient has had multiple relapses of schizophrenia and reside in a particularly stressful family environment, a more intensive problem-solving family therapy has been developed. ","_key":"d0993b4577c00","_type":"span","marks":["strong","em"]},{"_type":"span","marks":[],"text":"In these cases, we identify and correct overly hostile and critical parent-patient interaction. Sometimes stressful family dynamics can be mitigated by finding outside rehabilitative activities or supported employment for the patient.","_key":"d0993b4577c01"}],"_type":"block","style":"normal","_key":"d0993b4577c0"},{"_key":"96943029ade8","markDefs":[{"_type":"link","href":"https://www.uptodate.com/contents/grade/2?title=Grade%201B\u0026topicKey=PSYCH/15774","_key":"7c9f6b0448fc","blank":true}],"children":[{"_type":"span","marks":["strong","em"],"text":"3. For individuals who experience persistent delusions or hallucinations despite adequate trials of antipsychotic medication, we recommend adjunctive treatment with cognitive-behavioral therapy over medication alone (","_key":"96943029ade80"},{"_type":"span","marks":["strong","em","7c9f6b0448fc"],"text":"Grade 1B","_key":"96943029ade81"},{"marks":["strong","em"],"text":").","_key":"96943029ade82","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"The aim is to reduce the intensity of delusions and hallucinations or the subjective distress. It also helps individuals be more proactive in reducing the risk of relapse. It basically involves exploring the subjective nature of the symptoms, gently challenging the underlying assumptions and generating alternative interpretations. Many patients will strongly resist reevaluating delusional believes but one can reduce the related distress. Studies indicate that CBT is effective for chronic schizophrenia.","_key":"0e5fd9f6776d0","_type":"span"}],"_type":"block","style":"normal","_key":"0e5fd9f6776d"},{"_type":"block","style":"normal","_key":"76423a6c0a0a","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"4. For children with schizophrenia who have deficits and skills needed for everyday activities we usually recommend social skills training along with antipsychotic medications. Social skills training is generally conducted several times a week. ","_key":"76423a6c0a0a0"},{"_type":"span","marks":[],"text":"Children with observed deficits, such as problems with attention and working memory, should receive age-appropriate vocational skills training. This may include help with placement and support during employment. Therapeutic schools are also an option to educate children who struggle to understand the curriculum in typical school settings due to their illness.","_key":"76423a6c0a0a1"}]},{"_key":"cb76c5c9ed1e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Social skills training is necessary since negative symptoms of schizophrenia such as lack of motivation and lack of socialization do not respond well to medications. The ultimate goal of this training is to provide skills to community-based activities and improve the functioning.","_key":"cb76c5c9ed1e0"}],"_type":"block","style":"normal"},{"markDefs":[{"href":"https://www.brainhq.com","_key":"eab61d7dc868","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":["strong","em"],"text":"5. For children with schizophrenia who experience persistent cognitive decline such as difficulty concentrating or remembering, cognitive remediation is recommended along with antipsychotic medications. ","_key":"a5e7e7ea55ff0"},{"_type":"span","marks":[],"text":"The patient is asked to do simple information processing tasks and once they reach a certain threshold, they will move onto a slightly more complex task. ","_key":"a5e7e7ea55ff1"},{"_type":"span","marks":["eab61d7dc868"],"text":"PositScience","_key":"a5e7e7ea55ff2"},{"_key":"a5e7e7ea55ff3","_type":"span","marks":[],"text":" is a self-contained computer software program that provides cognitive remediation in an outpatient setting. Studies indicate that this approach leads to an overall positive effect."},{"marks":["superscript"],"text":"10","_key":"a5e7e7ea55ff4","_type":"span"}],"_type":"block","style":"normal","_key":"a5e7e7ea55ff"},{"children":[{"_type":"span","marks":["strong"],"text":"LEM: For clinicians concerned about treating schizophrenia, what advice can you offer?","_key":"0812a6b61ceb0"}],"_type":"block","style":"normal","_key":"0812a6b61ceb","markDefs":[]},{"children":[{"_type":"span","marks":["strong"],"text":"AR:","_key":"52e1fa34e86d0"},{"text":" It is roughly estimated that 13% to 23% of people experience psychotic symptoms at some point in their lifetime.","_key":"52e1fa34e86d1","_type":"span","marks":[]},{"text":"11","_key":"52e1fa34e86d2","_type":"span","marks":["superscript"]},{"text":" Most clinicians will encounter patients with psychosis and thus will greatly benefit knowing how to recognize psychotic symptoms and make appropriate initial evaluation and management decisions.","_key":"52e1fa34e86d3","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"52e1fa34e86d","markDefs":[]},{"_type":"block","style":"normal","_key":"a8870d0518d6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Prompt diagnosis of schizophrenia and aggressive treatment is necessary to limit impairments in development and learning. Repeated or prolonged psychotic episodes have negative neuropsychological and structural brain defects on patients. Some evidence also suggests that prolonged periods of untreated psychosis may also result in increased resistance to conventional treatments.","_key":"a8870d0518d60"}]},{"children":[{"_type":"span","marks":[],"text":"Having said that, I encourage optimism and discourage nihilism when it comes to treating schizophrenia. Schizophrenia necessarily does not follow the path of progressive deterioration. The majority of patients respond very well to comprehensive treatment and as many as 20% can be expected to have a full recovery. There is much we can offer patients, and it is valuable to be aware of our current treatment options","_key":"b59fbd3cd7920"}],"_type":"block","style":"normal","_key":"b59fbd3cd792","markDefs":[]},{"_key":"3a96c753c8f9","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"3a96c753c8f90"}],"_type":"block","style":"normal"},{"_key":"261ad9c4441d","markDefs":[{"href":"https://jaacap.org/article/S0890-8567(09)62080-3/fulltext","_key":"48002bc05c86","blank":true,"_type":"link"}],"children":[{"_key":"261ad9c4441d0","_type":"span","marks":[],"text":"1. Correll CU. "},{"text":"Antipsychotic use in children and adolescents: minimizing adverse effects to maximize outcomes","_key":"261ad9c4441d1","_type":"span","marks":["48002bc05c86"]},{"_type":"span","marks":[],"text":". ","_key":"261ad9c4441d2"},{"_type":"span","marks":["em"],"text":"J Am Acad Child Adolesc Psychiatry.","_key":"261ad9c4441d3"},{"marks":[],"text":" 2008;47(1):9.","_key":"261ad9c4441d4","_type":"span"}],"_type":"block","style":"normal"},{"_key":"3fe34c296883","markDefs":[],"children":[{"_type":"span","marks":[],"text":"2. Correll CU, Penzner JB, Parikh UH. Recognizing and monitoring adverse events of second-generation antipsychotics in children and adolescents. ","_key":"3fe34c2968830"},{"_key":"3fe34c2968831","_type":"span","marks":["em"],"text":"Child Adolesc Psychiatr Clin N Am."},{"_key":"3fe34c2968832","_type":"span","marks":[],"text":" 2006;15(1):177."}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"d5c1a54fe629","markDefs":[],"children":[{"_type":"span","marks":[],"text":"3. Correll C. Antipsychotic use in children and adolescents: minimizing adverse effects to maximize outcomes. ","_key":"d5c1a54fe6290"},{"text":"J Am Acad Child Adolesc Psychiatry.","_key":"d5c1a54fe6291","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":" 2008;47(1):9.","_key":"d5c1a54fe6292"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/27249081/","_key":"cb604a7e9e6c"}],"children":[{"_type":"span","marks":[],"text":"4. Wu CS, Wang SC, Yeh IJ, Liu SK. ","_key":"c6ce78ad2d6e0"},{"text":"Comparative risk of seizure with use of first- and second-generation antipsychotics in patients with schizophrenia and mood disorders","_key":"c6ce78ad2d6e1","_type":"span","marks":["cb604a7e9e6c"]},{"text":". ","_key":"c6ce78ad2d6e2","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"J Clin Psychiatry.","_key":"c6ce78ad2d6e3"},{"_type":"span","marks":[],"text":" 2016 May;77(5):e573-9.","_key":"c6ce78ad2d6e4"}],"_type":"block","style":"normal","_key":"c6ce78ad2d6e"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"5. Verdoux H, Geddes JR, Takei N, et al. Obstetric complications and age at onset in schizophrenia: an international collaborative meta-analysis of individual patient data. ","_key":"2303006e0eae0"},{"_type":"span","marks":["em"],"text":"Am J Psychiatry.","_key":"2303006e0eae1"},{"_key":"2303006e0eae2","_type":"span","marks":[],"text":" 1997;154(9):1220."}],"_type":"block","style":"normal","_key":"2303006e0eae"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"6. Rapoport J, Chavez A, Greenstein D, et al. Autism spectrum disorders and childhood-onset schizophrenia: clinical and biological contributions to a relation revisited. ","_key":"69fbca48dc1f0"},{"text":"J Am Acad Child Adolesc Psychiatry.","_key":"69fbca48dc1f1","_type":"span","marks":["em"]},{"marks":[],"text":" 2009;48(1):10.","_key":"69fbca48dc1f2","_type":"span"}],"_type":"block","style":"normal","_key":"69fbca48dc1f"},{"markDefs":[],"children":[{"marks":[],"text":"7. Varese F, Smeets F, Drukker M, et al. Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. ","_key":"e5d079c6a41a0","_type":"span"},{"_type":"span","marks":["em"],"text":"Schizophr Bull.","_key":"e5d079c6a41a1"},{"_type":"span","marks":[],"text":" 2012;38(4):661. Epub 2012 Mar 29","_key":"e5d079c6a41a2"}],"_type":"block","style":"normal","_key":"e5d079c6a41a"},{"markDefs":[{"_type":"link","href":"https://jamanetwork.com/journals/jamapsychiatry/fullarticle/497313","_key":"8993fdac72eb","blank":true}],"children":[{"_type":"span","marks":[],"text":"8. Kessler RC, Sonnega A, Bromet E, et al. ","_key":"40f6b67b9be30"},{"_type":"span","marks":["8993fdac72eb"],"text":"Posttraumatic stress disorder in the National Comorbidity Survey","_key":"40f6b67b9be31"},{"_type":"span","marks":[],"text":". ","_key":"40f6b67b9be32"},{"_key":"40f6b67b9be33","_type":"span","marks":["em"],"text":"Arch Gen Psychiatry."},{"_type":"span","marks":[],"text":" 1995;52(12):1048.","_key":"40f6b67b9be34"}],"_type":"block","style":"normal","_key":"40f6b67b9be3"},{"_key":"0c01a208603c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"9. Kallmann FJ, Roth B. Genetic aspects of preadolescent schizophrenia. ","_key":"0c01a208603c0"},{"_type":"span","marks":["em"],"text":"Am J Psychiatry.","_key":"0c01a208603c1"},{"_type":"span","marks":[],"text":" 1956;112(8):599.","_key":"0c01a208603c2"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"10. Harvey PD, Balzer AM, Kotwickib RJ. Training engagement, baseline cognitive functioning, and cognitive gains with computerized cognitive training: A cross-diagnostic study. ","_key":"ebb866922a080"},{"_type":"span","marks":["em"],"text":"Schizophr Res Cogn.","_key":"ebb866922a081"},{"_key":"ebb866922a082","_type":"span","marks":[],"text":" 2019;19:100150."}],"_type":"block","style":"normal","_key":"ebb866922a08"},{"_type":"block","style":"normal","_key":"0ce2dbaa28f2","markDefs":[],"children":[{"_type":"span","marks":[],"text":"11. Perälä J, Suvisaari J, Saarni SI, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. 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Gold, MD, MS"}],"_type":"block","style":"normal","_key":"hserPdjY","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"In our interview with Carol Tamminga, MD, we discuss biological psychiatry and the evolution of the field of psychiatry to now include a greater understanding of the neurobiologic underpinnings of disease through brain imaging, genetics, and circuits. We talk about the \"battle\" between biologic and psychologic and whether this should exist.","_key":"QGPjRdqw"}],"_type":"block","style":"normal","_key":"wSskaWoY","markDefs":[]},{"_type":"block","style":"normal","_key":"p0Y9N7Pg","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Dr Tamminga also discusses her groundbreaking research on schizophrenia and how trying to find biological confirmation for DSM diagnoses led her to finding \"clusters\" or \"biotypes\" instead. She details how she hopes her research will inform treatment in the future, as well as measurement of treatment response. She adds information about early intervention approaches for schizophrenia treatment and the role of cannabis in schizophrenia development.","_key":"GzIPNXMk"}]},{"children":[{"marks":[],"text":"Dr Tamminga is Lou and Ellen McGinley Distinguished Chair and the McKenzie Chair in Psychiatry at the University of Texas Southwestern Medical School and the Chief of the Translational Neuroscience Division in Schizophrenia at University of Texas Southwestern Medical Center, Dallas, TX.","_key":"xWgkndk6","_type":"span"}],"_type":"block","style":"normal","_key":"IZBI9RV4","markDefs":[]},{"markDefs":[],"children":[{"marks":["strong"],"text":"Links referenced in this podcast:","_key":"TWEmCFcb","_type":"span"}],"_type":"block","style":"normal","_key":"LX5dAWJI"},{"_key":"G7F432Jh","markDefs":[{"_key":"href_1582641090518001646","_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/21996268"}],"children":[{"_type":"span","marks":["href_1582641090518001646"],"text":"A dimensional approach to the psychosis spectrum between bipolar disorder and schizophrenia: the Schizo-Bipolar Scale","_key":"U6sGoKw0"}],"_type":"block","style":"normal"},{"style":"normal","_key":"YTEHAwjc","markDefs":[{"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/26651391","_key":"href_1582641090131487682"}],"children":[{"_type":"span","marks":["href_1582641090131487682"],"text":"Identification of Distinct Psychosis Biotypes Using Brain-Based Biomarkers","_key":"ANPI9UJy"}],"_type":"block"},{"children":[{"text":"Brain Structure Biomarkers in the Psychosis Biotypes: Findings From the Bipolar-Schizophrenia Network for Intermediate Phenotypes","_key":"zqxd7Y7J","_type":"span","marks":["href_1582641090820090167"]}],"_type":"block","style":"normal","_key":"YMaKiiSf","markDefs":[{"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/27817844","_key":"href_1582641090820090167"}]},{"children":[{"text":"Deconstructing Psychosis","_key":"Z1pQFTz5","_type":"span","marks":["href_1582641090396876348"]}],"_type":"block","style":"normal","_key":"KA9XDUlp","markDefs":[{"_type":"link","href":"https://academic.oup.com/schizophreniabulletin/article/33/4/861/1930329","_key":"href_1582641090396876348"}]},{"markDefs":[{"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/29628270","_key":"href_1582641090493521371"}],"children":[{"_key":"jKxRGEJY","_type":"span","marks":["href_1582641090493521371"],"text":"Associations between adolescent cannabis use and brain structure in psychosis"}],"_type":"block","style":"normal","_key":"EvqGUMzq"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"TRANSCRIPT","_key":"iZYzDTh0"}],"_type":"block","style":"normal","_key":"ZsEDSU9Z"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: Welcome to Psyched, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.","_key":"EfDHIxND"}],"_type":"block","style":"normal","_key":"8EJfSLN6"},{"children":[{"_type":"span","marks":[],"text":"David Carreon: Hey, everybody. My name is David Carreon.","_key":"DS0aJ8Gy"}],"_type":"block","style":"normal","_key":"DRNPafV6","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Jessi Gold: And this Jessi Gold.","_key":"CqZveMQJ"}],"_type":"block","style":"normal","_key":"eoh3wNod"},{"_type":"block","style":"normal","_key":"N5MUQztX","markDefs":[],"children":[{"text":"David Carreon: And are sitting with Carol Tamminga, the Lou and Ellen McGinley Distinguished Chair and McKenzie Chair in Psychiatry at UT Southwestern. She's the chair of UT Southwestern's department of psychiatry, and Chief Translational Neuroscience Division in schizophrenia.","_key":"zHxeqpKb","_type":"span","marks":[]}]},{"children":[{"_type":"span","marks":[],"text":"David Carreon: Thank you for joining us.","_key":"Tz8uUmCL"}],"_type":"block","style":"normal","_key":"ANbxgmJX","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Well thanks a lot for inviting me I appreciate being here.","_key":"j61YlIhB"}],"_type":"block","style":"normal","_key":"Nv6teUeB"},{"_key":"eXdDGqi6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: For those psychiatrists that are not terribly familiar with biological psychiatry, what is biological psychiatry?","_key":"tF2iE6gB"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"kBhE7iXW","_type":"span","marks":[],"text":"Carol Tamminga: Biological psychiatry I guess would be that group of people who are interested in the biology of the brain that underlies psychiatric conditions. This is a very, very old society that's gone up and down, and their attention on different kinds of biology over the years. And now the biologic basis, the biologic understanding of the brain and its normal function has grown so much over the last 25 years, that is a very exciting time in biological psychiatry."}],"_type":"block","style":"normal","_key":"Y4Hkh9ih"},{"markDefs":[],"children":[{"_key":"E2T4RYTJ","_type":"span","marks":[],"text":"David Carreon: Yeah I think that's something that's interesting to me too about like biology 50 years ago mean molecules, and, you know, and serotonin or dopamine. Now what is for somebody who went to residency 20 years ago or 30 years ago, what is biological focusing on these days?"}],"_type":"block","style":"normal","_key":"EmUfeg5w"},{"_key":"cTVDED4I","markDefs":[],"children":[{"text":"Carol Tamminga: Yeah biology is such a general term, and it's like the physiology of internal medicine or something like that. I don't think we have a better word to use right now, because we don't understand what the specific biologic ... perhaps pathophysiology would be a better word. We do not understand the pathophysiologies for our diseases, but as soon as we do then we'll be able to make that term, biology, more specific. And we'll be able to say that it's self-firing or it's circuit biology or something like that.","_key":"lkhhvkEK","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_key":"OGMZqElX","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: So is it that society's been around for a long time...","_key":"xvkrSwrW"}],"_type":"block","style":"normal"},{"_key":"Oqwzc1b8","markDefs":[],"children":[{"_key":"6RHnxS38","_type":"span","marks":[],"text":"Carol Tamminga: It's a fairly long society. As you might imagine 50 years ago the biology that they talked about was fairly crude, and it was a little bit more than a black box when this started, but now there's so much in that black box, it's really fabulous."}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Brain imaging has opened up the world of biology. Human postmortem brain analysis have opened all of it up. Of course genetics and then the transcriptome analysis have opened up what we know about different regions in the brain, and their connection to function. It's an exciting time in biology.","_key":"pHlJRoPm"}],"_type":"block","style":"normal","_key":"tJun2JJH","markDefs":[]},{"_key":"v5FiwLiu","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: I should say so.","_key":"a9frpHZN"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"Jessi Gold: I would assume that would make it an exciting time to be a psychiatrist too.","_key":"xztr4TtZ","_type":"span"}],"_type":"block","style":"normal","_key":"B3FAwiXY"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: It is. When I started out being a psychiatrist, and I would tell people about diseases, psycheat- what I call psychiatric diseases, I would really draw the brain in a black box, because we knew such a little bit about it.","_key":"xi21onOK"}],"_type":"block","style":"normal","_key":"4fN1YsSx"},{"_type":"block","style":"normal","_key":"Y76TbA2H","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Then we knew a few things about things like dopamine, and serotonin, and got to know a little bit more about the synapse, and what was the structure of the synapse, and how cells communicated with each other. And then we thought it was really all about cells, and how one cell converted with another. But these days there's a real emphasis on circuits, and how different regions of the brain are connected with each other, and how they're connected with each other not only by neuronal connections, but by the characteristics, by the dynamic characteristics of the connections. The terminology that they use these days, I'm gonna have to practice a little bit offline on the connection that they- on the language that they use, it's very interesting, very interesting.","_key":"olkFP0Dw"}]},{"markDefs":[],"children":[{"text":"Jessi Gold: I'd imagine the language for all of this changes pretty rapidly.","_key":"3jikDK93","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"uNoYFRT5"},{"_key":"j7WUhWXf","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: It does. Yes, yes.","_key":"3ZBEeLOM"}],"_type":"block","style":"normal"},{"children":[{"marks":[],"text":"Carol Tamminga: You know, the brain is the last undiscovered organ in the body. We know a lot about the heart, we know a lot about the pancreas. They're accessible to us, the brain has never been accessible, and it's much more complicated than any other organ. So it's taken a little while for us to get the brain ... for us to understand how even a normal brain works.","_key":"0drensd3","_type":"span"}],"_type":"block","style":"normal","_key":"OjoA96Bz","markDefs":[]},{"_type":"block","style":"normal","_key":"TdsuNySf","markDefs":[],"children":[{"_key":"GzBHVtna","_type":"span","marks":[],"text":"Carol Tamminga: And then we don't know the pathophysiology for any of our diseases, so we don't even how to segment psychiatric syndromes into understandable units."}]},{"style":"normal","_key":"v2jBM904","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: Now that's something that I think I'd like to talk more about, because the average person thinks about something like major depressive disorder or schizophrenia as a thing, as an entity, as some thing existing in reality, like diabetes exists in reality. What's your perspective on psychiatric nosology or how these diagnosis work?","_key":"slaKOGgT"}],"_type":"block"},{"style":"normal","_key":"ya3otabL","markDefs":[],"children":[{"text":"Carol Tamminga: So I used to think schizophrenia was an entity too, and I used to call myself a \"schizophrenia scientist\", I don't anymore. We did an experiment a few years ago where we took ... we decided to study the dimension of psychosis. So we took a number of different diagnosis and we did deep phenotyping on all the diagnosis. So we took people with schizophrenia, people with schizoaffective disorder, people with psychotic bipolar disorder. If we could've found enough people with psychotic depression we would've taken those too, but we didn't find enough.","_key":"gNog6s5O","_type":"span","marks":[]}],"_type":"block"},{"children":[{"_key":"ZcmWWA0x","_type":"span","marks":[],"text":"Carol Tamminga: Then we did, we had, this was a study across five sites in the United States, so we had an opportunity to recruit quite a number of people. About a thousand probands, and about 500 normal people when we did deep phenotyping project."}],"_type":"block","style":"normal","_key":"KKt4hmFq","markDefs":[]},{"_key":"UwaF425o","markDefs":[],"children":[{"marks":[],"text":"Carol Tamminga: So we looked at brain based behavior very carefully, we looked at brain imaging, we looked at EEG brainwave analysis, we looked at eye tracking analysis, we looked at cognition. We looked at signs and symptoms of course. And our intent was to find some number of tests that psychiatrists could use when a patient walked in their office. A psychiatric patient walks in psychiatrist office, and a psychiatrist sits down and talks to them for an hour. You know, they walk into a neurologist office, the neurologist says, \"What are your complaints?\". And they'll talk to them for 10 minutes, and send them off for three tests, and then they'll come back two weeks later and they'll get a diagnosis.","_key":"54XoM6hO","_type":"span"}],"_type":"block","style":"normal"},{"_key":"sXKIv0WG","markDefs":[],"children":[{"_key":"UdwQecHX","_type":"span","marks":[],"text":"Carol Tamminga: We kind of wanted a system like that, and we hadn't started out to ... not, we started out hypothesizing that we would find biomarkers associated with diagnosis, and we didn't find one. We had about 50 or 60 different phenotypes, and we didn't find one that clearly fell in a diagnostic way on any of these different psychotic diagnosis. So we were pretty disappointed, and we spent a little time being quite depressed, because it really meant that we didn't know anything. We didn't even know how to take psychotic disorders, and cluster them."}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: So we finally got over that part of it, because we needed to get our grant renewed. So we just simply stripped the diagnosis off all the probands together into a single group of psychosis people, and we took the brain biomarkers. We took the EG, we took the cognition, we took the brain imaging, and we u- we didn't take any signs and symptoms, we took just took the brain measures, and we took them together, and we reclustered the people. And we came out with three groups of three total experiment groups. These are, we're not up to diagnosis or anything like that. These are just are experimental groups. But the experimental groups had very interesting biological characteristics, and so we decided to study them more, and now we're into a second phase.","_key":"BKWBF2mb"}],"_type":"block","style":"normal","_key":"BIiuYu09"},{"_type":"block","style":"normal","_key":"yPIdPCK0","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: These are clusters of individuals, all with psychosis, as the diagnosis are spread through all the cluster, so why bother with that? The only reason we now have to really confirm that this makes sense for selecting treatments, or biologic sense so that we would have genes that perhaps, genes or epigenetic phenomena that categorize the groups. So we're now in the process of doing that.","_key":"WKENLFhL"}]},{"style":"normal","_key":"TwwGs7MD","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Jessi Gold: Would you say that the initial failed experiment kind of forced you to rethink kind of what you had put on the diagnosis? Like being able to kind of shake up your thinking, and to clustering things, instead of just assuming that things fell into these nice diagnosis, that DSM created. Having the failed experiment sort of forced you away from that?","_key":"VtfMpYey"}],"_type":"block"},{"_type":"block","style":"normal","_key":"3aavC7wr","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Totally, totally. We never would've thought of it otherwise. Because we didn't start out making the hypothesis that we didn't know anything, in terms of how to cluster our patients in a group. If people have lesions, so, in Alzheimer's disease patients have plaques and tangles. It's at least a place to start, you may not know the complete path of physiology, but at least you have the lesion. Parkinson's disease, you know, if you have the VTA, the dopamine cell degeneration a lot, it's very simplistic, but at least it's a place to start. We don't have that in psychiatry for psychiatric diagnosis.","_key":"owLEKsR8"}]},{"style":"normal","_key":"L3U257Cw","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: So I think that the way that we did it for a long time is just by pure phenomenology. That we looked at people, we looked at their symptoms, we looked at their course of illness, and we assumed that that was meaningful way to ... divide people up. But it's turned out to not be a good thing to do, it's a little bit like dropsy in 1910. Dropsy is morbid obesity- excuse me, morbid edema. And dropsy is really a group of illnesses that determined my cardiac pulmonary renal disorder. So that's how I kind of think of psychosis. So now it's really back to the drawing board.","_key":"Vqbm8nRd"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: Now this is really astonishing. I mean if we think, I mean, there are some people that I've talk to who just start out skeptical. There are some people that I've talked to, that never since they were a young psychiatrist believed in DSM or the diagnostic categories, but it sounds like you're saying you were somebody who really believed at the beginning of your career that schizophrenia was a thing, and then over the course of your research you changed your mind.","_key":"IDvM9RRd"}],"_type":"block","style":"normal","_key":"O9i8lufr"},{"_key":"o4NaudKT","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: That's it. That's it.","_key":"b2oy6EUV"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: I don't know that I ever believed that schizophrenia, and schizoaffective disorder were very different from each other. That's seemed like a little wishful thinking, but I certainly understood, I always believed that schizophrenia was an illness. And now I really think that psychosis is a category like congestive heart failure, and that we'll over the course of the next, I don't know how many years find individuals.","_key":"g2y7SfXo"}],"_type":"block","style":"normal","_key":"GUZRqsbA"},{"style":"normal","_key":"S5rFw5Fq","markDefs":[],"children":[{"_key":"jTxC9cts","_type":"span","marks":[],"text":"Carol Tamminga: The three groups we've found we've named BSNIP biotypes. They're very different from each other, and they're very interesting, and I think that if each of these three different group hadn't been so interesting, from a biologic perspective, we would never have gotten caught on them."}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: This BSNIP biotype one is a group of people that have very low cognition, they have very low brain EEG, and they have the highest gray matter reduction of the three groups.","_key":"5HIwD6uS"}],"_type":"block","style":"normal","_key":"TZVqUTMX"},{"children":[{"_key":"az9kGnhz","_type":"span","marks":[],"text":"Carol Tamminga: The group in the middle, which we call them biotype two, was a group with only modestly low cognition. And instead of low EEG, they had high EEG. So they had, instead of hyporeactive brains, they had hyperreactive brains. Both at rest, and in evoked potential paradigmes."}],"_type":"block","style":"normal","_key":"1kds9Z29","markDefs":[]},{"_type":"block","style":"normal","_key":"gK5sSj90","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: And then biotype three was the most amazing of all the groups, because of all the biotypes that we used to measure, they were hardly abnormal at all. But their psychosis was just as bad as all the other people's psychosis. So it was ... it's a group of people who are kind of a negative control with the same clinical presentation.","_key":"YEtlUekx"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Jessi Gold: What do you think that actually means?","_key":"vbRbtg8Y"}],"_type":"block","style":"normal","_key":"AEEp5JJl"},{"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: We were wondering. And we were sitting around a table thinking, so this is all of the 5 PI's, and all of the friends and stuff. So we were thinking.","_key":"PHSZz1d0"}],"_type":"block","style":"normal","_key":"Kg53lMWl","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"David Carreon: Paint this picture, where was this table?","_key":"2P5DyMCG","_type":"span"}],"_type":"block","style":"normal","_key":"o8GOeYoD"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: We get together once a year. And we get together once a week by telephone and talk about a lot of practical things. And once a year we get together and sit around in a library. It was a kind of old fashioned not very updated room, where we're sitting on chairs that are falling apart, you know. We have a lot of coffee around the table, and there's a little bit of fruit in bowls in the middle.","_key":"rwDo9mum"}],"_type":"block","style":"normal","_key":"QWj5fLcH"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: So we're talking about what clearly the people who are very, very low cognition, very low EEG people look like. What we had all probably imagined psychosis or schizophrenia was gonna look like. We were surprised in the second group by modestly low cognition, and very high, we didn't expect people to have very high EEG. It wasn't synchronous EEG , so we didn't imagine that the EEG was productive in some way. That those were people who were smarter in s- they weren't smarter, but they had high EEG anyway.","_key":"sOHqdnJ8"}],"_type":"block","style":"normal","_key":"L0FBxQob"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Then we were puzzling about what was happened to this third group, and one of the guy's all of a sudden said, \"I know those are the potheads\". So there was one of the five sites, it just happened to be mine, that taken a careful enough marijuana history, because one of the people at our sites is interested in marijuana. And this was in fact, the statistics aren't very strong because it was just one of the five different sites, so it was not nearly a thousand people. But in fact they were, there was a good, a very high percentage of early cannabis use. And there was a 90% of that third group had at least some adolescent cannabis use, not even early adolescent cannabis use. So now in our second iteration of going back and looking at these things we have a very careful, especially early cannabis, early psychosis screening.","_key":"fvVdA3nM"}],"_type":"block","style":"normal","_key":"HOCJKUCY"},{"style":"normal","_key":"1BCNpuiG","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Jessi Gold: When you look at that, and then you see all these people coming and saying like cannabis no problems, and cannabis is-","_key":"TQgbvX7G"}],"_type":"block"},{"_type":"block","style":"normal","_key":"SbV7vV0D","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Oh boy I really worry. It looks to me, and most of our studies. It looks like the worst time for cannabis is somewhere between 9 and 15 years of age. And that ... still a vulnerable time for cannabis is somewhere up to 20. But if you smoke cannabis after 20 it doesn't look like much bad happens. So it's clearly a vulnerable window for cannabis. It may be a vulnerable window for other things too we don't know, but we're studying it.","_key":"4AyDn7CK"}]},{"style":"normal","_key":"jC9KiTHg","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: With this, I mean this transition from the DSM to ... I guess this is some people would categorize what you're doing, and maybe explicitly as being under the research domain criteria. Is that true?","_key":"5r6ISuns"}],"_type":"block"},{"style":"normal","_key":"9XTGg5ty","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Well we got started before Doctor Enzo had suggested the RDoC, so we call ourselves \"pre-Doc\". But I think the RDoC principles must've been emerging all at the same time. They must have been emerging at the same time as we had developed measure where we could really distinguish, brain measures where we could distinguish one person's brain activity from another.","_key":"zN92bOl6"}],"_type":"block"},{"children":[{"_key":"MlIH1OFB","_type":"span","marks":[],"text":"Carol Tamminga: We now have, we took fibroblast from at least some of these people. And we transformed them to iPS cells, and now we're growing them to matur-"}],"_type":"block","style":"normal","_key":"bOUmUF8u","markDefs":[]},{"style":"normal","_key":"imzqQST0","markDefs":[],"children":[{"text":"David Carreon: What's a iPS cell?","_key":"C8OlEhyu","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Pardon?","_key":"56mPONxB"}],"_type":"block","style":"normal","_key":"89wVoj0C"},{"markDefs":[],"children":[{"_key":"BFfGrzzA","_type":"span","marks":[],"text":"David Carreon: What's an iPS cell?"}],"_type":"block","style":"normal","_key":"f3ADHIfq"},{"style":"normal","_key":"sqgfWXEF","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: It's stem cell. So we took fibroblast and transformed them to stem cells, and then we took stem cells and transformed them to neurons. So now we get a chance to see whether between biotype one, two, and three, we can find cellular fingerprint of what we're, of some kind of pathology. I mean it would be very nice to have some kind of pathophysiology for all of this.","_key":"151c89kf"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Still, I don't think, I don't think at all that these three different categories, we're still in the process of figuring out how many categories there outta be, and figuring out- these are still hypothetical categories I should say it that way. We don't think that those three categories are even gonna be diagnosis, we think that each of those three categories have buried in them perhaps a hundred different diagnosis, maybe. It would just be a guess without any, based on no knowledge.","_key":"xcTzYZbe"}],"_type":"block","style":"normal","_key":"DbWLkT6c"},{"markDefs":[],"children":[{"marks":[],"text":"David Carreon: And I guess, what is the average practicing psychiatrist to do with this information? I mean we see people every day who have a you know, they come in and it's a you know, 34 year old patient with schizophrenia. What does that, what am I supposed to take that as if I'm in the emergency room or if I'm in clinic? What does that mean?","_key":"mBWrsLz1","_type":"span"}],"_type":"block","style":"normal","_key":"DVSp65l3"},{"_type":"block","style":"normal","_key":"DXxvM340","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: So psychiatry doesn't have tools that are specific and selective enough to bother with the kind of data I just talked about. So what we would like to do with these data is find out what the pathophysiology is, and find out what the target for drug development is, and then find you new drugs, find psychiatrists new drugs to use in the emergency room. So that when somebody walks in, and they, the doctor can do more than say, \"You have cancer\". I mean if you walk in we would like to say, \"You've got this kind of cancer, and these are what the cells look like, and your cells are responsive to the following medication\".","_key":"mWuWz2Qi"}]},{"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: So really it's almost premature to learn about what I'm saying, because we can't do anything about it anyways. Well we could tell teenagers never to use marijuana, but this is for sure good advice, I know that. What we would hope to do one day is to work backwards to pathophysiology, and then use pathophysiology to move forward to provide new treatments.","_key":"iiesAuB5"}],"_type":"block","style":"normal","_key":"WtVesZ2N","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"Jessi Gold: To make our treatments a little bit less like a dartboard that you just shoot at depending on side effects?","_key":"i6f9R96N"}],"_type":"block","style":"normal","_key":"gTLfcFDW","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Exactly. Sometimes it's not, it's most of the time it's much less precise than exactly what you're talking about. In ... I work at the state of Texas, and there's clearly not enough psychiatrists there. When psychiatrists see patients they treat the serially, and one person will give them an antidepressant, one person will give them a mood stabilizer, another person will give them antipsychotic. And no doctor really takes away what other people have had before.","_key":"IfjcTIKV"}],"_type":"block","style":"normal","_key":"SNUBZdNU"},{"style":"normal","_key":"fSlopP0l","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: So you see these people on, in fact in this particular study where we had probands, we psychotic probands, we had a wide range of diagnosis. So people always say, \"Well you must've found that people in different diagnostic categories were treated with different drugs?\"","_key":"GE6d53WK"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: And the sad part about it is the answer to that question is, \"No\". We found almost all the patients treated with almost all of the drugs that we have. So how wrong is that?","_key":"Q6gp7tGe"}],"_type":"block","style":"normal","_key":"dQ0Pqn7r"},{"markDefs":[],"children":[{"text":"Jessi Gold: Something's wrong.","_key":"97QtIM2c","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"WcpzbZ8G"},{"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: But it's unclear how to tell somebody how to do it in a better way.","_key":"VOxOBpef"}],"_type":"block","style":"normal","_key":"6YgDWNu7","markDefs":[]},{"_type":"block","style":"normal","_key":"3bgDQqJa","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Jessi Gold: Do you feel like that's because we also don't know how to really measure response?","_key":"K72KVObe"}]},{"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: You're exactly right. And response comes ... not right away. I mean we work with symptoms ... where it may take a while for the drug you have the person to work, but you don't know how long it's going to take, and you don't how long to wait. Most people wait maybe two weeks or something, before making a change.","_key":"oU055BW2"}],"_type":"block","style":"normal","_key":"bodFBK1A","markDefs":[]},{"_type":"block","style":"normal","_key":"enIKmczn","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: The kind of symptoms that psychiatrists look at are, that first of all, are poorly treated and generally treated by the drugs that we have. So that's clears. And then they ... we don't know what the relationship is between the background of the illness with the drugs that we use. We're pretty lucky to have the drugs that we use. We could have nothing, because we don't know pathophysiology. I'm not gonna say we don't know anything, but we don't know pathophysiology.","_key":"MQHI2BID"}]},{"_key":"LwLXFHGH","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: The drugs that we have were just accidentally discovered, and then very well exploited from their discovery, but we need to know a lot more to get more precise drugs.","_key":"14EqI0gg"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"David Carreon: And I think, I'm interested also, I think there is almost this feeling in psychiatry sometimes that it's a battle between the biological psychiatrists, and the people who care something about psychology. And that these, you know, people are dismissing each other, there's these two camps and battle lines are drawn. But would you say your perspective on this ... ought there be a battle?","_key":"a5YOstWm"}],"_type":"block","style":"normal","_key":"JNXDXxm4","markDefs":[]},{"markDefs":[],"children":[{"text":"Carol Tamminga: No, no, no. Not a battle at all. In fact all behavior is based on brain behavior, so even psychological phenomenon, even though we look at them as psychological phenomemon are totally based in brain behavior. And I'm not psychologically oriented as a psychiatrist, but I would think that there's a huge area of looking at the relationship between brain changes and psychoanalysis that could really be looked at. Because psychoanalysis can't be anything other than changes in brain regional plasticity. And they would be very, very easy to study. Every time I interact with my psychoanalyst colleagues I try to talk them into doing brain imaging, and other kinds of tests.","_key":"ujikK8du","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"O7pJoyV9"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Jessi Gold: When you were in training, did you know that you weren't like psychotherapeutic minded, and you wanted to be more focused on biology, like the whole time?","_key":"he3sZkmT"}],"_type":"block","style":"normal","_key":"KwbxXaD1"},{"_type":"block","style":"normal","_key":"ySUp3YMX","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: I did. I'm sorry to say. I studied Freud when I was a resident, I think all residents really do. And I asked biologically oriented questions of Freud to my teacher, and I quickly learned that that was not the proper student attitude. This was a long time ago. So I stopped asking questions. But I, you know, I, even Freud himself said all of these big behaviors are gonna be explained by brain activity in the future. So Freud himself when he was was explaining in using psychological phenomenon to explain to his students, he was very biologically oriented himself.","_key":"iYwYWq77"}]},{"style":"normal","_key":"rXA0Kg1q","markDefs":[],"children":[{"marks":[],"text":"Jessi Gold: And I know that, maybe, even if you're not so much like a therapeutically minded you are really early intervention minded, when it comes to early psychosis.","_key":"tPJLFPlg","_type":"span"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Yes.","_key":"PixzeEdV"}],"_type":"block","style":"normal","_key":"GnXb01oX","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"Jessi Gold: What does that look like? Can you explain that a little bit more?","_key":"lmpxrVyf"}],"_type":"block","style":"normal","_key":"wYaQxlXF","markDefs":[]},{"children":[{"_key":"X0lvSpF9","_type":"span","marks":[],"text":"Carol Tamminga: Well this is another kind of phenomenon that I've only come to realize recently. You know when you talk about cancer care, early detection is what it's all about. You don't let the cancer develop and loo at where the metastasis go, and how fast they grow, before you decide treat it. That's what we do in our field. Somebody gets a little bit psychotic, and you wait for it to develop a little further. You see if the psychosis is paired with affect changes. Whether the affect changes started before or after. Then you let it go a little bit more, and see what their social function is. If their social function deteriorates fast, deteriorates slowly."}],"_type":"block","style":"normal","_key":"KirWCwzA","markDefs":[]},{"_type":"block","style":"normal","_key":"BiToWoWk","markDefs":[],"children":[{"marks":[],"text":"Carol Tamminga: And finally we do most of our testing for new drugs, and a lot of our research, we do in people who are 30 to 40 years old, and have had their illness for 15 years. And I think that the realization that we really need to get to all of this very early, and we need to get to people who are psychotic early to stop their psychosis, and particularly stop the psychosocial deterioration early. And then they'll stay better for longer. We're still in the process of testing whether they really stay better for long, and we'll have tweak our treatments so that they help the people stay better for longer. But I have no doubt that we're on the right track.","_key":"noTWrpJw","_type":"span"}]},{"style":"normal","_key":"DB34ifVb","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: You know, and that's something that also I, at some point in my career that I've heard lectures about schizophrenia that are rather fatalistic. It's this, you know, it's a biological illness, which has a 1% chance, and it just if you happen to have the unlucky gene at birth then you're just kind of up a creek, and so no point in early detection because it is what it is, and there's no turning, you know, changing it.","_key":"JavkLW5Q"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: Is that a true view of schizophrenia?","_key":"KWwXZ07L"}],"_type":"block","style":"normal","_key":"NsdlxYSU"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: So I think that's wrong. I don't think that there would be a lot of psychiatrists who would be so ... fatalistic, would see it as such a single path forward. I don't think that we can take every person with a diagnosis of psychosis or schizophrenia and turn their illness around and cure them. We can't take everybody with cancer and cure them. We can't take everybody with heart disease, and give them, even do a transplant and get them cured. But we can do our best in tryin to predict which people to do the complex early treatments with.","_key":"Te1hK2kV"}],"_type":"block","style":"normal","_key":"cA56I6DU"},{"_key":"t7TiOyRq","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: And what is that, for those who may never have heard of the early intervention, what does that involved? And I guess how, just very superficially or overview wise, how could that change somebody's course? Somebody on track to another or would get what we call schizophrenia? How would that change","_key":"Jpr2im7K"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: So a lot of people, these studies started in Europe and most European countries. Probably in the 1990s, and there were several studies that studied at them, giving intensive interpersonal psychosocial, and constant antipsychotic treatment to people with early schizophrenia. These studies happened in Europe.","_key":"Qp9frkuE"}],"_type":"block","style":"normal","_key":"4WTkSREK"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: There were a couple of scientists in the U.S., Lisa Dickson being one of them, who kept and eye on those studies, and who was very interested in early treatment. And she was very interested in treating early everything that was, all of the psychological and medical burdens of people with early psychosis. So she paid attention to drug abuse in early schizophrenia. She paid attention to not only just the psychosis, but of course she treated the psychosis too, but she cared about families, and family patient interactions, and things like that.","_key":"OjZCHeYA"}],"_type":"block","style":"normal","_key":"6xgKApvd"},{"children":[{"_key":"RKUFRkLM","_type":"span","marks":[],"text":"Carol Tamminga: She's the one that was the inspiration RAISE Study which then got completed around the country. Which was a two year early intervention study. Where people who with psychosis got, they were watched very carefully over two years. They had ... very intensive treatments, both psychological treatments, and the pharmacologic treatments, and family treatments, and CBT, and cognitive remediation for two years. And at the end of the two years, the people were better"}],"_type":"block","style":"normal","_key":"9ArbH7uP","markDefs":[]},{"_key":"g7UoH3Fk","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Why they're better is unclear. It could be, it has to be that they watched very carefully by a group of people who were treating them, and therefore they stayed on their medication more. That must be a possibility. And another possibility there's just nothing that's worse for psychosis than drug abuse. So that drug abuse was given some attention, and people were treated for their drug abuse. Whether or not the cognitive remediation turned things around cognitively in the brain is a big question.","_key":"5voB7hFJ"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"aNmZKKSe","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: Okay well we are coming to the end of our time. I wanna as-","_key":"AF1zMzZT"}]},{"_type":"block","style":"normal","_key":"xykkwHKw","markDefs":[],"children":[{"marks":[],"text":"Carol Tamminga: Well it's been nice talking with you guys.","_key":"swg64OKL","_type":"span"}]},{"children":[{"marks":[],"text":"Jessi Gold: You too. Thank you for making time.","_key":"tC97ZhBf","_type":"span"}],"_type":"block","style":"normal","_key":"kaIvhuYF","markDefs":[]},{"_type":"block","style":"normal","_key":"cJcpdYVw","markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: We have some rapid fire questions to close it out.","_key":"vtZBCrQI"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Okay.","_key":"q5IUdmT1"}],"_type":"block","style":"normal","_key":"j2bYBjiw"},{"children":[{"text":"Jessi Gold: What's your favorite book?","_key":"sZwOsU1k","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"QCgCBPaU","markDefs":[]},{"_type":"block","style":"normal","_key":"6puGUhCP","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: One of my favorite books is Elyn Saks' book \"The Center Cannot Hold\". And Elyn Saks is a lawyer, very accomplished person, brilliant, brilliant person. And she has what she always thought was schizophrenia for her whole life, and she was, she had a rather typical schizophrenic course. She was able to partition her psychosis to a part of her life, so she still had, she could still go through law school and come out in the top of her class, and she can get her job at University of Souther California. And you guys may know her, do you?","_key":"9yaM08V3"}]},{"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: And then she always said she was never gonna telly anybody she had schizophrenia, because she'd never get a good job. So she came to California, got a job at the university in the law school at U.S.E. And she went from assistant professor to associate professor, she finally got to be full professor with tenure, and then she wrote her book.","_key":"Zr8PDUlM"}],"_type":"block","style":"normal","_key":"BKKu30Io","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"Jessi Gold: Oh that's awesome.","_key":"exiujfn4","_type":"span"}],"_type":"block","style":"normal","_key":"ux8PNkR2"},{"style":"normal","_key":"JwMZNSWx","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Jessi Gold: Is one of the reasons you like it because she is so high functioning, and tells a different story of schizophrenia?","_key":"XrdodYc4"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: She talks about her, in one of her books, \"The Center Cannot Hold\", she talks about the nature of her symptoms. And she's so bright, she can explain it so that you and I can understand it. And she can tell you what her experiences are. And people who are a little less bright, can't quite say it very clearly, and their own symptoms interfere with their articulation of it, but she's really brilliant.","_key":"OzrKhGMV"}],"_type":"block","style":"normal","_key":"6iPsIR8I","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"Jessi Gold: Our next quick question is, what would be your best advice to psychiatry trainee?","_key":"vRyU15TQ"}],"_type":"block","style":"normal","_key":"NyJ5KjWu","markDefs":[]},{"children":[{"text":"Carol Tamminga: Oh learn about the brain. Oh without doubt, absolutely.","_key":"XRlVEshi","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"yLrI1jSI","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"David Carreon: What is your favorite psychiatry word?","_key":"lmVtEYN8","_type":"span"}],"_type":"block","style":"normal","_key":"zg4c8cGT"},{"_key":"ehqC6yPA","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Biotype.","_key":"d9Z9UZNI"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"text":"David Carreon: And last but not least, who is your favorite hero, either from history or fiction?","_key":"e4Vuxr3j","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"cfVoDXkM"},{"markDefs":[],"children":[{"_key":"iP38zvBB","_type":"span","marks":[],"text":"Carol Tamminga: My favorite hero from history or from ... I mean it could be a good writer or something like that?"}],"_type":"block","style":"normal","_key":"HwoVvmGu"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"David Carreon: It could be.","_key":"moMPVyeB"}],"_type":"block","style":"normal","_key":"9Yy5lfDu"},{"children":[{"text":"Jessi Gold: Or like a role model or anything that you remember someone, like looking up to someone.","_key":"IAyZdSBd","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"TaYj6er8","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"David Carreon: Spider-Man, I mean.","_key":"AC9k18Rn"}],"_type":"block","style":"normal","_key":"YOsoA7wW","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Jessi Gold: Wonder Woman.","_key":"FWhUP75y"}],"_type":"block","style":"normal","_key":"1Udic5xx"},{"_type":"block","style":"normal","_key":"e2al0N2r","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Carol Tamminga: Wonder Woman, no. 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That sounds hypothetical and whatnot, but over time that’s exactly what I’ve been able to do. My medication management appointments are 15 minutes, so I have to use my time wisely. But we have the responsibility to provide our patients with all their options. Let them know what the benefits are—perhaps this could delay the time to relapse. Let them understand what can happen to an individual who has chronic schizophrenia that’s not optimally managed and how that relies on a nice therapeutic relationship with both of us. It’s going to take a village to get the individual back where they’d like to be, to give them the best opportunity. The other thing I would definitely say is—and I really believe this—that if we want to change someone’s life in psychiatry, start a long-acting injectable [LAI] early in the course of illness for a person who’s been diagnosed with schizophrenia.","_key":"e176e2dd08721"}],"_type":"block","style":"normal","_key":"8528241dcd0a"},{"_type":"block","style":"normal","_key":"2e2edeaebaff","markDefs":[],"children":[{"marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"94abb81679370","_type":"span"},{"_key":"94abb81679371","_type":"span","marks":[],"text":"Yeah, I agree. I’ll just add that I’ve had a fair number of clinicians say to me, “I don’t think my patients will accept this treatment,” or they’re scared of injections, or whatever else it is that we’ve been taught to believe. It’s interesting because we do have literature on this. We clinicians often think patients won’t accept LAIs. If we present it to them in a fair way, highlighting not just the risks but also the benefits, more of them will take LAIs than we think. In addition to what you said, that’s been my advice to clinicians: “I know you don’t think they’ll accept it but why don’t you just give it a try. Ask them, and you may be surprised.” I’ve had a number of them come back who were surprised. They say, “I didn’t think this guy was going to take it, but I asked him and he actually did agree to take it.”"}]},{"children":[{"marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"5536c3a471050","_type":"span"},{"_type":"span","marks":[],"text":"Yes. I’ll have patients or their therapist tell me, “Good luck. This person will never take the injection—never.” The next thing you know, they’re like, “I can’t believe it. It’s already scheduled. They’re coming in tomorrow.” They’re amazed. But it’s all about the presentation. If we present it as an opportunity, not the last resort, not a punishment. I’m cautious with the terminology I use. I’ll make sure to not say things like your shot. I will say your injection. I’m also very cautious with providing them with a realistic picture of what that looks like.","_key":"5536c3a471051"}],"_type":"block","style":"normal","_key":"1bf146d0ce09","markDefs":[]},{"_key":"7da5aac03fc8","markDefs":[],"children":[{"text":"You mentioned earlier that some of the injectables require 2 doses to get those concentrations up a little higher. It’s interesting. If you tell a patient you’re going to get 1 injection every 28 days, and then you’re giving them an appointment for 2 injections in 2 weeks, they look at you like, “Wait a minute, what are you talking about? This isn’t consistent with what we discussed.”That can have a huge impact on therapeutic rapport with our patients, and they’ll lose that confidence in us. I’m very realistic with them, and try to give a very clear picture of what they can expect from my experiences with working with patients.","_key":"8492e456fe610","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"e1207aa3b0f50","_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: "},{"_type":"span","marks":[],"text":"Just from this last hour, I can tell that you and I could probably talk about this for the next 2 hours and not run out of things to talk about with regard to LAIs and the treatment of our patients. But sadly we’re out of time, so I’m going to have to close. I want to say it’s been a pleasure having this conversation with you.","_key":"e1207aa3b0f51"}],"_type":"block","style":"normal","_key":"59cb71e2df30"},{"_type":"block","style":"normal","_key":"38c83bd7a82e","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"465f6dca57e30"},{"_type":"span","marks":[],"text":"Thank you. I’ve enjoyed it. Thank you so much for this opportunity.","_key":"465f6dca57e31"}]},{"_key":"349e379f9990","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"976d4be2c1e60"},{"_type":"span","marks":[],"text":"Absolutely. 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In the VA [Veterans Affairs] system, our barriers to getting LAIs are very minimal, and we’re encouraged to have as many people on LAIs as we possibly can. As you’ve looked around not just at your practice but elsewhere, what have you seen as some of the barriers to LAI adoption? And how do you get around those? How do we help people work with that?","_key":"84c4006d2f231","_type":"span"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP:","_key":"74404833eb250"},{"_key":"74404833eb251","_type":"span","marks":[],"text":" I think back to my years when I was working in inpatient and how we would have a patient who was rehospitalized several times and their symptoms very poorly managed. We’d get them established on a long-acting injectable and send them back out to the community only to have their local provider say, “I don’t give long-acting injectables, so I’m going to substitute and put you back on the same oral medication that was not working before.” One of the big frustrating points is inequitable access."}],"_type":"block","style":"normal","_key":"2970c27e9191"},{"_type":"block","style":"normal","_key":"35cc802b3190","markDefs":[],"children":[{"_type":"span","marks":[],"text":"But what’s really interesting is that, especially in my area, some pharmacies have become extremely innovative. They’re willing to send an Uber to get a patient to come in for a long-acting injectable. They’ll go to the house to give the injection, looking at what’s available in the community, as well as what’s available in our own practice. Some of the barriers that I hear from other providers in psychiatry are, “We don’t have a Sharps box. We don’t have anyone comfortable giving the injection. I’m not comfortable even touching the patients.” If it’s an injection that needs to be given in the gluteal muscle, they don’t want to see that element of body. Good education or even a reminder. That’s OK—not every practice would need to accommodate but to be open to other options. Sometimes providers don’t want to prescribe something that they themselves would not administer, and I appreciate that, but I still think it’s a sometimes disservice to the patient.","_key":"835bec2cc5d10"}]},{"_key":"36a0b59814fe","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"941745ec88ba0"},{"_type":"span","marks":[],"text":"Yeah. That highlights so many important things, and much of you talked about I categorize as system resistance.","_key":"941745ec88ba1"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"cfcd8d3c86240","_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: "},{"marks":[],"text":"Yes.","_key":"cfcd8d3c86241","_type":"span"}],"_type":"block","style":"normal","_key":"86d90a3ed2d2"},{"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"82aeef2d0bd90"},{"_type":"span","marks":[],"text":"There are inherent points of friction in our system of care that sometimes makes it difficult for patients to continue on LAIs even when they get started. Earlier on, we talked about patient resistance, how we might get around that, and the education we do. The 1 other thing I thought would be useful to highlight is clinician resistance, which you talked about and which I also think of as a by-product of how many of us were originally trained—this idea that LAIs are for the sickest people, and you don’t get there until later. The remnants of that training are still with us in a lot of ways.","_key":"82aeef2d0bd91"}],"_type":"block","style":"normal","_key":"a31bfe13295b","markDefs":[]},{"_key":"c44b54f9a9a7","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"e47ee72b55910"},{"_type":"span","marks":[],"text":"I agree.","_key":"e47ee72b55911"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"be4ec401b8ac0"},{"text":"Especially in the people who are making the decisions.","_key":"be4ec401b8ac1","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"1f19b5c0f93b","markDefs":[]},{"_key":"565fede7013b","markDefs":[],"children":[{"_key":"294127fa3eff0","_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: 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One of the biggest was just because you’re injecting them every 3 months doesn’t mean you have to see them only every 3 months.","_key":"c9a45396a4b0"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"568baca9b5a20"},{"_type":"span","marks":[],"text":"Yes.","_key":"568baca9b5a21"}],"_type":"block","style":"normal","_key":"451a55dd940f"},{"style":"normal","_key":"a6f0180011b8","markDefs":[],"children":[{"text":"Sanjai Rao, MD, DFAPA: ","_key":"a18238a0d5590","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":"In fact, you guys turned it into an opportunity to look at it in a different light. Because we don’t have to spend 5 or 10 minutes working out the mechanics of giving you an injection on these intervening visits, we can use that time to talk about other things.","_key":"a18238a0d5591"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"5e7b0cdb49880"},{"_type":"span","marks":[],"text":"Talk about other things, exactly. Find out what’s important to them.","_key":"5e7b0cdb49881"}],"_type":"block","style":"normal","_key":"d46fb2fff0c9"},{"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"ea359528aa3e0"},{"_type":"span","marks":[],"text":"It’s time regained.","_key":"ea359528aa3e1"}],"_type":"block","style":"normal","_key":"a3ba363aeb8c","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"c1946f7c78ba0"},{"_key":"c1946f7c78ba1","_type":"span","marks":[],"text":"Yes. It’s amazing how many of my patients who are on injectables. They’re able to get Social Security benefits, but they’re able to work part time too. It’s beautiful to experience that with them. They realize that it’s going to be very stressful, and for some of them it’s too stressful; they’re not able to do it. But it’s just nice to see our patients in a good spot. We’re able to think about more things than, “Did you take your medicine?”"}],"_type":"block","style":"normal","_key":"e35bf9a6cb0a"},{"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"f1c6f60670630"},{"_type":"span","marks":[],"text":"I imagine, even just from the perspective of the clinic and your staff, that this is much less burdensome. Having to inject somebody one-third as many times as you were before.","_key":"f1c6f60670631"}],"_type":"block","style":"normal","_key":"21bc8e2a854e","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"9e30bb1086280"},{"_key":"9e30bb1086281","_type":"span","marks":[],"text":"Absolutely, yes."}],"_type":"block","style":"normal","_key":"ba7e57930682"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA:","_key":"cd1df6a4d4c50"},{"_key":"cd1df6a4d4c51","_type":"span","marks":[],"text":" Circling back to your idea of letting us take care of it for you, when we can do this every 6 months then that’s the ultimate let us take care of this for you, right?"}],"_type":"block","style":"normal","_key":"6769875342b8"},{"_key":"6d4349bbc8b8","markDefs":[],"children":[{"text":"Kimberly Garcia, DNP, CRNP: ","_key":"7e626094e44a0","_type":"span","marks":["strong"]},{"text":"Absolutely, yes. Recently I had a patient come in with her mom, and the patient is in her mid-20s. The mother said she has never been well since she had her first psychotic episode. The mother said, “I’m at wit’s end with her. She’s become very paranoid at home. She’s done damage to the property.” The mom and the patient are arguing. We talked about some options, and the mom said, “You know what, we need that 6-month injection.” I’m like, “We’re going to need to take a couple of steps to be able to get there, but let’s have that goal and start working on that now.” So day 1 we’re starting to think about what that’s going to look like and when that can happen. And the patient was invested: “Every 6 months?” It made a big difference.","_key":"7e626094e44a1","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"8293b103d8830"},{"_type":"span","marks":[],"text":"It’s a great starting point, right?","_key":"8293b103d8831"}],"_type":"block","style":"normal","_key":"bb8664c07465"},{"markDefs":[],"children":[{"marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"d034dc3326090","_type":"span"},{"_type":"span","marks":[],"text":"Yes.","_key":"d034dc3326091"}],"_type":"block","style":"normal","_key":"5d90a7d22124"},{"markDefs":[],"children":[{"_key":"248c3de424dc0","_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: "},{"_type":"span","marks":[],"text":"When I’m talking to people about the monthly, I’ll often say, “Look, if you’re doing well on this, we can extend this to every 3 months.”","_key":"248c3de424dc1"}],"_type":"block","style":"normal","_key":"4e8f54761a7b"},{"_type":"block","style":"normal","_key":"f1d8ac7a18a8","markDefs":[],"children":[{"text":"Kimberly Garcia, DNP, CRNP: ","_key":"5254a416e91a0","_type":"span","marks":["strong"]},{"text":"Yes.","_key":"5254a416e91a1","_type":"span","marks":[]}]},{"children":[{"marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"7730adbea21d0","_type":"span"},{"_type":"span","marks":[],"text":"It’s a good thing for them to think that this will lead to something better.","_key":"7730adbea21d1"}],"_type":"block","style":"normal","_key":"be5c63300ed5","markDefs":[]},{"markDefs":[],"children":[{"marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"3b8c4ab31b720","_type":"span"},{"_type":"span","marks":[],"text":"Yes.","_key":"3b8c4ab31b721"}],"_type":"block","style":"normal","_key":"c39f8858ac87"},{"_type":"block","style":"normal","_key":"2e9bd2e1aea0","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"e9721aabb0a30"},{"_type":"span","marks":[],"text":"I’m glad you mentioned that transition though because it’s important to talk about how you get these things started and the idea that for any of these injections, there’s typically some initiation regimen. For the older ones, it meant you had to oral overlap for a few weeks. For the newer ones, it means you have to give them 2 injections, either in rapid succession or over a few days. But there are a couple—specifically I’m thinking of the monthly subcutaneous risperidone—that don’t require that overlap but also are limited to a max dose of the equivalent of 4 mg. With every agent there’s going to be a little trade-off, but you do have to have this initiation regimen. For the longer-acting formulations, specifically 3 and 6 months, you can’t start with those. You have to start with the monthly and build up a steady state over at least 4 months. Then you have the option to convert them to 3 or 6 months when we have that available.","_key":"e9721aabb0a31"}]},{"_type":"block","style":"normal","_key":"d29f3450a1af","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"0246bdb095c00"},{"_type":"span","marks":[],"text":"Yes.","_key":"0246bdb095c01"}]},{"_key":"ac7736e1f3c0","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"32f4e3b33e8b0"},{"_key":"32f4e3b33e8b1","_type":"span","marks":[],"text":"That’s an important thing to keep in mind. With the long formulations, there’s a process to get there, but it’s a very reasonable process. And getting there involves just being on the monthly for a while."}],"_type":"block","style":"normal"},{"_key":"9958a6c246b6","markDefs":[],"children":[{"text":"Kimberly Garcia, DNP, CRNP: ","_key":"fa587dc3fc790","_type":"span","marks":["strong"]},{"marks":[],"text":"Yes, and having those goals. I found that the majority of my patients are willing to put in the time and energy to get to that point. When we empower them to become active participants in their care, it’s a game changer because it’s no longer a punishment where the mom is like, “Take your medication.” It doesn’t seem as if it becomes as much of an issue. Patients are willing to come in to get their injections. Sometimes they even look forward to it. We’ll try to incentivize it whenever we can—we’d do a raffle or something for patients who would come in for their appointments, but we haven’t needed to do that. 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Schizophrenia","link":"/view/administration-of-available-long-acting-injectables-for-schizophrenia","body":[{"markDefs":[],"children":[{"text":"","_key":"84e988d443a5","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"da77ed5218ea"},{"_type":"video","videoID":"6282505038001","source":"brightcove","_key":"8c55d7648d82"},{"_key":"7987776527e7","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"a2f37de91256"},{"_type":"span","marks":[],"text":"It’s a great segue into talking about what’s available to our patients. It’s been gratifying for me because when you and I started doing this, all we had available were a couple of first generations and maybe the earliest of the second generations.","_key":"0e1114fb9bda"}],"_type":"block","style":"normal"},{"_key":"28e8d7faa5df","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"0dc276ed164e0"},{"_type":"span","marks":[],"text":"Yes.","_key":"0dc276ed164e1"}],"_type":"block","style":"normal"},{"children":[{"_key":"bc522834e6740","_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: "},{"_type":"span","marks":[],"text":"Now we’ve got so many options. We’ve got multiple versions of risperidone. We’ve got the 2-week version and now a monthly subcutaneous version. We’ve got aripiprazole, which you can give every month, every 6 weeks, every 2 months.","_key":"bc522834e6741"}],"_type":"block","style":"normal","_key":"88d91c359491","markDefs":[]},{"_type":"block","style":"normal","_key":"9e0149238f60","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"b8369ec3ab120"},{"_type":"span","marks":[],"text":"Yes.","_key":"b8369ec3ab121"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"73ed409901110"},{"_type":"span","marks":[],"text":"Then we’ve got paliperidone, which until recently with monthly and every 3 months, but now it’s every 6 months.","_key":"73ed409901111"}],"_type":"block","style":"normal","_key":"35980f79ce88"},{"style":"normal","_key":"f1a62ec19e71","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"4f06d7e23bbe0"},{"_type":"span","marks":[],"text":"Every 6 months, I know. I have so many patients who were absolutely counting down the days till that happened. That was something we’d been working toward for the right patient, so to see that—when we think about their goals and what they would like to do, it’s interesting. You mentioned going from 1-month to 3-month doses.","_key":"4f06d7e23bbe1"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"I use a great deal of Invega products for my patients with schizophrenia. My patients were on an every-28-day regimen, and I was comfortable with that because I felt that if I was to expand the duration between injections, perhaps they would be lost to follow-up, would feel that they were cured, and would not come back for their next injection. So I was very hesitant. I was not an early adopter of switching patients from the 1-month to the 3-month product. Some of that was because I did not have as much confidence in them as I should have.","_key":"2b919a5a427a0"}],"_type":"block","style":"normal","_key":"db55b4724d31","markDefs":[]},{"_type":"block","style":"normal","_key":"8147fb618e7a","markDefs":[],"children":[{"text":"Fast-forward to the middle of the pandemic, and I have patients who were coming to the alleyway in the back of the office. We were giving injections in an alley in a dark parking lot. It’s dark out. I’m using my cell phone light to illuminate the arm so I can give the injection. We had people actively with COVID-19 coming to the parking lot to give them their injections. I say to myself, “What am I doing? Why am I doing this when I have a viable option?” It felt like it was inappropriate for me to not at least broach the conversation. I had some patients who said, “No, I’m doing fine on my once a month. I’m not going to switch.” I respect that, absolutely, because they have to have comfort.","_key":"3262c0316efb0","_type":"span","marks":[]}]},{"style":"normal","_key":"15961363560c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"That’s the time when I started switching my patients to the every-3-month product. What was so strange about that in its own way was they didn’t stop coming to see me. They’d still be able to see me every month. They were very consistent with their appointment, their symptoms were very well managed, and yet we’re able to use some of that time that we didn’t usually have available because it was very focused on the mechanics of the injection. Now we’re like, “Let’s talk about metabolic screening. Let’s talk about your diet and exercise patterns and look at your cholesterol and all that stuff.”","_key":"82ecd03ef6720"}],"_type":"block"},{"style":"normal","_key":"a174a0113cc3","markDefs":[],"children":[{"_key":"e82a11bc6fda0","_type":"span","marks":[],"text":"I definitely realize that those issues were mine, and I believe I held back some of my patients. COVID-19 made that very evident to me. It’s been amazing. I’ll tell you what’s so interesting: patients will come in and out of treatment, especially those on oral products. My patients who are on injectables—and I’m not saying 1 particular type of injectable, I’m talking about across the board—are some of my absolute most consistent patients."}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript edited for 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When do you get this going?","_key":"24b1ace0bb3d","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"72d4b05930bb"},{"markDefs":[],"children":[{"text":"Kimberly Garcia, DNP, CRNP: ","_key":"141baf9b90560","_type":"span","marks":["strong"]},{"text":"Typically, as we’re new into treatment, listening, we’re going over their history. Typically they’ve been in the hospital already by the time they reach me in the outpatient practice. I’ll sometimes ask them, “What are some of your goals? Where would you like to see yourself 5 or 10 years from now?” Then what I’ll typically do is start the conversation and then follow through at subsequent visits. I usually leave a little information.","_key":"141baf9b90561","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"ecf011f917fc"},{"_type":"block","style":"normal","_key":"8830c837e2f8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"I will say to them, “One thing you may want to consider, we have a number of injectable products,” and they’ll say, “Injection?” I say, “My gosh, no, it’s not bad at all. It’s very well tolerated. We do many of them here.” I usually will use patient experiences. For some of my patients, they prefer to give me the responsibility of worrying about their medication regimen, so they don’t have to worry about anything. We can take care of having the pharmacy deliver the injection. Patients come in, depending on the product, in 1 to 3 months, now even up to 6 months. We have some patients with that, and it’s exciting if we present this as an opportunity for them.","_key":"7a2fc7e21af50"}]},{"children":[{"_key":"474d0bd173440","_type":"span","marks":[],"text":"Where I am in Pennsylvania, the state does not require prior authorizations for long-acting injectables [LAIs]. They want us to use them early and they want us to not experience any barriers to their use. Sometimes we have to educate patients about the reason for that and what that could mean for them and their illness over time. What I find is that, especially if they bring another family member or friend with them or an affiliate, even like a caseworker, for them to hear this information. I don’t push because as soon as we start pushing, there are psychological implications for that. So we just provide them with the information, letting them know that this is an option. We offer this service. If you’d like to take advantage, you could. How interesting it is that often at that next appointment with me, they’ll say, “Could you tell me a little more about that injection? Or “I was looking up information about the injection, and I might be interested in that.”"}],"_type":"block","style":"normal","_key":"093d19c9a8bd","markDefs":[]},{"_type":"block","style":"normal","_key":"79fd74afc516","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"fd572c9346410"},{"_type":"span","marks":[],"text":"It’s wonderful. You’re applying a motivational enhancement, motivational interviewing approach where you’re exploring it with them, giving them some options, reinforcing them when they come back with a positive impression of it and want to pursue it more. It’s often enticing them to want to come back and ask for it and increasing their investment in it. I love that. I’ve never heard this approach before, where some patients like us to handle all this stuff for them. If you’d like us to handle all this, we can do that. What a way of portraying the benefit of being on an injection: no, let us take care of it. All you have to do is arrive.","_key":"fd572c9346411"}]},{"style":"normal","_key":"cfdcbf7b5cc8","markDefs":[],"children":[{"_key":"41d9504b09710","_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: "},{"_type":"span","marks":[],"text":"And they love it.","_key":"41d9504b09711"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"0bba2592a25d0"},{"_type":"span","marks":[],"text":"And we’ll handle the rest.","_key":"0bba2592a25d1"}],"_type":"block","style":"normal","_key":"70ae89abc850"},{"style":"normal","_key":"c2f89aa0f47b","markDefs":[],"children":[{"marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"a6430ee077d00","_type":"span"},{"marks":[],"text":"At the end of the day that’s what it’s about. To say to a patient, “Bring me your arm, and that’s the expectation for today’s appointment.” It’s amazing. Injectables were sometimes portrayed in a very negative light, as a treatment of last resort. We’ve flipped that to present this, as I call it, an opportunity. “I have a nice opportunity if you’re interested,” and that’s a lot of the way that I will even talk about it: as an opportunity.","_key":"a6430ee077d01","_type":"span"}],"_type":"block"},{"style":"normal","_key":"973a18df4536","markDefs":[],"children":[{"marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"504337c6d78c0","_type":"span"},{"text":"That’s great. I often will try to figure out what part of the LAI experience would be beneficial to them. Are they someone who travels and leaves their meds behind? Someone who wants the freedom not to have to go home and get their med bottle when they need something? Someone who lives with someone and wants some privacy and they doesn’t want a medication bottle lying around? Or are they homeless and keep getting their meds stolen? Whatever their particular experience is, show them that if they were on the monthly injection or a longer duration injection, they wouldn’t have to deal with whatever this problem is that makes it hard to be on oral medications.","_key":"504337c6d78c1","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"8e395a40f4060"},{"text":"Absolutely. I have many patients who are from the Dominican Republic. My patients will oftentimes go for several months at a time back to their country. We know that insurances don’t like to provide a large amount of medication at once, so it’s created a number of barriers for them. Either they’ve had to rely on family members to mail them medications, which is always tricky, or they’ve tried to get equivalent medications or semiequivalent medications in their home country. For them, to get 1 of the longer-acting injectables has been a huge benefit.","_key":"8e395a40f4061","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"6084ec23fd62"},{"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript edited for clarity.","_key":"3741dcd43e76"}],"_type":"block","style":"normal","_key":"8936dd1fc766","markDefs":[]}],"link":"/view/discussing-long-acting-injectables-for-schizophrenia-with-patients","summary":"Sanjai Rao, MD, DFAPA, starts a conversation on how to discuss long acting injectables with patients and how to best transition from an oral medication.","documentGroupMapping":[{"_ref":"7e337b95-4da8-4702-be88-77181a21607f","_type":"reference","_key":"d9a7d20d40ea"}]},{"published":"2021-12-16T14:20:00.000Z","body":[{"style":"normal","_key":"49f641037b6e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"3797e36ec520"}],"_type":"block"},{"_type":"video","videoID":"6282507569001","source":"brightcove","_key":"4914d42bf2c4"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"fc2c5e5737e2"},{"_type":"span","marks":[],"text":"Let’s switch gears a little and talk more about the specific treatment for schizophrenia. I thought we could start by talking about treatment algorithms for patients with schizophrenia. When you’re thinking about a patient with schizophrenia, what algorithm do you follow, or is there 1 to think about? What am I going to treat this patient with, and how is this going to go?","_key":"bec97f62f914"}],"_type":"block","style":"normal","_key":"7e4d7c455756"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"82e51175b7400"},{"_type":"span","marks":[],"text":"I do have an algorithm. As a provider, it’s interesting to observe the evolution of my algorithm. If this was 15 years ago and we were having this conversation, I’d start with 1 particular antipsychotic. If it’s not effective, then I’d increase the dose until we achieve efficacy or there are tolerability issues. If that’s still not effective in controlling their symptoms, I may add a second agent or think about combining a first- and second-generation antipsychotic.","_key":"82e51175b7401"}],"_type":"block","style":"normal","_key":"bd92ca0f64f2"},{"children":[{"_type":"span","marks":[],"text":"These days, things have changed for me because I work in an environment that supports the use of long-acting injectables [LAI]. We have a whole nursing department. They administer the majority of those injections. We’ve become known in our community as a facility that offers this as a treatment option. It’s interesting how that gets communicated to other individuals. We’re often approached by patients who are interested in looking at that as a treatment option. The reason that I tend to gravitate more toward injections is, No. 1, the reality is that adherence is going to be a problem. Oftentimes, poor adherence is going to lead to relapse, which is going to lead to hospitalization, incarceration, or other very negative outcomes for the patient.","_key":"c71a3413ab2c0"}],"_type":"block","style":"normal","_key":"21241b1fed61","markDefs":[]},{"style":"normal","_key":"a8b18a7167ce","markDefs":[],"children":[{"_type":"span","marks":[],"text":"What I would do now is start them on an oral antipsychotic to begin. I try to identify 1 that has fewer adverse effects than the others. I provide as much education as I can in regard to metabolic syndrome, the need for AIMS [Abnormal Involuntary Movement Scale] testing and tardive [dyskinesia] symptoms, for example. Of course, that also scares patients, but at least allow them the sufficient knowledge to be able to make informed decisions.","_key":"00dc670d23970"}],"_type":"block"},{"markDefs":[],"children":[{"text":"However, it’s not long in the treatment trajectory before I start presenting the option to them. If they were interested, they could come into the facility and could receive 1 of the long-acting injectables. We talk about what that process looks like.","_key":"0df469e545de0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"0c35af0a486f"},{"_type":"block","style":"normal","_key":"a69de830d217","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"ea76aee9a8fc0"},{"marks":[],"text":"Is the potential availability of an LAI 1 of the things you think about when you’re selecting that initial agent for them?","_key":"ea76aee9a8fc1","_type":"span"}]},{"_key":"9116525e7165","markDefs":[],"children":[{"marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"2de9f0fe87310","_type":"span"},{"marks":[],"text":"Absolutely. My idea of using injections used to be that they were the last resort. If it was, “If you don’t take your medications, you’re in and out of the hospital,” this is almost going to be punitive for them. “You’re at the point where you’re going to have to have an injectable.” I’ve totally changed my perspective on the use of injectables. I see the value in them. I see the value in improving the patient’s quality of life—and the parents’ quality of life if they’re very involved and they have a child who has schizophrenia. There’s that constant fight between the parents and the young adult child to take their medications. I start them on an oral antipsychotic that would have the potential to be converted into a long-acting injectable. I start that conversation early, not just early in my treatment relationship with the patient but also earlier in the course of illness than I ever thought I would see possible.","_key":"2de9f0fe87311","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"737f0e87416b0"},{"_key":"737f0e87416b1","_type":"span","marks":[],"text":"Do you ever do it with first episodes?"}],"_type":"block","style":"normal","_key":"f8a44d684873"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"8e331f5fa3c20"},{"_type":"span","marks":[],"text":"I do.","_key":"8e331f5fa3c21"}],"_type":"block","style":"normal","_key":"74e91261b451"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"71449e5adab20"},{"_type":"span","marks":[],"text":"So you’re really looking at conversion to LAI, not just because they weren’t doing well on orals, but because you want them on an LAI earlier rather than later as a treatment.","_key":"71449e5adab21"}],"_type":"block","style":"normal","_key":"ccd0ab596417"},{"style":"normal","_key":"4afeb5092b31","markDefs":[],"children":[{"_key":"1a077b18cd050","_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: "},{"_type":"span","marks":[],"text":"Yes.","_key":"1a077b18cd051"}],"_type":"block"},{"_key":"843739b5d9cc","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"242284222a950"},{"_type":"span","marks":[],"text":"That evolution that you described mirrors the evolution of many of the treatment guidelines that we’ve seen. If you look at the American Psychiatric Association treatment guidelines—the previous set of guidelines, from 10 years ago—they basically said what you said at the beginning. You start oral medications, and you try different oral medications. If the oral medications aren’t working—if the patients are chronically nonadherent, if they have psychosocial or substance abuse problems, or all these other complicating factors—then way down the line you’ll give people a long-acting injectable. Their latest set of guidelines that came out in 2020 says, all those people should still get LAIs, but you can also think about LAIs earlier in the treatment course if the patient prefers to receive an LAI.","_key":"242284222a951"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"10dd31e80f390"},{"_type":"span","marks":[],"text":"Absolutely.","_key":"10dd31e80f391"}],"_type":"block","style":"normal","_key":"ad7d20a9b0ba","markDefs":[]},{"_key":"92ed255b9600","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"cf5dfe7135d10"},{"_type":"span","marks":[],"text":"I looked at this and said, “This is reasonable.” But I wish they’d gone further in the vein than you’ve gone. It’s not just that an LAI is an “if they prefer it” option. Saying if they prefer it or not really requires more along the lines of what you’re doing, which is actively educating the patient on the potential benefits and risks of an LAI—representing the true benefits of an LAI and then seeing if they prefer it. Not just kind of throwing it out there and saying, “Do you want to do this?” There are real reasons to take an LAI that might offer potential benefits over taking an oral.","_key":"cf5dfe7135d11"}],"_type":"block","style":"normal"},{"style":"normal","_key":"b2493376142b","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript edited for clarity.","_key":"11a91fc81fbd"}],"_type":"block"}],"documentGroupMapping":[{"_ref":"7e337b95-4da8-4702-be88-77181a21607f","_type":"reference","_key":"e410d876c1c8"}],"_id":"5973a7fa-849a-4206-9d19-63576e9374a5","factCheckAuthorMapping":null,"_updatedAt":"2022-01-20T05:36:09Z","summary":"Nurse Practitioner Kimberly Garcia and Dr. Sanjai Rao have a discussion on how they treat schizophrenia and highlight the considerations of prescribing long-acting 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relapse.","taxonomyMapping":[{"_createdAt":"2020-03-26T06:11:21Z","_type":"taxonomy","name":"Schizophrenia/Psychosis","_updatedAt":"2023-03-31T19:32:05Z","parent":{"_ref":"pst_taxonomy_53202_clinical","_type":"reference"},"perKeywordMapping":["Psychiatry","Neurology"],"_rev":"77mZ7PORfofI3dBGfWfij5","_id":"pst_taxonomy_362_schizophreniapsychosis","identifier":"topics/schizophrenia","cmeType":"per"}],"_rev":"h2cYLMqqBcG3FAtoIigWRD","link":"/view/schizophrenia-and-treatment-adherence","body":[{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"9f96d01e3be3"}],"_type":"block","style":"normal","_key":"36aaf28a3ffd"},{"_type":"video","videoID":"6282506819001","source":"brightcove","_key":"9e43aa46c212"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"dbbbdac0a982"},{"_type":"span","marks":[],"text":"Because we’ve gotten into the meat of adherence, I wonder if we can talk a little about what you’ve seen as being the factors that affect medication adherence in our patients. We talked a little about it, but maybe we can explore that a little more.","_key":"af2575db17cd"}],"_type":"block","style":"normal","_key":"d8b14e1b2ba6"},{"_key":"58808240622a","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"86f198a7005d0"},{"text":"The most important factor in adherence is adverse effects. The majority of my patients experience significant adverse effects to many of the psychotropic medications that we use. Also, there’s an overall burden of needing to be reminded sometimes 3 or 4 times a day that they’re living with a chronic illness. The fatigue that they experience after they take the medications. Things like dry mouth, not being as energetic or productive as they’d like to be, and those vegetative factors are held against them in many ways. Instead of recognizing that this could be a function of the medications, it’s really that they’re poorly motivated or even lazy. It helps to foster that stigma that comes with the disease.","_key":"86f198a7005d1","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"65e29a4d071b","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"390289ec3cee0"},{"text":"I agree with all that. I would add that in addition to the adverse effects, is the medication working or not?","_key":"390289ec3cee1","_type":"span","marks":[]}]},{"_type":"block","style":"normal","_key":"1562f6a93db5","markDefs":[],"children":[{"marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"6365044cf7b50","_type":"span"},{"_type":"span","marks":[],"text":"Yes.","_key":"6365044cf7b51"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"c6854185e7db0"},{"_type":"span","marks":[],"text":"Do they find it effective or efficacious? We’re in a bit of a bind on that, right? Because for the medication to be effective, they have to take it.","_key":"c6854185e7db1"}],"_type":"block","style":"normal","_key":"89f3d0deb519"},{"_type":"block","style":"normal","_key":"920c58e04d40","markDefs":[],"children":[{"_key":"d36bd0f669310","_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: "},{"text":"Absolutely.","_key":"d36bd0f669311","_type":"span","marks":[]}]},{"style":"normal","_key":"62c9ee57fabc","markDefs":[],"children":[{"text":"Sanjai Rao, MD, DFAPA: ","_key":"cf3341d404dc0","_type":"span","marks":["strong"]},{"text":"And they have to take it consistently and at the dose you gave it to them. If there’s partial compliance, their perception may be, “I’m taking this medication, and it doesn’t seem to be doing much good.” It might help if they took it 7 days a week vs 3 or 4 days a week, but there’s a perceived lack of efficacy there, so that might be part of it as well.","_key":"cf3341d404dc1","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"79f0c49636060"},{"_key":"79f0c49636061","_type":"span","marks":[],"text":"What do we do as providers? If a patient comes in and tells us, “My medication isn’t working,” we increase and increase. What’s going to happen when the patient finally starts taking the medications exactly as prescribed? They could be sedated. They could have other adverse effects. There’s no telling, but we can’t prepare for how they’re going to tolerate those doses when they’re not very consistent and very transparent with us as well."}],"_type":"block","style":"normal","_key":"dca515d2e6eb"},{"_type":"block","style":"normal","_key":"2cd89b403f34","markDefs":[],"children":[{"_key":"9168a48f36ae0","_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: "},{"_type":"span","marks":[],"text":"Right. We make the assumption that it’s a failure of the medication taken properly.","_key":"9168a48f36ae1"}]},{"_key":"0e1e75044aa9","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"abafae581ed00"},{"_type":"span","marks":[],"text":"Yes.","_key":"abafae581ed01"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"bf719b679d960","_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA:"},{"_type":"span","marks":[],"text":" In fact, the medication isn’t even getting into their system.","_key":"bf719b679d961"}],"_type":"block","style":"normal","_key":"c5c6f4550eee"},{"_key":"2e2cceb003f6","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"b5a596d19f2c0"},{"_key":"b5a596d19f2c1","_type":"span","marks":[],"text":"Exactly, yes."}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"2dae286e24900"},{"_type":"span","marks":[],"text":"How do you address this? Maybe you’re working with patients and they say to you, “I take my medication 3 or 4 times a week.” As you said, they’ll proudly admit to 3 or 4 times a week. What do you do to try and squeeze the extra 2 or 3 days out of them?","_key":"2dae286e24901"}],"_type":"block","style":"normal","_key":"2ad68aa33059","markDefs":[]},{"_key":"9b3cb3725fcd","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"f1f21d4545730"},{"_type":"span","marks":[],"text":"What I will typically do is try to normalize it. I’m a notoriously bad pill taker, so I’ll tell them, “I don’t take my acid reflux medication until I’m having a problem, and then it takes me twice as long to get my acid reflux under control.” They’re like, “I understand exactly where you’re coming from.” I try to normalize the fact that I’m almost expecting—I’m hoping it’s not the case—some issues with adherence. Then I’m looking at some practical things. Is there a particular time of the day when you typically will not take your medications? Am I giving medications multiple times in a day? Keep it as simple as possible. I’m a huge fan of if I’m going to have someone on oral medications. Once-a-day medications seem much more practical than something that’s 3 or 4 times a day.","_key":"f1f21d4545731"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"3147b22428ae0"},{"_type":"span","marks":[],"text":"I get to teach residents. I always tell them the nobody takes the afternoon dose.","_key":"3147b22428ae1"}],"_type":"block","style":"normal","_key":"0d7d07af1be7"},{"children":[{"marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"6ef812a1e7920","_type":"span"},{"_type":"span","marks":[],"text":"Yes.","_key":"6ef812a1e7921"}],"_type":"block","style":"normal","_key":"2ebab4ca859f","markDefs":[]},{"children":[{"marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"73b38f5e34df0","_type":"span"},{"_type":"span","marks":[],"text":"If you give somebody a medication 3 times a day, you may get them to take the morning dose and the evening dose. But I guarantee you, they’re not taking that afternoon dose. No one carries their medications around with them so that they can take that afternoon dose in the middle of the day. So you probably shouldn’t bother, right?","_key":"73b38f5e34df1"}],"_type":"block","style":"normal","_key":"8749b8fe465f","markDefs":[]},{"_type":"block","style":"normal","_key":"c9b9e0c31411","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"63e4ff541e120"},{"_type":"span","marks":[],"text":"Exactly. That’s right. It’s funny because once we come to accept that our patients may have a chronic and very profound mental illness, the reality is that they’re people just like us. So of course I can understand that. I can tell you that I wouldn’t be adherent to a very complicated medication regimen, or if there were multiple tablets, or if I was experiencing a lot of adverse effects. Taking a very realistic approach is important. It opens that opportunity for patients. I’ve had patients say to me, “To be honest, I haven’t taken that medication in 5 or 6 months.”","_key":"63e4ff541e121"}]},{"style":"normal","_key":"62dc6f4b3287","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"1e44566e7c280"},{"_key":"1e44566e7c281","_type":"span","marks":[],"text":"I like asking health care providers, “Have you ever taken a course of antibiotics? Did you ever miss a dose? Why did you miss the dose?” Of course, people will say, “I felt better,” or “I forgot,” or “I didn’t have the pills with me.” I ask them, “When was the last time you heard a patient say that?” You rolled your eyes inside your head because you were thinking, “Don’t you realize you felt better because you took the medication?” It’s something you and I could just as easily screw up."}],"_type":"block"},{"children":[{"_key":"9a0f8c91fa660","_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: "},{"_type":"span","marks":[],"text":"Of course.","_key":"9a0f8c91fa661"}],"_type":"block","style":"normal","_key":"44a15898fa6f","markDefs":[]},{"markDefs":[],"children":[{"text":"Sanjai Rao, MD, DFAPA: ","_key":"34f4219b052b0","_type":"span","marks":["strong"]},{"marks":[],"text":"The only difference is that for us the consequences aren’t catastrophic because we’re probably OK. If you miss a single dose of antipsychotic medication, the consequences of that could be severe.","_key":"34f4219b052b1","_type":"span"}],"_type":"block","style":"normal","_key":"15916288b16a"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"c76cfa3f3c0e0"},{"text":"Very significant. 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What do you say to them?","_key":"737427d14838"}],"_type":"block","style":"normal"},{"style":"normal","_key":"85635c059d32","markDefs":[],"children":[{"text":"Kimberly Garcia, DNP, CRNP: ","_key":"f126e8a6fc920","_type":"span","marks":["strong"]},{"text":"I try to take a realistic approach, especially once we have a nice rapport. I look back at my career 10 years ago, in a very optimistic phase of my career. I’d say to my patients, “Do you take your medications?” Of course they would say to me, “Yes, of course I take my medications.” We know that adherence is far more problematic. Once I have a rapport with my patients, I’ll ask them questions such as, “In the last 7 days, how many days do you think you took your medications exactly as prescribed?” It’s amazing the answers I get. You usually have very solid and proud 3 to 4 days per week with strict adherence, meaning a good portion of that time is spent without consistent use of the medications.","_key":"f126e8a6fc921","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Typically, as far as educating them about relapse prevention, I’ll let them know that relapse is almost inevitable. It’s not a matter of if; it’s often a matter of when. I’ll also talk about the fact that with each recurrence that they have, each symptom relapse, they lose a little functionality, which they may not regain, and about the cumulative impact that has on quality of life.","_key":"b94a935cf60c0"}],"_type":"block","style":"normal","_key":"462632bf0cbb"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"116f899f82b30"},{"_type":"span","marks":[],"text":"That’s such a key point, that relapses aren’t created equal. The further down the line you go, the harder it becomes to treat. You lose function, and it’s harder to get better. It takes longer to get better. It often takes more medication to get better. I say this to them a lot too: “If we do this better in the beginning, we can avoid going down this path where you end up needing more meds and lots of different meds. The further down we get and the more times you relapse, the more aggressively we’ll have to medicate you to get you well. Let’s try and avoid that. Let’s try to head that off at the pass by doing this now.” It’s great that you talk to them about relapse and that you’re up front with them. My experience has been that it’s something clinicians tend to avoid. We want to say to them, “If you take your meds, then you’re going to be fine,” but that’s not reality.","_key":"116f899f82b31"}],"_type":"block","style":"normal","_key":"6ca41e1b3021"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"14d246a32bc30"},{"_type":"span","marks":[],"text":"Right.","_key":"14d246a32bc31"}],"_type":"block","style":"normal","_key":"d97d1f2cce48"},{"markDefs":[],"children":[{"_key":"5b4c78cf256b0","_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: "},{"_type":"span","marks":[],"text":"Do you find that clinicians sometimes don’t talk about relapse?","_key":"5b4c78cf256b1"}],"_type":"block","style":"normal","_key":"de676ae8fbf5"},{"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"c906018e4cdd0"},{"_type":"span","marks":[],"text":"Absolutely. It’s an important piece, and I try to reinforce that too with students. We teach them about the kindling effect of schizophrenia. It’s an ethical responsibility that we have to our patients to advise them of the likely course prognosis of their disease process and ways that we can have an impact for them.","_key":"c906018e4cdd1"}],"_type":"block","style":"normal","_key":"5fde9d5c4dfa","markDefs":[]},{"_type":"block","style":"normal","_key":"9a0cfb93c791","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"a1050bf48aed0"},{"_type":"span","marks":[],"text":"Absolutely. The other thing I liked was the way you ask patients about whether they’re taking their meds. When we think about how we assess this, it’s often the way you said at the beginning, right? We say, “Do you take your medications?” We’re giving them this binary choice, right? They can say yes or no. If they say no, then they automatically know they’re going to be disappointing us. If there’s any yes at all, even if they take just a few meds, they might say yes but they’re taking it 2 or 3 days a week or something like that. I like your way of doing it: you ask how many days. Have you been doing that all along? Is that something you came up with after doing this for a while?","_key":"a1050bf48aed1"}]},{"_type":"block","style":"normal","_key":"142eb36d940e","markDefs":[],"children":[{"text":"Kimberly Garcia, DNP, CRNP: ","_key":"258a50f821b00","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":"It’s taken experience and being more realistic. Professional comfort comes from years of working with individuals who have schizophrenia to realize that if we’re not allowing them the opportunity to admit to issues with medications or whether they’re taking them, then they won’t go there. If we open the door, they’ll oftentimes walk through.","_key":"258a50f821b01"}]},{"children":[{"text":"Sanjai Rao, MD, DFAPA: ","_key":"20ca0935636c0","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":"I agree. It’s interesting, there’s some literature on how effective we are at figuring out whether patients are taking medications and even how effective patients are at accurately reporting it. Asked in a simplistic way, we’re terrible and they’re terrible, right?","_key":"20ca0935636c1"}],"_type":"block","style":"normal","_key":"cf1fe2951597","markDefs":[]},{"_key":"da6067e8ea8f","markDefs":[],"children":[{"text":"Kimberly Garcia, DNP, CRNP: ","_key":"26f033c98c230","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":"Exactly.","_key":"26f033c98c231"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"3465a080863f0"},{"text":"Patients typically misremember or misreport how much they take their medications if you ask them yes or no. We typically overestimate patient adherence, when we’re asked, “Do you think patients take their meds?”It’s easy to figure out. You can compare it with things like MEMS [Medication Event Monitoring System] cap and plasma levels, and you can see we’re way off compared with the objective measures of what’s happening.","_key":"3465a080863f1","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"f7ae17775b9e"},{"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"a505b40496200"},{"text":"Absolutely. Even now, we can search in the electronic record. We’re able to look at the refill dates, like the dates that their pharmacies dispense medications. That has been very telling. When you see that 30-day supply of medications is lasting for 90 or 120 days, and they’ll say, “This medication doesn’t seem like it’s working for me.”","_key":"a505b40496201","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"3b555137bdea","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript edited for clarity.","_key":"0fced439f727"}],"_type":"block","style":"normal","_key":"0d52b9339dd4"}],"url":{"current":"diagnosis-of-schizophrenia-relapse","_type":"slug"},"is_visible":true,"documentGroupMapping":[{"_ref":"7e337b95-4da8-4702-be88-77181a21607f","_type":"reference","_key":"4f60b8dae636"}],"_createdAt":"2021-12-08T17:21:59Z","_updatedAt":"2022-02-15T19:13:07Z","summary":"Sanjai Rao, MD, DFAPA, and Kimberly Garcia, DNP, CRNP, discuss how practitioners diagnose a schizophrenia relapse, and how to discuss relapse with patients.","_rev":"OP7H2echeMthIUyBlawmDA","_id":"fc251fee-6824-42ed-bc7b-481e1cfa21a8","seoTag":["schizophrenia","mental illnesses","schizophrenia relapse","schizophrenia diagnosis","schizophrenia relapse diagnosis","schizophrenia relapse signs","schizophrenia relapse symptoms"],"showSocialShare":true,"title":"Diagnosis of Schizophrenia Relapse","_type":"article","link":"/view/diagnosis-of-schizophrenia-relapse","factCheckAuthorMapping":null,"internalTag":["schizophrenia"],"contentCategory":{"_createdAt":"2020-02-10T10:49:36Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Videos","_id":"42000fd0-0d05-4832-9f2c-62c21079b76c","_updatedAt":"2020-02-25T09:35:54Z"},"authorMapping":[{"_type":"author","_id":"ceaf80c7-5698-4701-9aba-50113766bf17","_updatedAt":"2021-12-08T17:03:49Z","url":{"current":"sanjai-rao-md-dfapa","_type":"slug"},"displayName":"Sanjai Rao, MD, DFAPA","_createdAt":"2021-12-08T17:03:49Z","_rev":"hnY877aFOzIhu6RBuNOy52"},{"_rev":"jHv52opaezSRWzhtXwYQSA","_type":"author","_id":"41bfa049-a480-42e6-b02f-15e6e1882b93","_updatedAt":"2021-12-08T17:04:04Z","url":{"current":"kimberly-garcia-dnp-pmhnp-bc-fnp-bc-gnp-bc-np-c-cne-cnecl-carn-ap","_type":"slug"},"displayName":"Kimberly Garcia, DNP, PMHNP-BC, FNP-BC, GNP-BC, NP-C, CNE, CNEcl, CARN-AP","_createdAt":"2021-12-08T17:04:04Z"}]},{"body":[{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"cd02c002bc9c"}],"_type":"block","style":"normal","_key":"0e8da979412d"},{"source":"brightcove","_key":"e86c643cdaa0","_type":"video","videoID":"6282505039001"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"d8b01db8b645"},{"_type":"span","marks":[],"text":"Hello, and welcome to this ","_key":"255b1fce3f3e"},{"text":"Psychiatric Times","_key":"7bde2369c3fc","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":"® ","_key":"7108f22533f2"},{"_type":"span","marks":["em"],"text":"PsychView","_key":"c0a1c937f9be"},{"text":" series titled “Optimizing Management of Schizophrenia With Long-Acting Injectables.” I’m Sanjai Rao, a clinical professor of psychiatry and an associate residency training director at the University of California, San Diego, and the site director for residency training at the VA [Veterans Affairs] Medical Center in San Diego, California. We have with us Kimberly Garcia, the director of the psychiatric nurse practitioner program and an assistant clinical professor in the department of advanced practice nursing, nurse practitioner, and a doctor of nursing practice programs at the College of Nursing and Health Professions at Drexel University in Philadelphia, Pennsylvania. Thank you for joining us. Let’s get started.","_key":"da8481bbbacb","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"386ad9cb3a85"},{"_type":"block","style":"normal","_key":"a47f33958565","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Kimberly, I’ve been looking forward to this conversation. Schizophrenia is a huge part of what we treat, and I’m certain for you as well. I thought we’d start with a little background information for our audience. Talk a about how big of a problem schizophrenia is and some of the challenges and unmet needs you face when you’re treating patients with schizophrenia.","_key":"6f45c160f3660"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"c860f8d6c2220"},{"marks":[],"text":"Thank you for inviting me to participate in this session. I believe schizophrenia is a very significant issue. I work in community mental health, and we see individuals who tend to have refractory symptoms or are established in their disease trajectory. Schizophrenia, in my practice, makes up approximately 40% of our overall patient population.","_key":"c860f8d6c2221","_type":"span"}],"_type":"block","style":"normal","_key":"cb8634b0ed40"},{"_type":"block","style":"normal","_key":"3cb59911cc62","markDefs":[],"children":[{"_key":"e0c8a641fe780","_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA:"},{"text":" That’s huge. You obviously see many more than a lot of people do. I work at an inpatient unit, so I’m in a similar situation as you. I see an outsized amount of patients with schizophrenia relative to what’s in the population.","_key":"e0c8a641fe781","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"ba488585e1ee0"},{"_key":"ba488585e1ee1","_type":"span","marks":[],"text":"Yes."}],"_type":"block","style":"normal","_key":"84e26068587f"},{"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"68468c8d91390"},{"text":"Even if you consider what’s out there in the population at large, it’s around 1%, which doesn’t sound huge until you do the math and figure that’s around 2.5 million or more people who have schizophrenia. I was thinking about some of the unmet needs. Many times, when I see a patient, it’s someone on the younger side, someone recently diagnosed. They may not have a lot of psychosocial support. They may never have been sick in their life before, and so it’s hard for them to wrap their head around this idea that they’re sick. There’s a lot of difficulty with insight into the illness.","_key":"68468c8d91391","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"8fc2e366395f","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kimberly Garcia, DNP, CRNP: ","_key":"8edf9b24d54c0"},{"_type":"span","marks":[],"text":"Absolutely, and that goes in line with some of the core features associated with the disease process. It’s very hard when the patient is suspicious or paranoid or lacks insight to even establish rapport and be able to discuss treatment options.","_key":"8edf9b24d54c1"}],"_type":"block","style":"normal","_key":"004d94908b0e"},{"style":"normal","_key":"ea51447c3f3c","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Sanjai Rao, MD, DFAPA: ","_key":"0ceb159f1cd70"},{"marks":[],"text":"I completely agree. I’m sure that as part of that, you see what I see, which is that if you’re suspicious of the diagnosis, the treatment, and all that that, then you may not continue with the treatment. You may end up relapsing, and that’s obviously something that we see a lot in schizophrenia.","_key":"0ceb159f1cd71","_type":"span"}],"_type":"block"},{"style":"normal","_key":"dc72a05c2ba3","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript edited for clarity.","_key":"e6b9c5d93b31"}],"_type":"block"}],"display_summary":true,"is_visible":true,"thumbnail":{"asset":{"uploadId":"sHzbCaHhW10dsXuUDSgrZX9egZmTCpJt","_id":"image-b5bb1317deb7b809068f5e73ca93740c40d801c4-1098x618-png","originalFilename":"Screen Shot 2021-11-17 at 7.31.07 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Asbach, a psychiatric physician associate, emphasized the need to shift schizophrenia treatment goals towards recovery rather than merely managing positive symptoms. He highlighted the importance of comprehensive treatment strategies, including effective pharmacologic management, psychoeducation, family support, and prescription digital therapeutics. Asbach, who serves as associate director of interventional psychiatry at DENT Neurologic Institute, stressed that achieving a state of \"better but not well\" is insufficient. 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