Virtual Sessions

Shortly after Hurricane Katrina inundated a majority of the city of New Orleans with flood waters, then Senator Barack Obama noted, “The people of New Orleans weren’t just abandoned during the hurricane. They were abandoned long ago.” These words echo the increasingly obvious reality that systems of power wield a social calculus that disproportionately places vulnerable communities in harm’s way. Four years prior to Katrina, the federal government retracted previous limitations on wetlands development around the city, further eroding New Orleans’ natural defense. Simultaneously, the local Army Corps of Engineers budget for levee management was slashed by 80%. The net result of these decisions and climate change driven storm intensity was a mass casualty event of more than two thousand deceased and over 1.5 million displaced residents, disproportionately impacting the Black community. The parallels within the Katrina disaster resonate all too well with mental health practitioners in the United States. The weight of history hangs heavy in all aspects of psychiatric care. Housing laws, redlining, The War on Drugs, and failure to expand voting rights legislation are a few among the many injustices that have perpetuated race and class-based stratification affecting our patients daily. Within the field of psychiatry itself, implicit racial bias and racialized concepts such as cultural deprivation theory have previously entrenched subtle forms of racism in the name of race neutrality that to this day require dismantling. This session will explore historical injustices within the city of New Orleans as a backdrop for the systemic challenges that perpetuate inequities in care and exacerbate social determinants of mental health to the detriment of our patients, with the goal of fostering honest conversations that may begin to heal old wounds, lift up vulnerable communities, and ensure equitable mental health care across the country. 

PRESENTER UPDATE: L. Kasimu Harris will also present.

Even prior to the COVID pandemic, healthcare providers, especially physicians, faced an inordinate amount of stress as evidenced by the alarming prevalence of burnout symptoms for both trainees and practicing physicians, high self-reported job dissatisfaction, and concerning rates of mental health challenges. Affecting both personal and professional domains, burnout may be associated with a decrease in professionalism, higher medical mistakes, substance use, and mood disorders. For psychiatrists, the APA Board of Trustees Workgroup on Psychiatrist Well-Being and Burnout found that 78% of respondents were at an increased risk of burnout and 16% reported symptoms consistent with moderate to severe depression. In the private sector, employee burnout has consistently ranked among the top concerns for C-suite executives, ranging from start-ups and mid-sized to Fortune 500 companies. Per the Harvard Business Review, burnout costs companies $3400 out of every $10,000 salary due to disengagement and poor work productivity. Integrating lessons from both the academic and private sectors, this session will explore the effects of various stressors on healthcare provider well-being and burnout as well as proposed solutions, which have ranged from individual-level changes (e.g. building resilience, yoga, meditation) to system-level changes (e.g. reducing administrative burden, increasing time available for patient care, promoting team-based work). Furthermore, we will highlight a case study of service implementation for wellness support at a large academic health system: CopeColumbia. The case study will also review challenges, possible models of care, lessons learned, and successes. There is currently a dearth of research targeting burnout solutions in minoritized and marginalized physicians, especially in the intersectional dimensions. With COVID fueling the current “Great Resignation,” system leaders and healthcare organizations tackling burnout must address both individual and structural factors, such as, focusing on the individual’s physical and emotional depletion, restoring the meaning and connection to their work, and reestablishing a sense of trust in the workplace and overall organization.

Recent years have seen a surge of interests in both scientific research and private industry communities on psychedelic agents and their applications Classic psychedelics such as LSD and psilocybin exert their acute subjective effects through agonism or partial agonism of the serotonin 5HT2A receptor whereas dissociatives such as ketamine are thought to act via antagonism of the glutamate NMDA receptor. This session highlights key intersections of psychedelic innovations in research and potential applications in the general market and clinical practices. Scientific interest in these agents falls under three broad categories: 1) the neurobiology of consciousness, 2) as psychotomimetic models (i.e. models of psychosis) and 3) as therapeutics for several neurotic and substance use disorders such as depression, anxiety, psychological impact of life-threatening illness, OCD, eating disorders, body dysmorphic disorder, alcohol use disorder, and smoking cessation. Esketamine, “a psychedelic-like agent,” is FDA-approved for the treatment of depression, whereas psilocybin is entering a phase 3 clinical trial. In the business sector, the psychedelic drug market is anticipated to grow rapidly within the next two decades. Given the large unmet needs of mental health challenges, the psychedelic market is forecasted to grow to a 6.5 trillion dollar industry within the next decade with an impressive compound annual growth rate of 14.5%-16.3%. However, the limited clinical operations and scarcity of expert clinicians may circumscribe the scalability of widespread evidence-based clinical practices. Current theories propose that a loss of sense of self (i.e. ego dissolution) and mystical experiences are subjective predictors of treatment response; however, rodent translational research has shown antidepressant-like effects of classic psychedelics even when blocking the acute subjective effects of 5HT2A agonism. Promising future directions incorporating selective 5HT1A/2A blockers or nonhallucinogenic 5HT2A agonist analogs may help to address important clinical research questions in psychedelic-based psychiatric treatments: Is “tripping” necessary? In addition, the current scarcity of diagnostic and clinical tools in psychedelic treatments may serve as critical innovative opportunities. For example, there has been a scarcity of clinically-relevant biomarker work, and the little that exists is typically based on functional neuroimaging, which is not practical for wider dissemination to the community. Furthermore, neurophysiological biomarkers based on EEG may hold the key to more practical biomarkers that could be used to predict and track treatment response. A number of findings related to sensory-evoked potentials, ongoing neural oscillations, and information-theoretic (i.e. signal diversity) measures have shown promise and we propose they should be increasingly studied in clinical applications to enhance objectivity and reproducibility of findings.

A 2016 survey of transgender people found that 77% wanted to talk about their gender issues but only 55% had ever received therapy that addressed them. This indicates a significant knowledge and/or comfort gap in the treating providers. This talk will provide concrete tools for general psychiatrists to feel they are competent care providers for trans and gender nonconforming patients. Didactics and case presentations will be used.

Wellness in 8 D: A Peer led model to address the Social determinants of Health (SDoH): There is a growing awareness of the impact of the social determinants of health (SDoH) on the well-being of people with mental health and/or substance use challenges who face co-occurring medical conditions. This session will examine the how a peer led agency used a wellness in 8 D model considering SDoH as a lens for designing and delivering a variety of peer led community supports (wellness respite, supportive housing wellness institute, financial services). Meeting the Changing Needs in Community Mental Health: Montefiore Behavioral Health Center (MBHC) at Westchester Square is a Community Mental Health Center that provide timely access to evidence-based services for patients diagnosed with Serious Mental Illness (SMI). The clinic is located in New York City in the Southeast Bronx and serves a population of 290,052 (Bronx population 1.4 million). As the largest provider of outpatient mental health services in the Bronx, the clinic provides services to one of the lowest income communities in the nation. Approximately 90% of the 4,632 patients receiving care have a public payer as their insurance provider with 61% Medicaid and 29% Medicare. The mixed patient population reflects the Bronx community. The breakdown of patient population by diagnosis is: Major Depression 39%, Psychosis 18%, Bipolar Disorder 15%, Anxiety Disorders 12%, Attention Deficit Disorder 7%, Other Diagnoses 9%. The clinic has been designed to implement systemic changes to meet patient needs at point of contact and to facilitate immediate access to treatment for mental health and primary care, intensive outpatient programming, and ongoing development of specialty tracks (Transcranial Magnetic Stimulation/Esketamine) to improve access and outcomes in the Community Mental Health setting. MBHC combines analytics and an evidenced based system's approach to achieve clinical and fiscal sustainability.

This session has been canceled. 

The Bio-Psycho-Social model provides trainees with a method to understand their patients from differing perspectives and apply knowledge from each perspective to their formulation and treatment of patients. Educators must ensure that as knowledge about our field advances, those advances are reflected in the way we teach our trainees. Recent advances in neuroscience and psychopharmacology have significantly changed the approach to teaching the biological perspective. Recent social movements have also underscored the importance of understanding how oppressive social forces like racism, sexism and homophobia affect our patient’s social function and mental wellbeing. However, it is less clear how to teach trainees about those social forces or how to integrate the effect of those social forces into the bio-psycho-social perspective. This lecture will explicate a data-driven model to teach the bio-psycho-social model, provide examples of innovative methods to teach trainees about the effects of oppressive social forces, and consider new methods to structure incorporation of this data into the traditional bio-psycho-social dataset for patient formulation and treatment planning purposes.

“Brain Fog“ is really not a medical diagnosis nor is it a scientific term. It is a colloquial term that describes what patients feel in any condition that causes them to be confused, have memory loss, word-finding difficulties, inability to concentrate and focus. This so-called “brain fog” is a common complaint in a host of conditions that range from pregnancy, menopause, medications, sleep deprivation, to disorders that may affect the brain such as lupus, fibromyalgia, chronic fatigue, multiple sclerosis, cancer and more recently, it has been increasingly noted in COVID “long haulers”. Patients with “brain fog”, regardless of cause, complain that the cognitive disturbances affect their day to day functioning and diminish the quality of their life. We are living in unprecedented times with the pandemic caused by the coronavirus, SARS-coV-2, that leads to COVID -19. While COVID-19 is primarily a respiratory disease, it affects the brain. In a survey, 88% of COVID “long haulers” reported that they experienced some form of cognitive dysfunction or memory loss that to varying degrees affected their everyday lives, including the ability to make decisions, have conversations, follow instructions, and drive. “Chemo-brain” or “brain fog” in patients with cancer who undergo chemotherapy has long been recognized as one of the most commonly reported post-treatment complication in cancer survivors. “Chemo-brain” considerably impairs cancer survivors to a great extent in their personal and professional lives. Fibromyalgia and Chronic Fatigue Syndrome appear to be associated with prominent cognitive symptoms of memory lapses, distractibility, word-finding difficulties and slowed thinking. The cognitive dysfunction in Fibromyalgia has also been termed “Fibro-fog”. This Presidential session will address the cognitive dysfunction seen in COVID long haulers, chemotherapy patients and patients with fibromyalgia and chronic fatigue syndrome. Psychiatrists, especially those in Consultation-Liaison, encounter these patients in the work they do, both in the hospital and in specialty clinics. We hope to clear the fog surrounding “brain fog” by focusing on the recognition of symptoms, the theories on the causality of the cognitive dysfunction in these disorders and the treatment strategies to manage the symptoms that will help improve the quality of life of these patients.

Alcohol use disorder (AUD) causes an enormous amount of human suffering, loss of productivity and cost to our medical care system and the nation’s economy. Recent developments, including an increase in “deaths of despair” in the United States, increases in alcohol use by some individuals as a result of the 2019 coronavirus disease (COVID-19) pandemic, and limited availability of in-person treatment and recovery support, raise concerns about the use of alcohol and other drugs in an effort to cope with distress. A heuristic framework for studying addiction, characterized by a three-stage cycle—binge/intoxication, withdrawal/ negative affect, and preoccupation/anticipation—provides a starting point for exploring the intersection between alcohol addiction, deaths of despair, and social isolation that are caused by the COVID-19 pandemic. As such, advances in the science of alcohol use disorders can lead the way to better diagnosis, treatment and prevention of this significant public health problem. Using these heuristic frameworks, current challenges include addressing the intersection of pain, hyperkatifeia and negative reinforcement with deaths of despair impacts, and addressing the continuing challenges of women and alcohol, older adults and alcohol, pain and alcohol, and sleep and alcohol. In addition, using telehealth for prevention and treatment may help address continuing challenges in closing the treatment gap. Addressing such challenges will facilitate the implementation of evidence-based treatment for AUD in primary care, mental health, and other health care settings.

Prior to the pandemic, mental health conditions were a leading cause of disability worldwide, costing the global economy an estimated $1 trillion annually. Since the pandemic, we have seen a further large increase in anxiety and depression and the impacts on children will likely reverberate for years to come. New digital technologies and AI offer potential to enhance access and reduce stigma. Early studies suggest people may be more willing to share sensitive or embarrassing information with a virtual therapist (avatar or chatbot) than with a human clinician. The venture capital world had invested over $2 billion into digital tools since the pandemic. However, as with self-driving cars, the process of developing and testing autonomous artificial agents for mental health care comes with many new ethical dilemmas and the potential to worsen disparities and quality of care if not done correctly. My presentation will highlight the promise and perils of AI applications in psychiatric care.

Twenty first century psychiatry is marked by significant advancements in the pharmacological and behavioral treatment of psychiatric conditions. Less successful is our ongoing attempt at the recruitment, retention and advancement of psychiatric trainees of color, and treatment of patients that represent our diverse, multi-ethnic society. While the need for mental heal care in communities of color have never been greater, contributed by the Covid pandemic along with persistent mental health inequities and disparities, our ability to match the societal needs with diverse clinicians remain significantly compromised. Simultaneously, clinicians of color, especially African American clinicians, are leaving academic psychiatry in increasingly greater numbers. Our need to understand, mitigate, including not remain silent, and reverse this trend is paramount to the relevance of our field. This presentation intends to explore the challenges and opportunities of appreciating that we are, as Toni Morrison states, a raced society. Meaning, the impact of our historical past has solidified the intra-psychic development of being raced as integral and foundational to the development of mind in America in all its complexities. By taking a biopsychosocial approach I will elevate the psyche of race to its rightful place in mind. Today''s session is an attempt to move us beyond cultural competence towards a dynamic consideration of how race is a foundational exploration discoverable within the clinician, how mental health clinicians are trained, and within the therapeutic discourse.

American Indian and other Indigenous communities exhibit alarming inequities in mental health disorders and associated problems. Despite such needs, advocates and professionals in these settings insist that mainstream clinical interventions are frequently irrelevant and ineffective on cultural grounds. Instead, in the wake of a brutal Euro-American colonization, many American Indians today assert that “our culture is our treatment.” This presentation will review American Indian concerns and critiques of evidence-based practice in community mental health to ensure that researchers, professionals, and providers are prepared to address these challenges when undertaking service delivery within Indigenous communities.

The continuous collection of large volumes of various types of data is highlighting many opportunities for measuring, analyzing, and documenting individual and population health using “big data” approaches. These approaches lead to new technologies that can improve decision-making at both the individual and community level. This symposium will explore the opportunities and challenges that come with leveraging big data sets and artificial intelligence/machine learning (AI/ML) approaches to gain new knowledge about substance use disorders and related conditions.

The need to increase access to care for those with SMI is clear. Hybrid models that involve both in person or telehealth but also asynchronous care (ie using tools like apps) have shown promise towards accomplishing this vision of radically increased access to high quality care. In this interactive presentation, we present the concept of the Digital Navigator as a new team member and the key to hybrid care for SMI. The Digital Navigator is able to serve both the patient and the clinician through filling three key roles 1) Teaching digital literacy and technology setup/ troubleshooting), 2) App evaluation and 3) Engagement support for patients and data aggregation for clinicians. Outlining each of the five modules in the training of a Digital Naviagtor, we will present a case example through an interactive role play to highlight the real-world clinic need. After each role play, we will outline the curriculum, learning objectives, and metrics for that module. This will be followed with a problem solving and interactive learning experience from that module that the audience will be asked to assist and engage with. In completing this exercise for all five modules, learners will have a full understanding of the Digital Navigator role, its implementation, and importance for radically increase access to high quality care for SMI.

Epidemiological studies suggest that Hispanics generally have lower prevalence of psychiatric disorders than their non-Hispanic counterparts, a phenomenon often called the Hispanic paradox. At the same time, Hispanic individuals with psychiatric disorders seek treatment at lower rates than non-Hispanics. In this presentation, we will first examine different theories that try to explain the Hispanic paradox, as well as recent data suggesting that the paradox may not apply to all Hispanics only to certain subgroups. Second, we will examine predictors of treatment-seeking, including social determinants of help, how they may help explain rates of treatment for psychiatric disorders for Hispanic populations and how they can assist in identifying barriers to care for these populations. Third, we will suggest some ways to remove those barriers and increase rates of treatment among Hispanic with psychiatric disorders. We will also point out areas of research that can increase rates of treatment and quality of care for Hispanics. This presentation will seek to stimulate discussion to accelerate the implementation of approaches at the patient, clinician, health system and population levels geared towards the elimination of disparities in the treatment of psychiatric disorders among Hispanics.

The developing brain is particularly vulnerable to genetic and environmental influences. Socioeconomic inequalities, for example, are associated with differences in neurocognition, which could also impact risk for psychopathology. However, socioeconomic status, adversity, environmental exposures, and genetic factors are often confounded, making it difficult to determine the relative contributions of these factors to neurodevelopment. The panelists in this symposium will highlight recent findings from two longitudinal neuroimaging cohort studies (i.e., IMAGEN and the ABCD Study®) that strive to disentangle the unique vs. additive impacts of individual level factors (e.g., genetics, early life adversity), family and community influences (e.g., socioeconomic status, school setting), and environmental exposures (e.g., neighborhood deprivation, air pollution) on cognition, brain structure and function, and risk for psychopathology. These studies are poised to identify protective factors that can inform the development of targeted interventions that could improve neurodevelopmental trajectories.

Many educators find themselves in positions in academic medicine that are heavy on clinical duties, administrative tasks, and primary teaching, but leave little to no time or mentoring for scholarly pursuits. This unfortunate situation can, over time, can foster disillusionment and burnout, especially when institutional expectations for scholarly outputs are not met. In this workshop, we will talk about educational scholarship as not a separate or extra task to add to an already full workload, but rather, as something that can be done in the process of typical educational activities, such as teaching in clinical environments or preparing sessions for the classroom. In other words, scholarship can be successfully achieved when educators "make it count twice" with their educational activities. We will practice with some of the core skills needed to make it count twice, including developing an important and focused research question, designing data collection strategies, and communicating findings. We will model ideal real-world practices by having participants work in teams to achieve shared goals.

In 2020, Congress designated the new 988 dialing code to be operated through the existing National Suicide Prevention Lifeline. The Substance Abuse and Mental Health Services Administration (SAMHSA) is the lead federal agency, in partnership with the Federal Communications Commission and the Department of Veterans Affairs, working to make the promise of 988 a reality for America. Moving to a 3-digit dialing code is a once-in-a-lifetime opportunity to strengthen and expand the National Suicide Prevention Lifeline (the Lifeline). In reality, 988 is more than just an easy-to-remember number – it’s a direct connection to compassionate, accessible care and support for all Americans who might be experiencing suicidal thoughts, who are at risk of suicide, or who are struggling with emotional distress. Preparing for full 988 implementation and operational readiness requires a bold vision for a crisis care system that provides direct, life-saving services to all in need. SAMHSA sees 988 as a first step towards a transformed behavioral health crisis care system. An effective crisis system with 988 as its cornerstone will save lives and improve person-centered care by decreasing unnecessary law enforcement response, emergency department boarding and hospitalization. But the Federal government cannot do this alone. Success of 988 will rest heavily upon state and local leaders, along with key public and private sector partners, as we work in concert to meet the behavioral health crisis needs of people across our country. The session will review a number of specific examples of activities designed to build upon enthusiasm for crisis system redesign, with a particular focus on operational readiness, communications and ongoing implementation support. The panel will highlight how multi-sector partnerships can support: 1) Aligning vision and building momentum, 2) Assessing readiness for 988 implementation, 3) Ensuring system is designed from the perspective of the individual in crisis, 4) Identifying the messaging and design needs for individuals and populations at elevated risk of suicide, and 5) Providing ongoing technical assistance and learning opportunities.

Recent advances in our understanding of the neurobiological underpinnings of substance use disorders (SUD) and the effects of non-invasive brain stimulation (NIBS) open new avenues for improving the efficacy of treatment protocols. Identifying and quantifying neural circuits and proximal functions can define new targets for NIBS, tailor NIBS protocols for specific circuits and dysfunction, and more objectively measure the efficacy and outcome of NIBS. These advances add both to our understanding of the dysfunctions of SUD and the mechanisms of action of NIBS. In this symposium, a collection of early career scientists currently funded by NIDA will present findings of: new NIBS targets based on a lesion associated addiction remission brain network that aligns with existing circuit-based models of addiction and observed neuroimaging evidence (Dr. Moussawi); novel NIBS methods to restore flexible behavior and neuronal signaling in a pre-clinical model of cocaine use disorder (Dr. West); recovery of reward function associated with the mid cingulate cortex and basal ganglia as indexed by electrophysiological measures in human problematic substance users (Dr. Baker).

The history of persons with mental illness and intellectual disability is profoundly intertwined. Both groups have been marginalized by society to varying degrees and many psychiatrists are not confident in providing care for this patient population. As society moves away from the institutionalization of patients with ID, psychiatrists are treating more patients with ID in the community setting. Due to limited training treating ID patients, many clinicians feel inadequately prepared to address the complexities in this patient population. Non-pharmacologic treatments are an underutilized resource. This presentation seeks to fill this knowledge gap. Treatment for co-occurring Autism Spectrum Disorder, IDD, and mental illness will be discussed as well as non-pharmacologic treatment for co-occurring neurocognitive disorders in individuals with IDD. Additionally, interventions other than medications for common mental illnesses will be described. This presentation seeks to increase confidence and knowledge in the treatment of people with co-occurring mental illness and IDD.

Individuals with serious mental illness (SMI) are at increased risk for arrest and incarceration, but often for more minor crimes. Once they are involved in the criminal system, they face numerous challenges including additional stigma. They may also exhibit behaviors that were adaptive in correctional settings but become maladaptive in other settings. Many of these persons have histories of trauma and their exposure to criminal justice processes can be further traumatizing. Individuals with serious mental illness, especially those arrested for more minor crimes, are often routed through forensic competence to stand trial evaluation and treatment processes. Some will have co-occurring antisocial personality features that the mental health treatment provider may feel ill-equipped to support. Individuals with SMI in the criminal justice system often have co-occurring substance use disorders and medical conditions that compound their complexity. For clinicians, these features in their patient populations can present numerous challenges. In addition, clinicians may have limited knowledge or familiarity with the criminal system to know how best to help individuals in their care with these histories. As patients move from arrest to court proceedings to jail or prison and release, there may be opportunities to foster continuity of care and attention to aspects of their lives that can reduce their risks of further involvement in the criminal system. This session will provide an overview of the interaction of serious mental illness and the risk of criminal involvement and will provide practical information for practitioners to better serve their clients. There will be opportunity for questions and answers and curbside consultation.

Recent clinical studies are demonstrating promising effects of ketamine, MDMA and classical psychedelics such as LSD, DMT, ibogaine, mescaline and psilocybin for treating psychiatric disorders and addiction. These agents have long been known to modulate the classical neurotransmitter systems. However, recent convergent evidence suggest that their therapeutic potential results from their ability to promote structural and functional synaptic plasticity and that this is mediated through the regulation of expression of plasticity-related proteins, including BDNF. This panel will present data and discuss knowledge gaps on the molecular and cellular mechanisms underlying neuroplasticity and its translation to behaviorally relevant effects of psychedelics. Additionally, the panel will discuss the future of psychedelic research and the re-emerging therapeutic paradigms for treating mental health and addiction while reviewing on-going and future challenges for the approval of psychedelics for use in humans.

Because of wars, natural disasters, and political persecution, hundreds of thousands of people have been forced to leave their homeland to seek a better life. Refugees are persons outside of their country of origin, who are not able to reutrn to their own countries due to persecution, political beliefs, memberships in certain groups, religious beliefs or ethinicity. A special group of refugees are asylum seekers wo arrive in a country seeking safety and who then apply for protection. The legal process to finally gain asylum in the United States is complicated. In 2018, there were 38,000 people who were granted asylum in the United States. In the response to the Covid-19 pandemic, the CDC suspended the arrival of persons from Corona Virus impacted areas. Most asylum seekers, as well as high proportion of refugees, have had many severe traumatic experiences. PTSD and depression are the most common psychiatric diagnoses and account, by far, for the majority of psychiatric diagnoses in refugees, with an 80% comorbidity between these two diagnoses. The traumas are unusually severe and have often occurred over a long period of time. When settled in the U.S., refugees have post migration problems of learning a new language, finding employment, and reestablishing social relationships. These refugees are often subject to discrimination and physical attacks in their new country. Effective psychiatric treatment of refugees must be a sensitive process. The refugee may enter the treatment with distrust or even suspicion of doctors. Clearly, the first goal of the refugees' treatment is for the psychiarist to provide safety, which means forming an authentic relationship with a non-judgmental, accepting attitude. An important part of the treatment is the role of the interpreter(s), The goal is to have the psychiatrist and the counselor work together with the same ethinic group. The psychiatrist's role is to diagnose the disorders, provide explaniation, give a prognisis, discuss treatment options, provide supportive, usually interpersonal, psychotherapy, and prescribe medicine. Psychotherapy, which requires subjective awareness or cognitive restructureing, seems difficult for refugees to understand and usually is ineffective. However, all refugees have visited doctors, and the refugees know that doctors ask personal questions and provide information. When the psychiatrist starts in the medical role, which is familiar to the patient, a good relationship is possible. With time, it is possible to explore interpersonal dynamics. Reexploring the patient's trauma, except in the original interview. is counterproductive because it can lead to re-experiencing. The usual focus in therapy is on post migration life stressors. The interview is low key, practical, safe for the patient. Medicine has been shown to provide important relief from symptoms, the most disturbing of which are usually insomnia and nightmares. There's a need for more peer-reviewed research.

PRESENTER UPDATE: James K. Boehnlein, M.D. will no longer present.

The American Academy of Psychodynamic Psychiatry and Psychoanalysis Presidential Symposium workshop, "Psychodynamic Psychiatry Today," will present four strikingly different aspects of the current practice of psychodynamic psychiatry. William Butler, M.D. will present "The Digital Age: Psychodynamic Psychiatry and the Law" in which he will review the legal and ethical aspects of psychodynamic approaches during the COVID-19 pandemic. Eugenio Rothe, M.D. will present "The Elusive Chameleon: Working with Shame in Psychotherapy." Dr. Rothe will discuss the clinical presentations of shame, defenses employed to defend against shame, and the role of attachment in how shame is manifested among different patients. Jennifer Downey, M.D., world-renowned psychoanalyst and sex researcher, will describe and demonstrate through a case vignette how to take a sexual history with adult patients. Finally, Ahron Friedberg, M.D. will discuss the capacity for resilience during the COVID-19 pandemic and how this can be facilitated in psychodynamic psychotherapy. He will be making reference to his recent book "Through a Screen Darkly: Psychoanalytic Reflections During the Pandemic" (2021). The program and each of the four panelists will be introduced by Gerald P. Perman, M.D., DLFAPA, Immediate Past President of the AAPDPP, who will present a recap following the presentations and who will moderate the Q&A session, if this takes place,.

The US health care system is the most expensive in the world by a considerable margin, yet health indicators are among the worst in the developed world. This book examines the factors that have contributed to this disparity and offers a holistic vision for health care reform, one in which the psychiatric profession plays a critical role. Value is the product of Quality/Cost. In healthcare, systems that deliver high quality outcomes at a low cost would be considered to have high value. Thus, the definitions of both value and quality have a great impact on the perceived value of the services provided. Additionally, different stakeholders may define value and quality quite differently, depending on how they interact with the healthcare system. Overall, however, data indicates that the US healthcare system delivers very low value when considered from a population health perspective. This session will examine the roots of the conflicts that have shaped our current systems. The major emphasis of the session will be on strategies that could improve the value of the services if we were determined to do so. While some of these strategies are specifically targeted to emotional health issues and psychiatry, many encompass the entirety of health care systems. Each strategy discussed has implications for the overall health and wellbeing of the community at large. Overall systems changes leading to higher value include better methods of financing care that reduce administrative waste, provide incentives for prevention and primary care and enhance integration of services. Additionally, these methods would incentivize efficient use of health records and of other new technologies. They would promote diversification and enhancement of the workforce. Proposed changes within the psychiatric professions include expansion of the role of psychiatrists and allied psychiatric care providers, changes in prescribing and diagnostic processes, and the evolution of training curricula to emphasize recovery-oriented care, health maintenance, leadership and advocacy. In addition to these changes, it will be critical to consider social and policy changes which have significant impact on the well-being of communities. These include harm reduction interventions related to substance use, mitigation of the effects of climate change, reduction in the rate of incarceration and the discriminatory practices that permeate penal systems, creating healthier workplaces, and adopting more compassionate approaches to end-of-life care. The session will conclude by outlining various approaches to health care reform and a practical vision for implementing many of the strategies considered earlier in the discussion. Participants will be encouraged to share their reactions to these proposals and offer their own views on the evolution to a high value system for maintaining the overall health of communities and the value of the services we provide for emotional health care.

Despite large increases in antidepressant prescription rates in many countries, major depressive disorder is emerging as the largest cause of worldwide disease burden. Part of the reason for this is that initial response rates are poor and there is less emphasis on reduction of recurrence rates in this recurrent episodic disorder. Current clinical guidelines for the treatment of major depression recommend a sequence of six-week long medication trials or steps that leave half of the patients still depressed even after four steps or six months of treatment. Response rates after the first three months are abysmally low, suggesting the optimization of treatment in the first three months may be crucial. We have designed an application that does two main things that differ from major current treatment guidelines. First, it uses 3-week long sequenced treatment steps. Second, progression moves after only one step to medications that target more than one neurotransmitter system or two combinations of medications with different treatment targets. The session will explain the scientific evidence supporting these two modifications and describes how combinations of antidepressant medications can have a higher response rate than single medications, because the antidepressant effects of different classes of medication are potentially additive. Moreover, the use of multiple drugs, each from a different pharmacological class, explains reports of comparable side effects compared with single medications. The application and its convenient features for aiding the treating primary care physician and early career trainees will be described. The role for such an application in improving quality of care will be outlined.

They are strange experiences—a voice whispered on the wind, a god who speaks from on high—but far more common than we think. At the beginning of most great religions lies a voice. Who hears such voices? I have spoken to hundreds of people, in many countries, who have heard voices, some only once, some more often. Most of these people are not psychiatrically ill. Some are. In this talk I will discuss what we know about the difference between mad voices and sane voices, and what traits and practices and cultural ideas make sane voices more likely. I will also talk about the evidence that the way we think about voices changes our experience of them—and may soften the impact of psychosis.

Currently, over 6 million Americans have Alzheimer’s disease and other dementias and the number is expected to double by 2050. It is estimated that an additional 5 million Americans have mild neurocognitive impairment. With the aging of the population, psychiatrists are likely to see more older patients who are concerned about their memory. Subjective memory decline may be an early sign of a serious cognitive disorder, but may also occur due to other conditions. Teasing out the underlying causes of memory concerns can be challenging, and requires a multi-step assessment. In this session, geriatric psychiatrists, Dr. Susan Lehmann and Dr. Brent Forester will discuss the office approach to the assessment of memory complaints in older adults. Dr. Lehmann will discuss ways that psychiatrists can differentiate normal changes in memory with aging from those seen in mild neurocognitive impairment and in late life depression and other psychiatric disorders, such as late-life depression. She will review the appropriate office work-up of cognitive complaints, including cognitive and laboratory testing to rule out “treatable” causes. Dr. Lehmann will also discuss the differential diagnosis of memory complaints, focusing on how to distinguish memory concerns due to psychiatric disorders from the most common major neurocognitive disorders. Dr. Forester will discuss how understanding the underlying pathology of Alzheimer’s Disease and other dementias is leading to better treatment strategies. He will review current best practices for the pharmacologic treatment of cognitive impairment in dementia. Dr. Forester will also discuss practical strategies for clinicians to share with patients to maintain good brain health and prevent cognitive decline.

Nothing could be a clearer demonstration of the social determinants of health than the effects of CoVid, the MeToo movement, and the increasingly stringent limitations on abortion, on women’s mental health. This abstract is being written, by necessity, over 6 months before the lecture will be presented; of necessity, relevant factors will change. The lecture itself will reflect the status of the issues in May 2022. The CoVid pandemic has wreaked havoc all over the world, but there has been a differential impact on women. Women have been more likely to stop or cut back on their jobs; women in medical academia published fewer papers; their male partners did not. Women assumed most responsibility for the education of children in chaotic and unpredictable school situations. The MeToo movement, which addresses hitherto suppressed revelations about the sexual abuse of and discrimination against women, raises ongoing concerns. Apart from the unmasking, firing, and prosecution of a number of prominent men, has the movement really changed the workplace and home reality for the average woman/female psychiatric patient? What are the effects of the backlash against MeToo? Does MeToo exacerbate the perceptions and experiences of women as victims? The increasing attempts to outlaw abortion place every woman of childbearing potential, and her family, at risk of unwanted pregnancy, interrupted education and/or job, decreased energy and time for existing children, and poverty, not to mention the dangers of illicit abortions. Though there is compelling evidence of abortion’s psychological and physical safety, misinformation about its effects is promulgated, believed, and used as a basis for restrictive legislation. At least one quarter of the women in the United States have abortions; many others are affected by the unwanted pregnancies of their loved ones; our patients are among both. As psychiatrists, we can explore the disparity between the pro-choice majority of Americans and our election of anti-choice legislators. The frequent exceptions for incest and rape reveal that continuing an unwanted pregnancy is a generally, if unconsciously, considered just punishment for women who voluntarily engage in sexual intercourse and become pregnant. As psychiatrists, we are somewhat prepared to help the woman overburdened by the demands of CoVid. We also need to help the woman suffering sexual exploitation or workplace discrimination weigh the risks and benefits of coming forward, changing jobs, or coping in place. We can provide accurate information, and the opportunity to work through abortion decisions both past and present. All of these challenges are greatly magnified for women of color, immigrants, and other marginalized groups. For purposes of this lecture, women in the world includes all people presenting as women in society; with respect to pregnancy-related issues, women are those with female genitalia.

Behavioral health crisis services in the US are significantly underdeveloped, especially in comparison to other safety net services like EMS, fire, and police. In many parts of the US, first response to BH crisis may only be available through law enforcement, leading to inappropriate incarceration for people with clinical needs, particularly those experiencing social determinant challenges (e.g. homelessness). Fortunately, we are now on the cusp of a dramatic change, akin to the development of the 911 system decades ago. New legislation has mandated implementation of a national 988 BH crisis number by 2022, and new funding has been allocated for planning and implementation. 988 implementation creates both a driver and an opportunity for re-envisioning the BH Crisis System, and daring to conceptualize and implement an Ideal Crisis System rather than hoping for a barely adequate one. This transformation of crisis services will affect psychiatrists at all levels, as well as providing opportunity for psychiatrists to participate in making these efforts successful. This workshop is designed to provide the specifics that psychiatrists need to know to be effective partners in change. The first part of this presentation describes a new (2021) report prepared by the Group for the Advancement of Psychiatry (GAP) and published by the National Council, entitled: Roadmap to the Ideal Crisis System: Essential Elements, Measurable Standards, and Best Practices. This report creates a new vision of BH crisis systems as an “essential community safety net service” (just like police and EMS) and describes how any community can make progress in developing its system. It recognizes three major building blocks: Accountable Entity for each local system, coordinating multiple funding sources and monitoring performance; Continuum of Components and Capacities, including clinical/medical leadership throughout, and Best Practices for crisis intervention for diverse populations. It includes guides for communities to make progress (Ten Steps, Report Card), and will describe how psychiatrists can participate in local development. The second part provides a real world example of how progress to an Ideal Crisis System has occurred in Arizona, and specifically in Pima County (Tucson). This includes description of not only the Crisis Resource Center, but the way in which the state, local managed care entities, counties, and providers have partnered to create an effective system. The third part describes how the National Council is on the cutting edge of advocacy for Ideal Crisis Systems, including advocating for CCBHCs, other innovative funding strategies, supporting local implementation, and providing materials to reinforce psychiatric leadership roles through the National Council Medical Director’s Institute. Participants will be engaged in discussion to help answer questions about how to best make progress in their own organizations, communities, and state systems.

Ever since the development of the first two classes of antidepressant medications, tricyclics and monoamine oxidase inhibitors, psychiatrists have wished for development of predictors of response. This is of great clinical importance because the longer patients remain depressed, the greater the risk of a poor outcome including suicide and illicit substance abuse and alcohol abuse. Of course, there are now multiple classes of antidepressants and considerable pharmacological differences between the members of the different classes and even among those within a class, e.g. SSRIs. In the past several years much attention has focused on development of laboratory tests to predict response to antidepressants-both their therapeutic effects and their side effects. The use of phamacogenomic testing has received considerable attention in recent years. In spite of a focus on both genetic polymorphisms in candidate genes believed to be involved in the mechanism of action of antidepressants or the pathophysiology of depression, i.e the serotonin transporter and genetic variations in cytochrome P450 isoenzymes that are responsible for the metabolism of antidepressants (presumably impacting on blood levels), the randomized clinical trials that have been conducted have uniformly failed to show any value of pharmacogenomic testing. Primary outcome measures have failed to separate in the GUIDED study, in a replication study conducted at Mass General Hospital and now more recently in a Mayo Clinic study of adolescent depression. Multiple reports by commercial vendors of these pharmacogenomic test batteries of secondary outcome measures cannot hide the collective failure of these three randomized controlled trials. It is certainly possible and even likely that as additional genetic polymorphisms, based on recent GWAS studies, are included and the populations studied more homogeneous, there will be a role for pharmacogenomic testing in psychiatry. Other potential tests including EEG and functional magnetic resonance imaging studies have shown promise in early studies of antidepressant response prediction. In conclusion, the question of To Test or Not to Test using pharmacogenomics to predict antidepressant response is a resounding NO.

Over a decade ago a typology of proximal warning behaviors for targeted violence--acts that are planned and purposeful--was proposed by Drs. Meloy and Hoffmann and their colleagues. The eight warning behaviors--pathway, fixation, identification, leakage, novel aggression, energy burst, last resort, and directly communicated threat--have subsequently been researched in a number of targeted attackers in both North America and Europe. The findings of these studies which have focused upon both ideologically-motivated (terrorist) attackers and non-ideological (personal grievance) attackers have found the proximal warning behaviors to be both reliable and valid. Interrater reliability has been consistently in the excellent range, and validity studies have shown that these warning behaviors correlate with, and in some studies predict, acts of targeted violence. Validation studies have ranged from early uncontrolled pilot studies to test the ecological validity of the warning behaviors, to retrospective comparative studies, to postdictive studies. Very recent research has begun to look at the time sequencing of these warning behaviors in large samples of lone actor terrorists in North America and Europe. Such a typology can serve a useful clinical purpose for all psychiatrists tasked with assessing risk of targeted or instrumental violence, a mode of violence distinctively different from the affective, reactive, and defensive violence often commonly seen in treatment settings. The past decade''s worth of research has led to the incorporation of these proximal warning behaviors in violence risk protocols in colleges, universities, corporations, and various local, state, and federal agencies as an important element in their assessment of violence risk and mitigation of such violence. This presentation will teach the proximal warning behaviors and review the most relevant research for practicing psychiatrists.

Current mental health care for aging patients is often fractured across multiple clinicians and settings, and lacks timely and comprehensive access to geriatric-trained mental health professionals. These gaps are set against a background of a well-established shortage of both geriatricians and geriatric psychiatrists. At the same time, there is an explosion of mental health needs in aging patients, especially those living with Alzheimer''s disease and other neurocognitive disorders. Without clinicians and caregivers who have an adequate understanding of how mental health issues present in late life, key diagnoses such as Alzheimer’s disease and late-life depression and anxiety are often delayed or missed entirely, and treatment regimens are implemented without taking into consideration key age-related factors. Several unique care models have developed to bridge these gaps. One of them is the Care Ecosystem (CareEco) model, which is a telephone-based collaborative dementia care intervention that provides personalized support and standardized education through care plan protocols, and has demonstrated lower rates of emergency department utilization and reduced caregiver depression and burden. Another model is the VA’s Ask the Expert Geriatric Psychiatry program, a new consultation service provided by the National Telemental Health Center in which a team of VA Geriatric Psychiatrists are made available to answer general questions that VA clinicians may have about psychiatric care of older veterans with potentially complex and interacting psychiatric, medical, neurocognitive, and behavioral care needs. A third model is Project ECHO (Extension for Community Healthcare Outcomes) which provides telementoring to connect geriatric mental health specialists from the University of Rochester to clinicians in long-term care facilities and state psychiatric hospitals across New York State. Each of these models has pioneered ways to leverage geriatric psychiatry expertise through telehealth platforms to better educate clinicians and caregivers and coordinate care for patients who would not otherwise have access to such specialized care. 

PRESENTER UPDATE: Prasad Padala, M.D. will no longer present.

Obsessive-compulsive disorder (OCD) is a severe neuropsychiatric illness characterized by intrusive thoughts and repetitive behaviors. It has a lifetime prevalence of approximately 2%,(i.e., twice as common as schizophrenia), a relatively early age of onset (half of cases of OCD start by age 19 and a quarter by age 14), and typically chronic, waxing and waning course. Given its early onset and typically chronic course, OCD is associated with substantially reduced quality of life and impairments in occupational functioning. This session will present a clinical research update on OCD, focusing on scientific findings that can be used by clinicians to improve their practice. The speaker will review: 1) how to diagnose OCD and differentiate it from other disorders with intrusive thoughts and behaviors; 2) what are evidence-based medications and therapy for OCD and how best to deliver each; and 3) what to do when first-line treatments do not work. It will conclude by discussing two challenges in the field: why many patients do not receive first-line treatments; and why first-line treatments work well for only about half of patients.

Late-life Depression: It has been reported that over half of Major Depressive Disorder cases have their first onset after age 60. Some studies note a point prevalence for major depression of 4.6%–9.3% in some groups of patients over age 75, increasing to over 25% among those over age 85. The aging process itself may contribute to depression risk and there are credible mechanistic theories that posit vascular and/or inflammatory factors that may underpin and explain the unique clinical presentation of late-life depression (LLD) vs. depression in younger people. Depression in later-life is often under-recognized. Older adults may be less likely to verbally express their moods and depression symptoms, including anhedonia and cognitive problems. Some may attribute these symptoms to the normal aging process. Screening tools specific to geriatric patients, such as the Geriatric Depression Scale are helpful, especially in primary care settings. Key considerations in the evaluation of LLD include somatic comorbidity and cognitive testing that may indicate the presence of Alzheimer's disease or other dementia. Examination of anxiety is also warranted: prevalence estimates of anxiety disorders in LLD are as high as 50%. Antidepressant medication can have an important role in the treatment of LLD. But evidence suggests response among older adults may be limited. Relapse rates may be relatively high. Other biological therapies, such as ECT may also be effective, especially for psychotic depression or symptoms that affect nutrition and function. A variety of psychosocial therapies have positive evidence in LLD including problem-solving therapy, cognitive behavioral therapy, and interpersonal therapy. Another consideration in the management of LLD is the need to coordinate treatment with primary care, specialty-care providers, and families for collaborative treatment. Ketamine and Esketamine for Treatment-Resistant Depression Synthesizing Scientific Data and Clinical Application: A significant percentage of individuals with major depressive disorder respond insufficiently to conventional monoamine-based antidepressants. Ketamine has been identified as a "breakthrough" by the US FDA and is used off-label for adults with treatment-resistant depression (TRD). Intranasal esketamine is FDA-approved for adults with TRD in combination with conventional antidepressants. Notwithstanding the need for innovation for adults with TRD as well as improving access to such treatments, there are significant concerns as it relates to patient selection, personnel and training requirements, implementation of ketamine/esketamine, as well as safety and tolerability. This program, will reflect the recent publication of the international synthesis of data as it relates to the science and implementation of ketamine/esketamine in TRD. The emphasis of this presentation will be on pragmatic aspects of implementation with attention given to real-world effectiveness, tolerability, and safety.

Social justice entails equal access to liberties, rights, and opportunities, as well as care for the least advantaged members of society. This session addresses the ways in which society’s failure to deliver on that humane ideal harms people with mental illness. Dr. Sarah Vinson, at the forefront of the effort to make psychiatry responsive to critiques of institutional racism, will discuss how that in the United States, a perfect storm of unfair and unjust policies and practices, bolstered by deep-seated beliefs about the inferiority of some groups, has led to a small number of people having tremendous advantages, freedoms, and opportunities, while a growing number are denied those liberties and rights. Mental health clinicians must bear a special responsibility to be aware of these structural inequities, to question their own biases, to intervene on behalf of patients and their families, and to advocate for mental health equity. To that end, this session will provide a framework for thinking about why these inequities exist and persist and provide clinicians with a road map to address these inequalities as they relate to racism, the criminal justice system, and other systems and diagnoses.

Beginning in 2002, the WHO and the CDC have emphasized the role of social determinants of health. However, mental illnesses and mental healthcare have not been a priority in these conceptualizations. More people with mental illnesses and substance use disorders are in prisons and jails than in hospitals. Our patients are less likely to receive needed treatments and more likely to die prematurely. The primary reasons for this state of affairs are social (e.g., stigma against mental illnesses) – and not biological – factors. During the last 25 years there has been a behavioral pandemic of loneliness, social isolation, opioid abuse, and suicides. The increase in deaths of despair due to socioeconomic dislocation and ongoing mental health inequities caused by systemic racism reflect policies riven with inequity. Recently the COVID-19 pandemic and structural racism have worsened health inequities. Fortunately, there are some rays of hope. There is a societal refocus on promoting inclusive and equitable personal and societal well-being. The recent child tax credit, reducing child poverty by 50%, is a case in point. In May 2021, an APA Presidential Task Force (TF) on Social Determinants of Mental Health (SDoMH) was established by Dr. Pender. This TF will propose innovative strategies to help reshape future healthcare for our patients through SDoMH-focused clinical care, research, and training. We recommend broadening the definition of SDoMH to include aspects that have a far greater impact on the health of psychiatric patients. These include pervasive stigma against mental illnesses and substance use disorders and against psychiatric treatments. There is continued lack of mental health parity. Meta-analyses have shown that social connections have greater impact on both length and quality of life across the lifespan, and these have major effects in mentally ill persons. Dr. Lu will discuss what clinicians should do to assess and treat SDoMH in their everyday practice. The recommendations of the Clinical Workgroup will impact future APA Practice Guidelines. Dr. Malaspina will describe the type of research and training needed for making knowledge of SDoMH widespread at all levels, including the general public. Dr. Thompson will focus on the public health significance of SDoMH. He will review the literature on health consequences of SDoMH, and make recommendations for addressing them at systems level. Finally, Dr. Tasman will summarize what the APA and government policy makers should do to promote strategies to change the mental healthcare system to prioritize SDoMH in their economic and financing considerations. Attention to racial/ethnic minorities, LGBTQ, immigrants, and other marginalized groups is an important area for the entire TF. There will be at least 20 minutes for Q&A and general discussion at the end of the session.

The increased focus on social determinants of health by the WHO and the CDC presented a springboard for psychiatry to emphasize the social determinants of mental health (SDOMH), which was catapulted into the spotlight by the current national public health crisis as the enormous impact of socially driven health disparities was recognized. Individual clinicians, academic departments, and healthcare organizations are at last contemplating strategies to dismantle health inequities. Knowledge on SDOMH can be employed to improve the health of the population, reduce the risks for psychiatric illness and advance clinical care to optimize treatment response and quality of life for individual patients. While prevention necessarily involves policy changes and public sector interventions, there is a pressing need to address SDMH at the clinical interface. Current research is defining and standardizing assessment tools and examining the medical – psychiatric comorbidities associated with SDOMH as proinflammatory exposures requiring collaborative care. Trainees and clinicians need to learn how to assess patient exposures to SDOMH and understand the influence of these determinants on clinical presentations and treatments. Optimal outcomes may require interventions to address current needs for food, housing, transportation, safety and social isolation. Understandably, the largest impact for addressing SDOMH will be in child psychiatric approaches. Some training programs have developed curriculum on SDOMH for child and adolescent psychiatry (CAP) training, but strategies are also needed that incorporate social justice and anti-racism. Because of a lack of transparency about diversity, equity, and inclusion (DEI) processes and implementation efforts across institutions, there are discordant developmental approaches to building stronger child and adolescent psychiatry curricula among program directors that address social justice issues. Specifically antiracist approaches are needed to addressing the SDOMH in children and adolescents to achieve health equity for Black, Indigenous and Persons of Color (BIPOC). This change in practice may require changes in medical coding and systems of care, as will be presented, and in re-conceptualizing several aspects of cultural assessments.

Frontotemporal dementia (FTD) is the clinical syndrome typically caused by frontotemporal lobar degeneration (FTLD), a pathological diagnosis defined by atrophy of the frontal and temporal lobes and specific protein aggregates. The three main FTD spectrum disorders include behavioral variant FTD (bvFTD), nonfluent/agrammatic variant primary progressive aphasia (nfvPPA) and semantic variant PPA (svPPA). Related FTD disorders include frontotemporal dementia with motor neuron disease, progressive supranuclear palsy and corticobasal syndrome. The syndromes are distinguished by patterns of behavioral (bvFTD; r-svPPA), executive (bvFTD; nfvPPA), and language (nfvPPA; svPPA) symptoms early in the disease. Early bvFTD symptoms can look psychiatric and include behavioral disinhibition, apathy, loss of empathy, perseverations, and hyperorality. MRI and PET imaging and genetic testing can help determine diagnosis. The three genes most commonly associated with FTD are C9ORF72, MAPT and GRN. Lifestyle modifications can influence genetic impact. Common proteinopathies involve accumulation of tau, transactive response DNA binding protein 43 (TDP-43), and fused in sarcoma protein (FUS, part of the FUS, EWS and TAF15 [FET] protein family). While there are currently no approved treatments for FTD, behavioral symptoms can be managed by selective serotonin reuptake inhibitors, and speech-language therapy can help with the PPA symptoms. Managing difficult behavioral symptoms can help reduce caregiver burden and improve caregiver health. Promising disease-modifying treatments include anti-tau antibodies, antisense oligonucleotides, gene therapy and progranulin enhancers.

The 2022 Annual Meeting Opening Session will feature a keynote address by Anton Gunn, former senior advisor to President Barack Obama and a leading expert on socially conscious leadership.

Social determinants of mental health are shaped by the systems in which we all live. Having good mental health is more than just not being ill; it’s about assuming one’s role and using one’s voice in society. Education, vocational skills and good jobs matter to mental health, and psychiatrists and other mental health clinicians need to act with that knowledge. Meanwhile, with higher demands on the mental health workforce, understanding where the economic model for health care may be headed is essential for the workforce. Peter Q. Blair, Ph.D., Assistant Professor of Education at the Harvard Graduate School of Education and Principal Investigator of the Blair Economics Lab, will join Scientific Program Committee Member Sarah Y. Vinson, M.D., to discuss the social determinants of mental health and mental healthcare delivery. Drs. Blair and Vinson will draw upon economics, policy and mental health considerations and explore an interdisciplinary framework for how sociopolitical determinants of mental health can impact patient care and caregivers.

The 2022 William C. Menninger Memorial Convocation Lecture will be delivered by Soledad O'Brien. A champion of diversity, she gives voice to the underserved and disenfranchised through her Emmy-winning reporting and acclaimed documentary series, Black in America and Latino in America. A prominent philanthropist, Soledad is the founder of PowHERful, a foundation that mentors and funds college tuition and expenses for young women.

To gain an understanding of the origins of the current mental health disparities in the United States, it is important to understand the historical context and how data demonstrates the severity of these disparities. This helps to reveal the cultural disparities, reform efforts, and the wide variation in the way services have developed and evolved over time (Williams et al, 2016). In this presentation, priority will be given to understanding the importance of data access and equitable representation in data sources to ensure visibility of marginalized groups most affected by Behavioral Health concerns. We will highlight some examples of policies that have created this restricted access (i.e. Snyder Act, Civil Rights Act and distinctions in the development of the diagnostic manual), and provide a framework for thinking about burden through a lens that looks at political determinants of health (Dawes, 2020). Innovations will be explored through work being conducted at the Satcher Health Leadership Institute that aim to bridge these data gaps like the Health Equity Tracker, utilization of intersectionality based policy analysis and research (Hankivsky et al, 2014), and facilitation of unique dialogue spaces where lesser represented voices can convene with leading policy makers. We will then consider other innovative system-level solutions to address mental health disparity, with a focus on the Self-Assessment for Modification of Anti-Racism Tool (SMART) (Talley et al, 2021). We will describe the SMART’s development process including its grounding in existing health disparity organizational change frameworks (Spitzer-Shohat & Chin, 2019). We will highlight the key domains of SMART and process for using SMART in the organizational setting. Lastly, we will discuss SMART’s potential as one of many innovative tools to address system-level disparity, including lessons learned from SMART’s development and use on general system-level approaches to address health disparity.

The COVID-19 pandemic rapidly accelerated the adoption and implementation of many technologies in the practice of psychiatry. Overnight, in-person visits except for emergencies were prohibited, yet technologically ready and savvy organizations and psychiatrists were able to restore access with emergency adoption of video conferencing technologies. Additionally, adjunctive services such as psychiatric applications on the smartphone were able to provide psychotherapy and medication management whether via secure messaging with a provider or artificial intelligence-driven chatbots to provide therapy. Social media and professional networks online helped psychiatrists connect their patients to available resources as well as facilitated wellness and decreased their own risk for burnout. This panel will review current best practices as well as future developments such as digital therapeutics and predictive analytics in the future psychiatric practice.

Here is an ordinary uneducated married Beninese, a successful businessman who, upon going bankrupt in his mid-twenties, and close to committing suicide, underwent a profound change of heart and decided to dedicate his whole life to all those in distress. He founded in 1983 Association Saint-Camille-de-Lellis (ASC), tending the penniless, AIDS and leprosy patients, prisoners, and homeless children. In 1990, upon discovering the plight of African psychiatric patients, whose human rights were blatantly violated, went on to house them and treat them with dignity, enlisting the help of the local psychiatrist in Bouake, Ivory Coast, where he had settled since 1971. In the face of such a mental health care desert, ASC started setting up its own Mental Health Care facilities. Thirty years later, fueled by an unrelenting faith, a formidable energy, and unique qualities as an entrepreneur and as a therapist, and relying largely on charity from small NGOs across Europe and Canada, Grégoire founded an efficient universal Mental Health System, WHO-approved, spanning Ivory Coast, Benin, and Togo. Nearly 130,000 patients have now benefited from ASC’s services. Ten 200-bed Inpatient Centers have been set up across those countries, headed by registered nurses and staffed mostly by remitted patients who regularly obtain qualified training from visiting and local psychiatrists. Furthermore, patients who need it, get trained in a trade at one of seven ASC Rehabilitation Centers. There are two general medicine Saint-Camille Hospitals, where ASC’s patients and the poorer neighboring population get cared for their physical ailments. Nearly fifty Saint-Camille Outpatient Clinics are piggybacking on Catholic dispensaries across those countries where patients get followed up, obtaining their monthly neuropsychiatric medication, and where new cases are brought in from the surrounding villages to get screened and treated locally by nun nurses trained by ASC. Wherever ASC is based, chaining and confining practices have significantly subsided, as people increasingly use ASC’s neuropsychiatric services – a clear indication that stigmatization is declining with the provision of long-lasting affordable qualified psychiatric care and thanks to popular education ASC provides throughout those countries. Furthermore, ASC is soon to implement in Benin the first regional West African Addiction Clinic to face the ever-increasing problem of poly-drug addiction in Africa. Its pioneering use of peer helpers and practical clinical algorithmic screening and treatment tool, all have contributed to attracting the attention of medical schools in Canada and Europe as well as the USA''s National Institute of Mental Health, Johns Hopkins Bloomberg School of Public Health, and the London School of Hygiene and Tropical Medicine. Numerous TV reports, films, articles, and books have been done underscoring Grégoire''s and ASC''s work, both crowned with many international awards over the years.

As the rate of mental health and substance use disorders increase more and more individuals are seeking care from their primary care physician. Primary care physicians often feel overwhelmed and unprepared to care for these patients and often cannot refer to psychiatrist for specialty care. This has resulted in many practices beginning to learn about the collaborative care model – the only evidence-based model for improving patient outcomes in primary care. You will hear how psychiatrists can help their primary care colleagues with the care of these patients – in as little as a few hours a week, how primary care practices have overcome some of the parries of implementation, how payors are stepping in to assist with training and technical assistance, as well as how large systems are seeing not only the improvement patient outcomes but the financial costs of providing care through this model.

Over the past two decades, brain imaging studies have defined a set of distributed brain systems that contribute to cognition, emotion, sleep, mood and other mental processes. Perturbations in these circuits have been identified in different ways across psychiatric disorders. Yet, these insights have not translated to the development and deployment of novel precision treatments in psychiatry. I will discuss work on neural circuit signatures that either define specific biologically-discrete forms of psychopathology, or predict treatment outcome, doing so at the individual patient level through a range of new machine learning-based analyses. Together, these data suggest that we are now on the brink of scalable and clinically-applied innovations in circuit-based diagnostics and treatments for mental illness, thereby taking us beyond dependence on symptom checklists for diagnosis, and having only one-size-fits-all treatments.

This presentation, a lecture given as part of the American Psychiatric Association’s 2022 Health Services Senior Scholar Research Award, addresses how to translate evidence-based medical findings to a population of real world clinics and patients through a public health framework.

Psychiatric leadership during the syndemic of the early 21^st century will require a significant change to achieve the desired system change. Alternative approaches to training, clinical care and research are required if we are to achieve the goals that we have committed to: addressing health inequities, creating a diverse and welcoming medical culture, and incorporating strategies that position psychiatry to remove the institutionalized barriers in our systems and implement strategies that create more balanced, equitable, and welcoming environments in training and practice settings. With leadership and will, psychiatry can demonstrate to social justice–motivated medical students and residents that we will not abandon the commitments made during this time, remain deafeningly silent, or worse, gaslight them by suggesting that the person speaking out is the real problem. It is also clear that modifying medical and graduate medical education models and practices is not enough to produce the diverse mental health workforce needed for the 21st century. Future leaders will need to focus on redesigning educational models, including lifelong learning, if we are to achieve the changes we want in psychiatry. The lecture will describe strategies for making real change that includes policies to create transparent and accountable institutional systems. Examples of system barriers such as isolation, “minority tax”, unrealistic expectations for “super mentoring”, and intersectional identity issues (ie., race, gender, caregiver, etc.) will be discussed along with potential for burnout and moral injury.; Recommendations for addressing and overcoming these issues will also be provided.

This session will describe indications of severity of personality disorders, particularly severity of self-directed and other – directed aggression, severity of interpersonal relations breakdown, severity of impulsivity, severity of distortion and rupture of linguistic communication, and severity of dishonesty and other antisocial behaviors. The diagnostic evaluation of these symptoms will be followed by their therapeutic management, including the combination of treatment structure and control with selective interpretative approaches to these symptoms. The special characteristics of narcissistic psychopathology will be highlighted, and common therapeutic measures for all severe personality disorders outlined. A potential secondary topic of this session is the methodology for evaluation of the indicators of severity of personality disorders.

This session will focus on research findings from the past three years that have implications for the management of patients with schizophrenia. In important areas including the management of acute schizophrenia, first episodes of psychosis, long-term treatment, and treatment resistant schizophrenia selected published studies that include clinical trials, large cohort studies, expert consensus reports, and meta-analyses will be described. will be followed by a summary of the presenter’s view on how the findings should affect clinical practice. A similar approach will address recent research on physical health concerns of patients with schizophrenia and the adverse effects of antipsychotic medications. will include research on metabolic problems including type 2 diabetes, obesity, and dyslipidemia as well as neurological effects and brain health. Clinical trial reports of newer antipsychotics including lumateperone and olanzapine/samidorphan will be presented as well as the implications of these new agents for practitioners. Reports of new formulations of antipsychotic medications including new long-acting formulations of paliperidone, aripiprazole, and risperidone and transdermal asenapine will be described. The clinical implications of new research on non-pharmacologic somatic treatments including aerobic exercise, transcranial magnetic stimulation, and electroconvulsive therapy will be discussed. Finally, there will be a discussion of new drugs for schizophrenia that are in Phase 3 trials.

Transgender and nonbinary identities are increasingly recognized but not always well understood. This session aims to help psychiatrists bridge that gap. We will review terminology and concepts essential to understanding gender diversity as it relates to mental health practice. The session will include several case presentations highlighting those intersections, with a particular emphasis on multiple minority identities. We will encourage attendees to reflect on their personal trajectories of understanding and expressing gender in order to better support patients in their own journeys.

Perceived or actual ‘lack of insight,’ medication non-adherence, and decisions about involuntary holds/hospitalization are perennial challenges confronting psychiatrists working with patients experiencing early psychosis. In this clinical update, we will provide a state-of-the-science update on insight and medication decision making, and then segue into a discussion by a diverse panel including two community psychiatrists and three national leaders with personal experience of psychosis. Weaving together personal, family, practice- and research-based experiences and insights, the panel aims to collectively deepen and complicate thinking about and strategies designed to address these long-standing practice problems.

The goal of this session is to present the busy practitioner with a concise review of GAD, panic disorder, and SAD. The presentation will breifly discuss changes in our nosology as we move from DSM 5 to DSM 5TR and any implications this may have for diagnosis of these syndromes. Next, we will discuss an approach to conceptualizing how the social determinants of health and mental health may impact the pathogensis, recognition and treatment of anxiety disorders. The next portion of the presentation will focus on treatment options for patients with anxiety disorders. We will briefly discuss evidence-based psychotherapies and complementary and alternative treatment options but we will focus mainly on exisiting pharmacological treatment approaches for patients with anxiety disorders. We will discuss the value of both FDA-approved and non-FDA approved pharmacological strategies that can be employed depending on the severity and degress of treatment non-response encountered. The final component of this lecutre will explore how new technologies may play a disruptive influence on how we recognize people at risk for developing these syndromes, lead to preventative if not pre-emptive interventions, and may extend our treatment options.

Working alongside people experiencing psychotic symptoms can be enlightening and frustrating but is critical to promoting wellbeing and recovery. The therapeutic relationship is key but there is limited support for specific ways of enhancing it and securing collaboration across the range of psychiatric interventions available. However evidence for the use of cognitive therapy in psychosis continues to grow and the debate about its distinctive albeit small effect size for positive symptoms over and above treatment as usual does now seem to have been resolved (McKenna et al, 2019). Its value for use in clinical psychiatric practice has also been shown in terms of improving communication between patient and psychiatrist and the therapeutic relationship (McCabe et al, 2016). Theoretical conceptualisation of engagement, normalisation, assessment and formulation can enhance clinical practice and will be described and illustrated in this update. Relevant techniques will then be described and their application to enhance routine clinical practice outlined. Working alongside the individual, especially when they are apparently lacking insight, is developed through eliciting and developing shared understanding and goals. The latter can be derived from the psychiatric formulation, which elicits goals, challenges and strengths and examines possible precipitating events and circumstances in understanding current symptoms. Focused work in clinical settings is then possible, e.g. for collaboration with treatment and work on hallucinations, delusions, thought disorder and negative symptoms. Structured reasoning can assist in reattribution of voices, development of coping strategies and empowerment in managing critical content. Delusions may benefit from an exploratory narrative and understanding perpetuating factors, e.g. low self-esteem and isolation, focusing on worry, and systematically reorienting the patient towards dealing with these issues - ‘so what ..'' therapy. Negative symptoms seem to have benefited from attention to pacing, timing and, paradoxically, reduction in perceived pressure. The audience will be encouraged to consider and discuss the applicability or enhancement of these techniques in their own practice in working with people with severe mental illness.

Eating disorders are serious psychiatric conditions associated with significant medical and psychiatric morbidity and high mortality rates. Eating disorders affect all ethnic and racial groups and have been identified in all parts of the world, although prevalence rates vary for different populations. The purpose of this Clinical Update is to review some of the current issues relevant to identifying and treating eating disorders. Drs. Joanna Steinglass and Evelyn Attia will discuss the restrictive eating disorders including Anorexia Nervosa, and Avoidant-Restrictive Food Intake Disorder (ARFID) as well as emerging data about the importance of recognizing Atypical Anorexia Nervosa, one of the conditions included in the Other Specified Feeding and Eating Disorders in DSM5. Dr. B. Timothy Walsh will discuss Bulimia Nervosa and Binge Eating Disorder (BED), focusing on pharmacotherapy that has demonstrated efficacy for these conditions. The Clinical Update is intended for practitioners who see individuals with eating disorders in their clinical practice and are interested in new issues, and advanced discussion of treatment strategies. Program format will include time for audience Q & A.

Substance use disorders (SUDs) and sleep disorders are intricately interconnected. Exposure to addictive substances evoke disturbances in sleep homeostasis, while sleep disturbances can increase the risk of development and severity of SUDs. Acute substance use disrupts sleep parameters such as latency, duration, quality and architecture of sleep. With chronic use, sleep disruptions intensify and withdrawal from substance use is often associated with chronic insomnia that enhances impulsivity and craving, increasing the propensity to relapse. Conversely, disruption in sleep homeostasis may increase drug intake, craving and the susceptibility to relapse to SUDs. This bidirectional relationship between sleep and SUDs has been demonstrated with a variety of substances with known addictive liabilities. While the relationship between SUDs and sleep is well known to be complex and bidirectional, less is known about the neurobiological mechanisms that underlie the intersection between sleep and SUDs. There are several brain regions and neurotransmitter substrates that underlie the regulation of arousal and sleep homeostasis, as well as motivation and reward. Locus coeruleus noradrenergic neurons, serotonergic neurons in the raphe, basal forebrain cholinergic neurons, midbrain cholinergic neurons, hypothalamic hypocretin (orexin) – ergic neurons, the endocannabinoid, the histaminergic systems and their projections regulate arousal and sleep while also having known roles in reward-related behaviors. This panel brings together diverse expertise highlighting advances in understanding how discrete molecular targets, neural circuits and/or neuropeptidergic systems mechanistically intersect to create an inter-relationship between sleep and SUDs. Firstly, Dr. Yanhua Huang will discuss work identifying specific sleep signatures and their causal link to drug craving and seeking behaviors using an operant rodent self-administration model. Secondly, Dr Ryan Logan will present recent work using human postmortem tissues from people with opioid use disorder and describe molecular alterations upon exposure to opiates, as well as novel molecular mechanisms involved in sleep and opioid withdrawal, craving and relapse. Finally, Dr. Jerome Siegal will discuss the role of lateral hypothalamic hypocretin (orexin) neurons in opiate use disorder.

Opioids, a class of drugs that includes heroin, synthetic opioids like fentanyl, and pain relievers legally available by prescription, such as oxycodone, and hydrocodone, exert their effects by attaching to opiate receptors found in the brain and many other organs. These drugs block the transmission of pain messages though peripheral and central effects, cause pleasurable sensations by activating brain reward regions including the brain dopamine reward pathway and regulate respiration by its effects in brain stem breathing centers. When used as indicated, opioids can be therapeutically very useful such as when used for severe pain conditions including cancer pain or to facilitate anesthesia among others. Non-medical use, in contrast, often results in physical dependence and addiction and can lead to overdose deaths from respiratory depression. After repeated opioid use, tolerance often develops, necessitating progressively higher doses to achieve the desired drug effect. The individual and public health burdens of OUD in recent years are staggering with >100,000 opioid overdose deaths annually. OUD is a chronic, relapsing, treatable disorder which is best understood as a biopsychosocial disorder in which genetic factors, exposure to adverse childhood experiences, mental disorders, and accessibility of drugs in the environment influence the extent of exposure and the opportunity for drug use. Over the past several decades, a range of treatments including medications and behavioral therapies have been developed which are effective at helping patients stop using opioids and achieve recovery. And, on the horizon, there is ongoing research to develop anti-opioid immunotherapies, new medication, and neuromodulation techniques to treat OUD. Three medications are currently available for treatment of opioid use disorder, all acting at opioid receptors, with diverse mechanisms—methadone, a full opioid agonist; buprenorphine, a high-affinity partial agonist; and naltrexone, a high-affinity antagonist available as an extended-release injection. Clinical trials among patients presenting with active heroin or other opioid use show that 40% to 75% of patients will be retained in treatment 3 to 6 months after treatment entry with opioid use reduced or eliminated. This is remarkable effectiveness in a patient population where the placebo response rate is very low. Yet, most people with opioid use disorder are not receiving medication. Barriers to more widespread use of these medications include stigma around substance use disorders and around medication treatments, variable adherence by patients to taking the medications, limited funding for treatment, and lack of willingness or knowledge on the part of prescribers and health systems to get involved. Progress is being made on each of these fronts with strategies including anti-stigma public health messaging, development of treatment systems, and education and mentoring of psychiatrists and other physicians. 

PRESENTER UPDATE: Wilson M. Compton, M.D. will replace Nora D. Volkow, M.D.

Patients with serious mental illnesses have higher rates of medical morbidity and die 10-20 years earlier than the general population. This symposium will provide an updated view of the clinical and policy landscape on this topic, highlighting emerging roles for psychiatrists in addressing this health disparity. First, we will present a framework that psychiatrists can use for better integrating physical health, mental health, and social services in their patients. Second, we will describe new models of service delivery including Certified Community Behavioral Health Centers and Health Homes, and how they will both facilitate and necessitate better integration of services for individuals with SMI. Finally, we will review APA''s newly updated Position Statement on the Role of Psychiatrists in Reducing Physical Health Disparities in Patients with Mental Illness, and how it can help you to address your patients'' whole-person needs.

In recent decades psychiatric residency training in the United States has mostly avoided teaching about sexual dysfunctions, sexual disorders, and even the basic skills required to take a sexual history. The proper diagnosis of sexual disorders is often not taught in many psychiatric training programs. Despite this current situation in our profession, patients entering treatment for a range of different problems may also have many concerns about sex, sexuality, and gender. A small number will ask these questions un-prompted. Most will need an invitation to express their concerns. This panel, composed of 3 speakers and a moderator, will address three questions that come up in the general psychiatrist’s office: What do we do about our teen? They are calling themselves “non-binary!” Doctor, I want you to tell me, “Am I gay?” “I’m watching too much porn on-line and some of it’s weird. My wife sent me.” Treating Transgender Children and Adolescents.

Suicide is a critical public health concern that has persisted despite increased awareness and diminishing stigma. The twin pandemics of COVID-19 and systemic racism have further underscored the urgent need for national leadership to engage in suicide prevention. Suicide rates have been increasing for decades, and this trend could be exacerbated by challenges associated with social isolation, financial strain, grief, continued uncertainty, and racial trauma. Our culture is experiencing a sea change in national dialog, perceptions that embrace mental health as a valid component of human health and that understand suicide as a potentially preventable cause of death. These culture shifts are a key foundational step, however political will has only begun to ramp up the level of national investment required to address this complex problem. Just as investments in other leading causes of death have led to reductions in mortality, a more significant investment in suicide research, prevention programs and implementation to a broader scale can be mounted to address this complex health issue. The suicide research field has grown in momentum and sophistication, and while there are still many unanswered questions, new information and interventions are showing evidence for reducing suicide risk. A body of evidence has grown for particular community-based and clinical interventions demonstrating reductions in suicide risk. Many of these interventions were developed and studied in recent years; we cannot wait the average 17 years to translate from bench to bedside since lives are at stake. Scientists, clinicians, policy makers, and people with lived experience and suicide loss are speaking with one voice as a national movement to speed up translation and dissemination. A national initiative called Project 2025 led by the American Foundation for Suicide Prevention (AFSP) aims to reduce the annual suicide burden 20% by 2025. Using the best available science, a data-driven implementation strategy is underway focused on healthcare, corrections, and the gun owning community. Numerous health systems are engaging in system change with policies and practice that prioritize suicide reduction as a quality issue and clinical target. Regulatory bodies including The Joint Commission have begun requiring screening and clinical care and the public’s readiness to address mental health needs and suicide risk is at an all-time high. Key initiatives of Project 2025 include a partnership between the American Academy of Pediatrics (AAP), American Foundation for Suicide Prevention (AFSP), and National Institute of Mental Health (NIMH) to develop a Blueprint for Youth Suicide Prevention, which serves as a strategic plan to engage pediatricians, adolescent medicine specialists, and other care providers involved with youth in clinical and community settings.

The American Psychiatric Association’s Principles of Medical Ethics emphasize competence, respect and up-to-date knowledge as a basis for appropriate professional behavior toward lesbian, gay, bisexual, transgender and queer (LGBTQ) patients. This presentation first reviews historical psychiatric attitudes towards LGBTQ patients that could be construed, at best, as patronizing and, at worst, overtly hostile. In modern clinical practice, as opposed to trying to “cure” homosexuality or “transsexualism,” LGBTQ patients are helped to live their lives according to their own natures and desires. This presentation outlines some common clinical questions raised by LGBTQ patients—what is known and not known about the origins of homosexuality and transgender expression, sexual orientation conversion efforts (SOCE), therapist self-disclosure, how therapists should address LGBTQ patients, and controversies surrounding treatment of transgender children—as well as ethical issues raised in these clinical encounters.

Intellectual and developmental disabilities (IDD) are lifelong conditions that affect one’s physical, intellectual, or emotional development. Examples include intellectual disability (ID) and autism spectrum disorder (ASD). Many individuals with IDD require support in terms of education, community services, and healthcare across the lifespan. Psychiatric disorders in people with IDD are common yet often undiagnosed and undertreated. Much of the research on phenomenology, outcomes, and interventions for individuals with IDD and co-occurring psychiatric illness is devoted to children and adolescents; however, with the aging of the population and improvement in lifespan for individuals with IDD, the population of adults with IDD continues to expand and has its own clinical and research needs. Many adults with IDD experience high rates of depression and anxiety, which correlate with impaired global functioning and increased risk of suicide, particularly in adults with ASD. This session will utilize a case-based approach to understanding the diagnosis of psychiatric conditions in individuals with IDD. Diagnosing psychiatric illness in IDD is challenging for several reasons, including individuals’ variable premorbid baselines, language impairment, and difficulty reflecting on and expressing their internal mental experiences (phenomenal world). Psychiatric presentations of illness can be atypical, and in addition to assessing the patient, the clinician must interview caregivers and other reliable informants. The diagnosis of dementia in older adults with IDD is also difficult due to varied cognitive baselines, communication challenges, and lack of a reliable informant in many cases. There are limited robust pharmacological treatment studies of psychopathology in adults with IDD, and no FDA-approved medications for the treatment of co-occurring psychopathology in adults with IDD. Research on psychotherapy for anxiety and depression in adults is also limited. Nonetheless, treatment of psychiatric illness in adults with IDD should be multimodal and collaborative, with medication, psychotherapy, psychosocial interventions, and caregiver involvement all playing a role.

The population of the United States is aging. Currently people over the age of 65 years constitute 13% of the general population. By 2050 this number will rise to about 25% of the population. As the population ages, the number of older adults with mental illness will also rise. Available data indicates that there are inadequate numbers of trained geriatric psychiatrists in United States to care for older adults with mental illness. The additional burden for services in the future on an already strained healthcare system can lead to catastrophic failure of the system. International Medical Graduates (IMGs) constitute almost half of the work force of geriatric psychiatrists. The IMGs have had successful career as clinicians, educators, academics and researchers in geriatric psychiatry. In this symposium I will enumerate the unique challenges faced by the IMGs and strategies on how to enable them to integrate into the mainstream geriatric psychiatry workforce. I will review the roles of IMGs as private practitioners, educators, academicians and as researchers. I will also discuss how organizations like the APA can play a greater role in attracting larger number of IMGs to join the geriatric psychiatry workforce. This will enable greater access to care for the older adults with mental illness.

The growing shortage of psychiatrists has exacerbated problems with access to psychiatric care in America. An important aspect of addressing this shortage is to focus on expanding the number of psychiatrists being trained in United Sates. However, to meet the psychiatric care needs of the population, it will also be necessary to utilize other trained professionals, including psychiatric advanced practice nurses (APNs), physician assistants (PAs) and other mental health professionals. Increasingly, psychiatrists will need to work effectively in teams with APNs and PAs, which requires mutual understanding of training, roles, and scope of practice. Given the psychiatric workforce shortage, it is important that each practitioner be able to fully utilize their education, skills, knowledge, and expertise. In this workshop, participants will build understanding of the training and skill set of the various mental health disciplines with focus on psychiatric APNs. Understanding the educational background of APNs is an important first step for psychiatrists seeking such partnership and for leaders in psychiatry who are hiring. The workshop will also highlight and discuss noteworthy differences between APN training and psychiatrists training and the practical implications for workplace settings. We hope that better understanding each other’s educational background will allow the participants to brainstorm models of effective collaboration that optimize the health and well-being of our patients while minimizing unnecessary costs.

The COVID-19 pandemic was a global disaster with far-reaching impact on mental health. The scope and duration of the event created unique challenges for workforce and organizational sustainment with most unprepared to protect workforce mental health during a protracted global disaster. Healthcare workers were at particularly high risk, many of whom were required to work extended hours under constant threat of infection to themselves and family members. In addition, healthcare systems were overwhelmed and resources unable to meet demands, requiring a transition to crisis standards of care in which healthcare workers had to make life and death decisions about which patients would receive life-saving interventions. Exposure to these extreme and frequently unprecedented conditions led to a range of responses for healthcare workers, including fear, anger, moral distress, insomnia, substance use, and others. The United States active duty military trains to work within environments that involve high stress and risk to safety for prolonged periods of time and often with limited resources and protects mental health using the principles of Combat and Operational Stress Control (COSC). Early in the pandemic, partnerships emerged in which the military provided support to healthcare systems, embedding within community hospital teams to augment delivery of care as well as to share and adapt COSC principles to enhance sustainment of the civilian healthcare workforce. One of the largest and earliest partnerships occurred in New York City, beginning with military deployment to the Javits Center, which was transformed into a COVID-19 field hospital. The military also provided consultation to New York City’s healthcare and first responder leadership, collaboratively developing the HERO-NY resilience program, which incorporates COSC principles to support healthcare workers and responders within the largest public health system in the country. Additional military deployments during the pandemic provided critical resources to augment health systems and dissemination of COSC principles to our nation’s healthcare systems. COSC principles can be adapted within healthcare and other work settings to fundamentally enhance worker well-being and operational sustainment during future disasters and other crisis events. This session will review unique principles of public mental health in disasters, how these inform a military COSC framework, partnerships during the pandemic that enhanced workforce sustainment and public health, adaptation of military principles to support national mental health during COVID-19, and bidirectional lessons learned during these partnerships. Presenters will share robust resources that can be freely used and adapted to enhance workforce well-being and operational sustainment during future disasters, including pandemics, earthquakes, wildfires, mass violence, and others. Presenters will engage the audience through a variety of interactive modalities.

Post-traumatic stress disorder (PTSD) is a disabling serious psychiatric illness which has been increasing in prevalence in recent years. The diagnosis, epidemiology, pathophysiology and treatment of PTSD will be described with an emphasis on evidence based treatments. At the current time the vast majority of patients receive one of the two FDA approved treatments, sertraline or paroxetine with some percentage of patients treated with either one of the evidence-based psychotherapies (trauma focused Cognitive-behavior therapy or Cognitive Processing Therapy) or a combination of the two. In spite of advances in the field, the majority of patients do not achieve remission, though they do exhibit reductions in symptom severity as measured by the CAPS or PCL-5, the two most common dimensional measures utilized in this population. Risk factors for the development of PTSD will be described including a history of child abuse or neglect, as well as the nature of the index traumatic event and genetic factors. Pathophysiology studies using PTSD as the prototype gene X environment interaction disease will be described with an emphasis on candidate genes that have proven to be predictive of development of PTSD such as FKBP5 and CRHR1. The role of epigenetic mechanisms in the pathogenesis of PTSD will also be described and how this effects expression of critical genes. Brain imaging studies will be described highlighting structural and functional CNS changes in patients with PTSD and how they change with effective treatment. Finally and most importantly, each of the various treatment modalities that have been studied in PTSD will be reviewed in detail including various psychotherapies, pharmacotherapies, and novel treatments (ketamine, MDMA, Stellate ganglion injection). If time permits, management of treatment resistant PTSD will be discussed as well in the context of a case presentation.

Substance use disorders and the behavioral addictions have spiked during the COVID pandemic. Now more than ever, mental health providers are asked to assess for addiction and are expected to manage people’s problems with substances and addictive behaviors effectively. Along with the psychopharmacology for opioids, tobacco, and alcohol, psychotherapy has been shown to be the staple of safe and effective addiction treatments. Brief Intervention (BI), Cognitive Behavioral Therapy (CBT), Contingency Management (CM), group psychotherapy, mindfulness, Motivational interviewing (MI), and mutual-help facilitation are the primary psychotherapeutic modalities that treat addiction and bolster recovery. In this clinical update, we will provide an overview of the theory behind different psychotherapies for addiction, as well as give practical suggestions on how busy psychiatrists can implement these techniques in their own clinical work. Special emphasis will be given to the integration of different psychotherapies with the psychopharmacology of addiction and other co-occurring psychiatric disorders. BI, CBT, CM, groups, mindfulness, MI, and mutual-help programs can be paired with medication management for great outcomes. Furthermore, we will examine how these therapies may (or may not) lend themselves to tele-health in the COVID and, hopefully, post-COVID era. We will discuss tele-health platforms; new applications that are used in conjunction with psychotherapy to help patients on the road to recovery; and mobile applications that can assist with medication management. Technology may deliver much needed support for many patients during the pandemic—ironically, even for patients who suffer from one of the emerging technological addictions!

Psychiatrists and other mental health professionals are often presented with the opportunity to advocate for children experiencing symptoms and behaviors that affect their educational performance. However, the educational system can be a difficult one to navigate. Understanding the general frameworks and access points, including families’ legal rights, educational policies and procedures, and what kinds of services and accommodations may be helpful to address specific needs, are crucial. With this information, mental health professionals can be allies to patients and families and collaborators with schools to translate psychiatric need to educational support. This is especially true for the most vulnerable children who are at an increased risk for adverse educational outcomes, like poor achievement, school dropout, expulsion, and involvement in the juvenile justice system. Further, the COVID-19 pandemic has amplified the need for collaborative care between educators and mental health providers. The compounding impact of the pandemic will make collaborative work even more crucial in the years to come.

Physicians are known to be a group of individuals who are more at risk of suicide than the general public. Data are sparse about attempted suicide, but we do know that medical students and residents have rates of suicidal ideation that are higher than age-matched peers. Robust and well-intentioned efforts to study and treat the painful cognitive and affective states that drive suicidal impulses in physicians are thwarted by shame. Physicians do not feel comfortable or safe sharing something so private and frightening or so dark with their peers, families, training directors and treating professionals. What’s worse is that medicine itself, the so-called culture of medicine, is too often a partner in this scourge of embarrassment, unacceptance, judgment, denial and suppression. This is dangerous. The intent of this session is to unravel these forces, present new learning from look-back research, share personal narratives, and offer ways to save doctors’ lives. Michael Myers, MD specialist in physician health, will discuss findings from his qualitative postvention research on shame with two groups: families of doctors who have died by suicide and doctors who have made near lethal attempts at suicide. He will also introduce the notion of caste in the house of medicine, a pernicious force that shuns and shames doctors who speak openly about their mental health challenges. Katherine Termini, MD PGY-1 resident in psychiatry at Vanderbilt University will share her story of entering medicine after grappling with mental illness and suicidality years prior. She will discuss her perspective on stigma within medical training, how it may be contributing to physician suicide, and why it is important to shine a light on mental health. William Lynes, MD board-certified urologist, will share his story of medical practice and suicide attempts, and the shame felt during his practice and in the years that followed. He will chronicle his writing and speaking on the subject of physician suicide and the resulting restorative result. Linda Wrede-Seaman, MD a primary care and palliative care physician and former emergency medicine physician is a survivor of her husband Dr Matthew Seaman’s suicide. He was an emergency physician who was sued during his first year of retirement. The stress was prodigious, unrelenting, and included publicly humiliating disclosure of details. He crashed into a severe depression and required hospitalization. Following an onerous deposition and feeling unsupported by counsel, Dr Seaman took his life on March 28, 2019. Dr Wrede-Seaman will argue that shame is real, stigma is real, litigation stress is real, and that something must be done to end this abuse of America’s physicians. One-third of the session will be preserved for interaction with attendees and the panelists.

Ten states currently require physician assessment of “mental competence” before allowing patients to end their lives with medical assistance (Dugdale, 2019). Three panelists representing the Committee on Professionalism and Ethics of the Group for the Advancement of Psychiatry in collaboration with the Scattergood Ethics Program at the University of Pennsylvania and St. Elizabeths Hospital (Washington DC) will present specific approaches to assessing patients making end-of-life decisions. In this presentation, we propose that the aim of the physician is not to write the prescription, but rather, to assess the capacity of the patient to determine the time of their own death. Such assessments cannot follow the mere technicalities of common clinical interviews, not simply because of the finality of the choice, but also because of the limitations of common cognitive assessments. General psychiatrists are not unique in their ability to perform these assessments but because of their training and professional experiences, are well suited to make these assessments (Owen, 2018). There are already models to assess these capacities; however, an under-appreciated element of this decision-making lies in the emotional components that invariably accompany life-and-death decisions. The assessment we are proposing includes seeking a narrative about the patient’s life, past coping, and reversible emotional states. A narrative inquiry seeks to understand rather than judge the appropriatenes of end-of-life requests. This approach expands the present, prevailing capacity assessment model, thus providing guidance for assessing the full range of cognitive and emotional capacities necessary for making these difficult and permanent decisions. This theory-neutral and belief-neutral approach may be implemented by general psychiatrists who themselves may have a different personal outlooks on participating in medical assistance in dying. The approach focuses on understanding the patient, not making a decision about the appropriateness of the patient’s request. A tool as common as the psychiatric interview and the Defensive Functioning Scale (Perry, 1998) can allow psychiatrists to understand not only how patients think and feel about dying, but also how and whether they can consider their context, choices, and desired outcomes. In this session, the panelists will enumerate selected key features of this expanded approach in more detail, including considering the emotional and development capacities necessary for making this decision (Hafter Gray, Submitted for publication).

Amidst growing consensus about the potential harms of exposure to law enforcement for minoritized individuals in mental health crisis,1 crisis services have increasingly become a focus of attention for advancing equity and antiracism within psychiatry. Additionally, healthcare system pressures such as limited access to care, emergency department boarding of psychiatric patients, and inadequate inpatient psychiatric bed capacity have aligned with national initiatives such as the highly anticipated 9-8-8 crisis line to increase attention on crisis services.2 Crisis response programs that serve as alternatives to traditional police response have drawn widespread attention and sparked major implementation efforts, such as the introduction of the Street Crisis Response Team (SCRT) in San Francisco in December 2020.3 However, in the absence of conclusive, high-quality evidence on effective crisis intervention,4 public fervor for new programs may obscure meaningful ongoing challenges in defining, implementing, and evaluating high-quality crisis services. In this session, emerging leaders and seasoned experts in crisis research and program implementation will equip participants to address the challenges of establishing effective crisis services with a focus on health equity and quality improvement. We will summarize the current landscape of crisis services research, highlighting gaps in identifying best practices and in accessing meaningful data to inform quality and equity aims. Next, using the example of an ongoing evaluation of San Francisco’s SCRT, we will review research methods from the discipline of implementation science that can help address the unique challenges of crisis services research. In particular, we will describe how high-quality crisis services research should extend beyond conventional metrics (such as emergency service reutilization) to include measures related to social determinants of mental health (such as linkage to housing and jail diversion) and qualitative data that illuminate how patterns of service utilization depend on social determinants (such as phone access). Finally, we will discuss how to develop and refine meaningful quality measures for crisis services that can be used in research as well as program evaluation and continuous quality improvement activities.5 Participants in this session will have the opportunity to practice applying implementation science principles to hypothetical evaluations of their own health systems and to engage with the panelists in a Q&A focusing on how psychiatrists can shape policymaking regarding crisis service implementation and evaluation.

Despite the possible stigma associated with disclosing a disability, a recent survey indicates that the number of medical students who report having a disability (physical, sensory, learning, psychological, chronic health condition) rose 69% 2016-2019, suggesting either more existing students disclosing a disability and/or better reporting. This number is likely to increase further as more medical schools and training programs improve accessibility. Having more medical students and trainees with all categories of disabilities can have a positive influence on the future physician workforce, including increasing diversity, reducing stigma and stereotypes about people with disabilities, and informing patient care. Physicians with disabilities provide unique perspectives that can translate to better and innovative patient care. Mental health issues, including substance use disorders (SUD), depression, burnout, and suicide risk merit special attention. Despite wide prevalence (depression or depressive symptoms range from 20.9% to 43.2%, SUD from 10 to 15%, and suicide rates 1.4-2.3 higher than the general population), some experts believe the number is even higher given the “code of silence” that exists in medicine. This has allowed sick friends, colleagues, or mentors to suffer out of fear of disciplinary action or harm to their professional reputation, ignoring the potential benefits of early interventions. Not only have medical systems been slow to respond to the growing mental health crisis, but physicians themselves are hesitant to engage in mental health treatment, creating a vicious cycle. The most common reasons reported by physicians as to why they began using alcohol/drugs were to relieve stress and physical/emotional pain. Emerging evidence suggests physician burnout is also a significant factor in SUD development. This is concerning given the events over the last couple of years with the COVID-19 pandemic, social injustice, and increased incidence of burnout among physicians. Furthermore, it is well known that SUDs among physicians is associated with a higher rate of suicide. Physicians have one of the highest rates of suicide among any profession globally, with a 40% higher rate of suicide for male physicians compared to male peers, and approximately a 130% higher rate of suicide among female physicians compared to women in the general population. Facilitating access to care for physician colleagues, including trainees, and monitoring upon return to work is critical to save lives and maintain patient safety. Session presenters have significant experience working with psychiatrists and trainees with disabilities affecting work and training. Case review and discussion with presenters and colleagues will allow participants to enhance their confidence in dealing with these complicated situations and balancing open dialogue and privacy.

Amidst heightened recognition of a national public health crisis, individual practitioners, academic departments, and healthcare organizations are contemplating strategies and solutions to dismantle health inequities. Few training programs have reported curriculum specifically on Social Determinants of Mental Health (SDoMH) for child and adolescent psychiatry (CAP) training, and fewer have offered strategies to incorporate social justice and anti-racism in its development. Even fewer academic centers have been transparent about their diversity, equity, and inclusion (DEI) process and implementation efforts, creating a schism of developmental approaches in building strong CAP curricula for program directors across institutions. This workgroup outlines how an academic institution and a psychiatry department alignment of a DEI infrastructure helped to foster the creation of an antiracist approach to teaching SDOMH and has merit in achieving mental health equity for future generations, especially children and adolescents. In this abstract, we report on the pre-development and implementation phase of a novel Antiracist social determinants of mental health curriculum for child and adolescent psychiatry trainees at University of Maryland. Child psychiatrists have a key role in addressing the social, structural, and environmental determinants of mental health and fostering the building of healthier communities especially for our most vulnerable populations, such as children and adolescents whose developing brains are significantly heavily influenced by these factors. However, child psychiatrists received limited training in both understanding and addressing the impacts of racism as a Social Determinants of Mental Health (SDoMH) in their standard medical training. Antiracism and Social Determinants of Mental Health (SDoMH) must become central knowledge in child psychiatry and not be deemed a specialty topic by program directors. We believe that this workshop will share a novel Anti-Racism Social Determinants of Mental Health curriculum that is innovative, demonstrates academic leadership and advocacy, and that aligns well with values of social justice and health equity for all, especially those most vulnerable.

Over the past year, COVID-19 has underscored pre existing structural inequities, such as healthcare disparities, un- and underemployment, and poorly resourced schools in vulnerable populations, especially disenfranchised communities of color (Levinson et al, Kentor and Thompson). In the midst of the ongoing community crisis, recovery is occurring on a continuum, but toxic stress from systemic social determinants of health may impede recovery and necessitates community and cross-sector collaborations (Fortuna et al, SAMHSA). Healthcare responses to previous disasters, such as 9/11, provide a template for ways in which psychiatrists may intervene during this current pandemic, especially in evaluating factors that contribute to risk and resilience (DePierro et al). However, vulnerable populations, such as children, deserve special consideration. In particular, children from minority groups are also thought to be at increased risk for experiencing adverse outcomes related to COVID-19, such as inadequate education, increased separation and loss in their families, decreased access to food and healthcare, and social deprivation (WHO-UNICEF). Globally, there has been an increase in the prevalence of anxiety and depression in children during the COVID-19 pandemic in systems which already had difficulty meeting the needs of children and families (Racine et al, Benton et al). In addition to the pandemic, youth are also experiencing the impact of other disasters, such as wildfires, hurricanes, earthquakes, and floods. Given the additive nature of trauma, children and their families are at increased risk for negative mental health outcomes. Psychiatrists can and should advocate for at-risk children and families after a disaster. The engagement of youth by psychiatrists and others in the work of disasters and community trauma is an important and meaningful experience for both young people and the adults involved (Berkowitz et al, Chokroverty et al, Chokroverty and Tompsett). It has great potential in facilitating resilience and recovery around disasters and traumatic events for these young people and their communities. This session aims to increase awareness of disaster systems and roles for psychiatrists; appreciation of threats to children’s health created by destruction and loss; advocacy for vulnerable children; management of disruptions in infrastructure and resources; and awareness of challenges faced by schools and communities. Participants will also consider how we can support culture, religion, and spirituality for resilience. In addition, participants will discuss resources available for caring for children, families and vulnerable populations such as online resources available on American Academy of Child and Adolescent Psychiatry, the National Child Traumatic Stress Network, Center for Traumatic Stress Studies, and the CDC.

Background: Depression is the number one cause of disability in the world. Across different societies and social contexts throughout the world, depression affects significantly more women than men. Social determinants of health (i.e., income, education, and health status) may play a crucial role in the development or exacerbation of depression among Latinx/Hispanic women. Methods: According to a WHO definition, the social determinants of health are the conditions in which people “are born, grow, live, work, and age.” Recent studies found U.S. women experienced increased incidence of health-related socioeconomic risks, such as food insecurity and interpersonal violence, early in the COVID-19 pandemic. This was associated with high rates of mental health problems, including depression and anxiety. The effect of the pandemic on women in vulnerable situations has been largely forgotten. We examined the relationship between the social Determinants of Health and depression in Women from Latinx/Hispanic America. Analysis: Hispanic/Latinx culture is, traditionally, very family oriented but it retains firm gender divisions. The COVID-19 pandemic has sharply revealed the inequalities that already exist in terms of socioeconomic status. Women are principally responsible for parenting, family caregiving and other essential work — they are key to managing and recovering from this pandemic, and now are afflicted by very significant socioeconomic risk levels that appear to be drivers of depression. Conclusion: Among the social determinants of health, poverty, is a vital stressor in which a substantial number of threats and unmet needs converge. We should be especially concerned that socioeconomically vulnerable women are at high risk for developing pandemic-related psychiatric morbidity. It is necessary to pay more attention to Latinx/Hispanic women in vulnerable situations due to the high risk of depression. Women require a broader approach to analyze variables associated with depression and, consequently, specific strategies. This symposium is in collaboration with the American Society for Hispanic Psychiatry (ASHP) and WARMI (Mental Health Network for Women’s Mental Health in LA) 

PRESENTER UPDATE: Thelma S. Sanchez-Villanueva, M.D. will no longer present.

Persons with Intellectual Disability (PWIDs) that act out sexually are a heterogeneous group whose motivations and pathology range from a simple lack of adaptive functioning to more complex, comorbid paraphilias. These behaviors can be seen anywhere… from the inpatient unit to a group home, even in the community at large. They may result in a variety of negative consequences for PWIDs, including administrative discharges, removal from care facilities (with subsequent challenges finding alternative housing) and even criminal charges. The behaviors also negatively impact those who witness them and of course their victims. Further, clinicians are often not well equipped to manage behavioral issues in those with intellectual disability; thus, the management of sexual acting out in the PWID population can prove a daunting task to many practitioners. This session aims to supplement the psychiatrist’s knowledge about PWIDs by discussing the evaluation and management of these inappropriate sexual behaviors. We will first present two complex cases, focusing on how such inappropriate sexual behavior by PWIDs may manifest itself. We will then address the etiology of these behaviors. We will review diagnostic considerations relevant to paraphilic disorders in PWIDs and discuss ways to distinguish these from non-paraphilic disorders. We will then cover treatment and management considerations. After the presentation, small groups will be formed; each group will discuss the aforementioned cases and apply their newly acquired knowledge to each situation. The group will then present their findings for further discussion and collaboration. The presentation will conclude with a Q&A session.

Our goals in this session are to: 1) Provide background information regarding emergency psychiatric symptoms in the transgender and gender nonconforming (TGNC) community, 2) Share new data from our research on TGNC emergency psychiatric care, and 3) Provide concrete steps that psychiatrists can take to provide gender-affirming care in the ER setting. Approximately 0.6% of adults in the United States identify as TGNC.^1,10 Compared with the general population, TGNC individuals are at increased risk for psychiatric symptoms, including depression, anxiety, and substance use disorders.^1,2 Alarmingly, the lifetime prevalence of suicidal ideation among TGNC individuals is thought to be as high as 83%, and the lifetime prevalence of suicide attempts in this population is ~40% (compared to ~4.6% in the overall population).^2,8 While TGNC patients appear to be at increased risk of acute psychiatric symptoms, few studies have examined the demographics, symptoms, and/or experiences of TGNC patients presenting for emergency psychiatric care.^3,5,10 Concerningly, data suggests that most emergency room physicians lack basic knowledge of how to provide gender-affirming care.¹⁰ In addition to describing existing data regarding acute psychiatric symptoms in TGNC patients, we will summarize new data from a 7-year retrospective case-control study, in which we performed a chart review of each TGNC patient who presented to a Manhattan psychiatric ER between 2012-2019. We will describe the most common presenting symptoms in this cohort, as well as demographics (including housing, trauma history, and race/ethnicity), and the frequency of pronoun discordance in the EMR. We will then argue for the importance of providing any psychiatrist practicing in an ER setting with basic education regarding: gender and gender diversity, gender-affirming medications and surgeries, and stressors faced by the TGNC community (including racism, poverty, assault, and lack of access to care).^4,8 We will then posit several key components of gender-affirming emergency psychiatric care, including: use of appropriate language and terminologies, use of appropriate questions to elicit information related to gender, availability of gender-neutral spaces (bathrooms, hospital rooms), maintenance of respect/privacy around gender, and knowledge of local aftercare resources.^5,9 We will then provide interactive case examples in which participants will work in small groups to identify obstacles to gender-affirming care, practice asking gender-affirming questions and making appropriate interventions, and practice providing brief education to colleagues. Finally, we will open up for group discussion regarding additional measures that practitioners and healthcare systems can take to provide more gender-affirming care. We will also share information regarding existing educational resources that participants can access after the session.⁹

Psychiatry is a constantly evolving clinical science. As the body of knowledge grows, practitioners must constantly incorporate new information into their practice. This evolution is fraught with ambiguity manifesting itself in day to day clinical encounters. Without deliberate attention paid to the diagnostic process practitioners can inadvertently commit thought errors and invite cognitive bias. These preventable errors can lead to incorrect diagnosis, costly inappropriate interventions, and inadvertently harm our patients. While mistakes are inevitable, it is essential that psychiatrists hone our diagnostic skills to mitigate the effects of cognitive bias and cognitive error. It is necessary for a practitioner of medicine to focus inward and to analyze how we employ cognitive strategies, utilize heuristics, mitigate cognitive bias, and utilize fast versus slow thinking. Only by understanding how we diagnostically approach ambiguity can we begin to mitigate the effects of cognitive error. Data has shown that through education, providers can decrease diagnostic error and improve clinical outcomes. The objective of this workshop is twofold. first objective is to help learners become familiar with various cognitive strategy theories and learn to mitigate personal contributions of diagnostic error. Second goal is to assist teachers to create a concise approach to educating residents and fellow psychiatrists on these principles. Residency programs and daily practice are filled to capacity with educational requirements. Many curricula compete for the limited time available to residents and attendings. The goal of this workshop is to deliver this lesson in a single 90 minutes session. While not comprehensive, it will provide a foundation for continued self-learning and clinical growth. Participants will be provided teaching content and other deliverables to easily incorporate this workshop into their residency’s curriculum.

Access to nutritious, low-cost food is considered one of the principal social determinants of health of an individual and thus, of a nation. “An army marches on its stomach” so it is said. We are taking it a step further to say that “A nation thrives on what it eats and drinks”. In ancient times, herbs, spices, plants and foods in general played a pivotal role in treating mental health disorders, prior to the advent of psychotropics. This is documented in ancient texts of Chinese, Greek, Egyptian and Indian civilizations. In modern times, advice about nutrition has become the domain of the Nutritionists and Dietitians. Our colleagues in sister specialties emphasize the role of changes in diets in prevention of obesity, hypertension, diabetes, or kidney problems. Is it not about time that mental health providers did the same? In various stages of life and in different populations, nutrition changes can help or hinder mental health. As we age, chronic hyperinosemia and diets high in saturated fats increase our risk for Alzheimer’s disease. Diet also has an undeniable effect on inflammation processes in the body. As a nation we are consuming almost 25% more calories a day than we were in 1970, and those calories are increasingly composed of more refined grains, fats, oils, and corn-based sweeteners and less essential nutrients. The Standard American Diet (SAD) has been linked to increased obesity, excess adiposity, and increased release of pro-inflammatory cytokines including tumor necrosis factor a (TNF-a), interleukin 1 (IL-1), and interleukin 6 (IL-6). Recently, research has demonstrated a link between these inflammatory cytokines and major depressive disorder, post-traumatic stress disorder, and schizophrenia. Unfortunately, access to healthy foods is not universal and for some it is cost prohibitive. Access to low-cost healthy foods is essential in improving both our physical and mental health, but there are numerous barriers to access adequate nutrition that have worsened in the setting of COVID-19. Food insecurity can have devastating effects on mental and physical health, the pandemic has highlighted the pre-existing holes in our social safety net that have kept millions of people from accessing quality nutrition. Addressing food insecurity in a sustainable way will help reduce the burden of mental health problems and reduce social inequality. What can we as mental health providers do to address these issues? Perhaps including diet and nutrition in every treatment discussion will help us gather more data and be better equipped to offer resources to help our patients optimize their diets. We are seeking a more holistic approach to patient care, but there are barriers to this as well. FDA dietary guidelines currently do not elaborate on the mental health impact of specific foods, but if this were to change it would improve all healthcare workers'' ability to counsel patients on the importance of diet and nutrition.

Medical students are at increasing risks of burnout, depression, and anxiety (1). LGBTQ+ identified students, specifically, are at increased risks of isolation, discrimination, and mental wellness challenges compared to their non-LGBTQ+ counterparts (2). LGBTQ+ identified medical students are exposed to additional long-term stress due to stigma associated with their sexual orientation and gender identity (3). This additional stress can impact students’ burnout and attrition rates (3). Mentorship can be extremely beneficial to students, especially when mentors and mentees share similar identities. Additionally, mentorship has been proven to have a positive impact on both the professional and personal well-being of LGBTQ+ medical students. This workshop focuses on mentorship needs and the impact it can have on LGBTQ+ medical students pursuing psychiatry. It will feature a panel of medical students and residents who will share why mentorship is important, the various ways that a successful mentorship relationship can operate, and their experiences in seeking and maintaining those relationships. In a time when medical students’ exposure and ease of networking with psychiatrists from across North America has drastically increased, a more traditional mentor-mentee relationship may appear antiquated. This shift in the ease and immediacy of access to mentors long-distance, may leave students feeling less sure about how to initiate and maintain a more personalized, longitudinal relationship. This workshop aims to provide LGBTQ+ identified students and psychiatry mentors with a toolkit on how to initiate as well as foster an enriching and sustainable mentorship experience. Throughout a portion of the workshop, the panelists hope to empower audience members and share, in a moderated as well as a open-format question and answer format, specific issues, concerns, or advice on their experience with mentorship. Our panel is excited to share why, what, and how LGBTQIA+ medical students can find benefit and meaning in a sustained meaningful relationships with mentors.

In recent years, there has been an increased acknowledgment of the longstanding inequities and injustices perpetuated by policies and structures rooted in racism. The field of medicine has contributed to these injustices, and disparities based on race have been detrimental to our patients and their communities. Persons of color often suffer from poor mental health outcomes due to misdiagnosis, lack of access to quality mental health care services, limited culturally competent mental health care, ineffective communication, and discrimination. For example, Black persons are less likely to be offered evidence-based medication therapy or psychotherapy and have lower rates of utilizing prescription medications and outpatient services, but higher rates for use of inpatient services. Additionally, implicit racial biases have been shown to play some role in mental health assessment and intervention. These biases can negatively influence provider’s willingness to engage in patient-centered care, provide referrals to specialized treatment, or adhere to evidence-based guidelines when serving diverse populations. With the increased awareness of the pervasive effects of racism and biases, Psychiatrists may feel ill-equipped to begin addressing these inpatient encounters. Clinicians are in a position to mitigate the impact of racism by becoming aware of their own implicit biases, providing space for patients to process personal experiences of racism/discrimination, and recognizing the impact of structural inequities on mental illness presentation and prognosis. While we will discuss definitions of concepts surrounding race and discrimination in our session, we plan to reach beyond definitions with practical applications of how to approach conversations about race and racism with patients and their families. During the session, we will review general principles for interacting with patients from various backgrounds, how to initiate a dialogue with patients about race/racism, tools for assessing experiences of racism and discrimination and discuss patient cases. There will be simulations of patient encounters, giving participants the opportunity to reflect on what racial/cultural tensions are present and to determine the next steps for the Psychiatrist to take in each scenario. This can help Psychiatrists learn to identify when race, ethnicity, or culture have an impact on patient experience and/or their perception of a patient and to utilize patient-centered methods to address these situations. We are at a critical point to transform the dynamic between patients and Psychiatrists, and this session is a concrete step towards cultural humility, improving therapeutic alliance, and ultimately better mental health care.

During the course of residency training, significant efforts are made to instruct residents about the recognition and treatment of primary psychiatric disorders such as major depression, bipolar disorder, post-traumatic stress disorder, panic disorder, and schizophrenia. However, exposure to cases that initially appear to be primary psychiatric disorders but are actually due to underlying medical conditions is often lacking, despite their common occurrence. Infections, hypoxia, electrolyte imbalances, endocrine disorders, autoimmune disorders (e.g. lupus, sarcoidosis) neurologic conditions (e.g. epilepsy, multiple sclerosis, delirium) and medications are just some of the causes of patient presentations that can mimic primary psychiatric disorders. Awareness of these “mimics” is needed as patients may otherwise appear to have “treatment-resistant” psychiatric disorders or, of greater concern, actually worsen when given psychotropic medications. This is necessary information for both trainee and general psychiatrist alike. An additional area of clinical knowledge that would benefit trainees and general psychiatrists is the recognition and management of psychiatric disorders that mimic medical conditions. Limited exposure to consultation-liaison psychiatry during residency training may result in lack of experience with conversion disorders, somatic symptom disorders, and factitious disorders. These are patient populations that are often responsible for excessive utilization of medical resources and healthcare dollars as well as being sources of mounting frustration and misunderstanding for medical colleagues. Requests for psychiatric involvement are not unusual, especially when medical work-ups are negative yet patients persist in their requests for medical/surgical intervention. The following workshop aims to provide residents, fellows, and general psychiatrists with an opportunity to learn more about secondary psychiatric disorders (psychiatric mimics) as well as somatic symptom and related disorders (medical mimics) in a case-based format with opportunities for questions and discussion with residents, fellows, and attending physicians with experience and/or expertise in consultation-liaison psychiatry patient populations.

Asians were the fastest-growing racial or ethnic group in the United States (US) from 2000-2019 and currently account for 19.9 million Americans. Asians, particularly East Asian and South Asian Americans are known to be at high risk of prejudice and microaggressions in multiple community settings. South Asians are more likely to report racial discrimination in institutional settings and interpersonal settings than East Asians and White Americans. First coined in 1970 by Dr Chester Pierce for the African American population, the term microaggressions has expanded to include other minority populations. This presentation will examine the existing bias against Asian and South Asian American populations; special focus will be placed on local community members, members of professional organizations, health care workers, and persons with any existing mental health issues. Although the direct impact of anti-Asian hate has been highlighted and exacerbated during the COVID-19 pandemic, subtle prejudice against Asian and South Asian Americans has always existed. Asian Americans frequently face unique challenges such as the model minority myth and the spokesperson phenomenon; both of these can affect self-esteem and lead to symptoms of anxiety, depression, and other mental health-related sequelae or consequences. Given the continually increasing presence of Asians in the US, it must be considered imperative to educate health care providers of discrimination risks and impacts within the South Asian population. Given the dearth of resources on the mental health impacts of microaggressions specific to South Asians, the presenters will review and extrapolate existing literature regarding the health and mental health effects of microaggressions among minority communities broadly. The prevalence of microaggressions and prejudice among Asians and South Asians may be a social determinant of mental health, as seen in other minority populations. The goal is to increase awareness among mental health providers to help incorporate the effects of microaggressions in assessments and treatment planning for this population, similar to their approach for other vulnerable groups. We will walk through the process of evaluation and assessment of microaggressions against South Asians and explore areas of future research and “clinical assessment.” As a conclusion to the presentation, we would like to facilitate a discussion on solutions. Some talking points for this session will include the idea of leveraging the strengths and resilience of the South Asian family and community, starting from a smaller scale within the family unit and then extending to a larger scale outside the family unit to include cultural community centers, religious organizations, and other community groups. This discussion will also focus on strategies to counter microaggressions for recipients, as well as allies, on an individual and community level.

"Publish or Perish" has long been the lament of academicians through the centuries. Within academic medicine and graduate medical education, "academic productivity" and "scholarly work" have become the often repeated buzz words in the assessment of the quality of a training program and academic departments. Often, the primary currency of a faculty or resident''s academic productivity is measured in the quality and number of publications. Over the past 15-20 years, there has been a significant increase in the overall number of scientific journals, including predatory journals. Distinguishing between predatory and legitimate journals has grown increasing difficult. On a very basic level, publishing in predatory journals can harm authors with exhorbitant publishing fees, damage to reputaiton of academic credibility, and potential loss of intellectual property. This workshop will provide an overview of the development and current state of predatory publishing and its effect on academic productivity. The presenters will also review several resources that can assist an author in confirming the legitimacy of a publication. Through the use of polling, case discussions and didactics, the workshop will provide participants with the training to be able to identify predatory publishing practices. In addition, participants will learn of several key steps in how to avoid falling prey to predatory journals. Participants are encouraged to bring forward examples or experiences that they may have had with predatory publishing practices.

While effective mentorship is critical for the professional development and success of trainees in medicine, URiM trainees often lack adequate opportunities for mentorship relationships. This can arise from bias, systemic discrimination, lack of support, and is exacerbated by a lack of URiM faculty role models. Further, establishing such programs is challenging when there is a dearth of mentors from backgrounds similar to those of mentees, often leading mentees to feel uncomfortable in their mentoring relationships and highlighting the need for developing cross-cultural mentoring programs. Working to mitigate these barriers and promoting comprehensive mentorship programs is a strategy widely proposed to help overcome the barriers faced by URiM trainees. Through this workshop, we hope to identify barriers in establishing effective mentorship programs for URiM trainees, discuss its overarching consequences (e.g., imposter syndrome, feelings of social isolation, limited opportunities for workforce diversity, among others), and present strategies to provide mentorship for URiM trainee success. We will present a mentorship model which highlights the importance of: connecting URiM trainees to research and clinical mentors with shared interests, encouraging involvement in scholarly projects, liaising with leadership to provide positive feedback, and serving as a resource for trainees. Next, provided the relatively lower numbers of URiM faculty members, we will shift to a discussion on cross-cultural mentoring and faculty development, focusing on strategies for non-URiM faculty to mentor trainees culturally different from them. Mentorship relationships between non-URiM faculty members and URiM trainees must openly address social injustices, institutional racism, stereotypes, and bias with intent to acknowledge structural inequities that lead to differential educational opportunities. In addition to circumventing the shortage of URiM mentors, cross-cultural mentorship promotes diversity by creating groups that are more culturally aware, innovative, and have improved outcomes. In part two, the audience will be engaged and participants divided into small groups, composed of trainees and faculty members. They will be provided cases consisting of mentorship scenarios and recommended discussion questions to promote dialogue on barriers faced by URiM trainees, impact it can have on their professional development, and strategies to effectively mentor them. Hereafter, we will engage group members in role-plays, with simulated opportunities to practice building a mentorship relationship between a non-URiM faculty member and a URiM trainee, followed by opportunities for feedback from group members. We will conclude by reconvening participants; we plan to elicit experiences for an active discussion on URiM trainee mentorship and robust strategies to promote equity, diversity, and inclusion within training programs.

The Committee on Judicial Action reviews on-going court cases of importance to psychiatrists and our patients, and it makes recommendations regarding APA participation as amicus curiae (friend of the court). This workshop offers APA members the opportunity to hear about several major issues that the Committee has discussed over the past year and to provide their input concerning APA's role in these cases. Three cases will be summarized and the issues they raise will be addressed: 1) Corbitt v. Taylor involves the right of transgender individuals to obtain drivers licenses consistent with their gender identity; 2) Wit v. United Behavioral Health involves coverage of treatment for mental health and substance use disorders by employer-sponsored insurance plans; 3) Planned Parenthood v. Philip and Sistersong v. Kemp involve access to abortion and government interference in medical decisions. Since new cases are likely to arise before the annual meeting, the Committee may substitute a current issue on its agenda for one of these cases. Feedback from the participants in the workshop will be encouraged.

In this era of evidence-based psychiatric practice, it is important to recognize that there are evidence bases, too often overlooked, that provide guidance not about what to prescribe to optimize pharmacotherapy outcomes, but, rather, about how to prescribe. Indeed, for some of the most common conditions, the evidence suggests that psychosocial factors exert a larger influence on treatment outcome than do the actual medications. Mastery of these psychosocial factors in prescribing constitutes an important part of the art of psychopharmacology. In this session, some of that evidence base will be explored, addressing the science of the art of psychopharmacology. The importance of the doctor-patient relationship will be highlighted, as well as the importance of a patient-centered evaluation that considers who the patient is, and not just what the patient is. The presenters will show how a deeper understanding of the patient may help guide prescribing decisions in ways that facilitate the patient’s healthy use of treatment. The presentation will also explore some common errors in prescribing that, though sensible from the perspective of the standard of care, may undermine effective treatment.

Patient aggression is one of the most complex and dangerous occupational hazards in the healthcare environment. Aggression toward healthcare providers is especially pronounced, as The World Health Organization (WHO) reports that nearly a quarter of workplace violence occurs in healthcare settings, and health professionals are 16 times more likely to be attacked than workers in other industries. While aggression in patients with psychiatric diagnosis is a well-known phenomenon with an estimated presence in 20 per cent of psychiatric admissions, it is important to recognize that this behavior is not limited to acute psychiatric settings, and also occurs with high prevalence in the general hospital setting. A recent study of US hospitals reports an overall 12-month prevalence rate of 39% for aggressive and violent behavior against hospital workers, with mental health and behavioral issues as contributing factors in about 2/3rd of cases. In this context, it is critical to frame patient aggression as a behavioral emergency associated with a high risk of injury for both patients and healthcare professionals. Patient agitation and aggression can lead to physical and psychological suffering, not only for the patient, but also for staff who witness these incidents. In addition, patients with aggressive behavior are subjected to more restrictive interventions, have increased cost of care and higher resource utilization. Clearly, the current practice of assessing aggression in the healthcare setting is imperative to the health and safety of patients and staff. The Broset Violence Checklist (BVC) has been found to be highly reliable and easily implementable in predicting aggression and violence in patients with agitation. However, violence risk assessment tools have limited prognostic value as they are rule-based engines with the golden time (time between initiation of aggression and intervention) close to zero. In effect, these scales identify aggression too late to have the most meaningful effect and a predictive tool with more “lead time” would be a novel approach leading to an initial treatment plan specifically targeting aggression at, or close to the time of the patient’s admission. Natural language processing (NLP) is a subfield of linguistics, computer science, and artificial intelligence that processes and analyzes large amounts of natural language data to "understand" the contents of documents. The technology can then accurately extract information and insights contained in the documents as well as categorize and organize the documents themselves. Using NLP, we processed our manually completed BVC screening and clinical notes accompanying that to create an algorithm using both structured and unstructured data to predict patient aggression. We have tested this algorithm to ensure sensitivity and specificity of the predictions and the potential to increase early intervention to aggression.

Publishing is a fundamental part of (psychiatric) research, but conducting good research is not enough to get published. Indeed, the publication process is a discipline of its own, which is unfortunately not taught in medical schools nor in postgraduate clinical/research training. Further, the challenges and opportunities of publication extend beyond research to other types of scholarly writing. Therefore, the aim of this session is to provide the participants with some of the tricks of the publication trade. The three speakers have experience both as publishing researchers and as editors for internationally renowned journals in the field of psychiatry. During the session, the speakers will engage with the audience and address some of the common challenges encountered during the peer review and publication process. First, Dr. Anthony J. Rothschild (Editor-in-Chief of Journal of Clinical Psychopharmacology) will touch upon a sensitive and critical topic, namely the order of authors on a manuscript. Furthermore, he will give advice on how to choose a target journal. Second, Dr. Lisa Dixon (Editor-in-Chief of Psychiatric Services) will discuss the differences between various submission types and how to choose the right one for a given manuscript. Third, Dr. Søren Dinesen Østergaard (Deputy Editor of Acta Psychiatrica Scandinavica) will share his experience on how to respond to the comments raised by peer reviewers. Also, he will provide examples of the rare situations in which appealing a rejection may be considered. Finally, 25 minutes is allocated for a Q&A during which the speakers will take questions and discuss with the audience. The aim is to have a very interactive session.

Effective leadership is vital to quality healthcare, and leadership positions in residency or fellowship are often the first stage of one’s professional development as a leader. Trainees, however, receive little preparation for these roles within their programs. Trainee-leaders often serve in important roles within their program’s administration and function as chiefs, class representatives, task force chairs, et cetera. They promote resident cohesion, liaise between faculty and residents, and hold key administrative, management, and mentoring duties. Resident leaders must negotiate between being in the position of a trainee and of an administrator who serves both the interests of the program and that of their peers. Resident leaders, therefore, face a unique set of dilemmas. They must balance advocating for their peers with managing professionalism, gain an understanding of the institution’s needs and how to best serve them even when it might conflict with that of residents, find solutions between groups with conflicting agendas while holding no formal authority, and be attentive to how their decisions affect their peers, such as in scheduling. These challenges are amplified when trainee leaders are from under-represented backgrounds, and face additional layers of microaggression, biases and different cultural practices. In addition, trainees within an institution are often more diverse than the faculty and have different viewpoints and concerns than faculty, and trainee-leaders are tasked with the challenge of bridging this gap and serving both sides. This session presents tools and techniques to mitigate these dilemmas and is tailored to the needs of resident leaders, particularly those from under-represented backgrounds. As a group of first-generation, minority, female, or international medical graduate APA/APAF Leadership Fellows, we will share common conflicts and challenges for trainees in leadership positions and the most useful strategies we have found to tackle these challenges. Participants will identify common challenges for trainee leaders and highlight special challenges faced by those under-represented in medicine. Participants will learn applicable leadership skills, such as conflict management, negotiation, team management, and how to use them as trainee leaders. Participants will be provided with real-life cases from the Leadership Fellows highlighting challenges and work in small groups to identify the challenges and leadership strategies to solve them. Participants will then discuss how to apply these strategies and practice them in small groups. As a large group, participants will share and reconcile reflections from each small group to incorporate into their leadership development. By the end of the session, participants will have learned strategies that they can use to teach colleagues on how to increase their efficacy as resident leaders through skills such as conflict management, negotiation, and team management.

When our patients sit down in front of us, they bring a story associated with each ache and pain. Sometimes these injuries are visible--we see the calluses and swollen joints from years of manual labor, and sometimes they are not. There is little question that every aspect of a person’s life plays a role in their health. This could be the genetics they were born with, their position in society, the religion they practice, or the defense mechanisms they use to deal with stress. As psychiatrists, we are keenly aware of how these factors affect someone’s psychological wellbeing. Medical comorbidities, like chronic pain, are one such factor that play a significant role in someone’s mental health. The presenters will focus specifically on the intersection of chronic pain and mental health. Research shows patients suffering from chronic pain are more likely to experience depression and anxiety compared to the general population and have an increased risk of suicide. Many of the same neurotransmitters in the brain related to psychiatric pathology share the same pathways as pain. Why do some patients with an injury fall into the path of pain chronification and others recover without any residual deficits? One way to answer this question, and conceptualize the vast and competing aspects of a person’s life, is to use the biopsychosocialcultural formulation. This allows one to consider all the important factors of a patient’s journey. The presenters will demonstrate how to use this formulation and engage the audience by applying it to a patient case. Not only does this approach allow a provider to understand a patient’s whole being, but it demonstrates the need for a multidisciplinary approach. The presenters will conclude by highlighting the need to combine pharmacological and non-pharmacological treatment modalities, to address the many needs and concerns these patients have. Psychiatrists are gifted with knowing some of the most intimate parts of a patient’s life. By using this information, we can attempt to treat and support the many visible and invisible wounds our patients have.

The care of women in life stages related to childbirth (pregnancy, postpartum, lactation) poses unique challenges and risks for psychiatrists. The adverse effects of untreated maternal mental disorders such as perinatal depression on fetal and infant development are significant such as low birth weight and pre-eclampsia. Fetal and/or infant exposure to psychotropic medications is a major concern for psychiatrists and patients due to the possibility of major congenital malformations or other long-term developmental problems in children. The use of neuromodulation therapies in this patient population is also growing and offers some advantages such as possible lessened need for psychotropic exposure, but with unknown long-term risks. Obtaining timely, relevant, and evidence-based information in a rapid and easily understandable format is critical for both psychiatrists and patients. Developing strategies for ensuring safe and quality care as well as mitigating any practice risks is key. The presenters are psychiatrists with decades of experience in the practice of women’s mental health and neuromodulation (electroconvulsive therapy and transcranial magnetic stimulation) and experts in risk management who will review foundational knowledge and relevant cases from their practice to illustrate quality and safe women’s mental health care. Participants will discuss relevant cases with colleagues and debate best practices. Sound risk management strategies including the ABCDEs and the 3 Cs will be reviewed. Helpful resources including online and literature references for the practicing psychiatrist and residents/fellows will be provided and demonstrated.

The current practice of medicine in the US is facing a major paradigm shift wherein precision medicine is increasingly being used to improve treatment efficacy, medication selection and response, and patient outcomes. This paradigm shift emphasizes the need for objective measures of psychopathology, which can be informed by advances in machine learning, neurobiology, genetics, neuropsychology, imaging and pharmacology. As such, a comprehensive approach needs to be envisioned for future DSM. For example, advances in neurobiology, genetics, neuropsychology, imaging and pharmacology indicate that mental disorder are better understood as dimensional rather than categorical construct, which is the diagnostic approach of DSM-5. In contrast, RDoC, a theoretical framework for classifying mental disorders aims to capture this dimensionality of mental and substance use disorders but requires validation to understand the relationship between the hypothetical dimensional domains identified and psychopathology. The harmonization of these two systems may help to move the field forward by identifying objective measures of psychopathology thus improving the diagnosis of mental and substance use disorders. Another important area to emphasize in future DSM would be to understand the influence of the social determinants of health (e.g., patient’s living situation, exposure to advantages and disadvantages in life course, education level, race, etc.) on mental health, especially in the marginalized populations, and their implications for diagnosis and treatment. How race, ethnicity and nationality are handled in the DSM is also an important factor. As done in DSM-5-TR, future DSMs need to implement strategies to avoid biases in how symptom presentations across ethno-racial groups are interpreted given the potential for this to lead to misdiagnosis for certain conditions. Additionally, to bring a more personalized care, assessments of functioning using a valid and reliable tool at the time of diagnosis and over the course of treatment is important since impairment in functioning is a key factor that causes patient experiencing mental health symptoms to seek care. Understanding the patient’s level of functioning could provide valuable insights about their integration in the society and their coping mechanisms while serving as proxy measure for assessing the progress of care. In this session, we ask the field to come be part of the solution in addressing these issues. Experts in the field will give brief updates on the importance of each of these issues. Next, breakout groups will work with an expert to take a deep dive into each topic to identify education, training, and clinical implications and potential strategies that could be leveraged to improve future DSM.

Behavioral and Psychological Symptoms of Dementia (BPSD) refers to a group of non-cognitive symptoms and behaviors that occur commonly in patients with dementia. They result from a complex interplay between various biological, psychological and social factors involved in the disease process. BPSD is associated with increased caregiver burden, institutionalization, a more rapid decline in cognition and function and overall poorer quality of life. It also adds to the direct and indirect costs of caring for patients with dementia. Available data indicate efficacy for some non-pharmacological and pharmacological treatment modalities for BPSD. However, the use of psychotropic medications for the treatment of BPSD has generated controversy due to increased recognition of their serious adverse effects. In this symposium, we will first describe the discuss the epidemiology and neurobiology of individuals with BPSD. Then we will describe the assessment of individuals with BPSD. This will be followed by an elaboration on the evidence-based management of individuals with BPSD. Finally, we will conclude with a review on the controversies in the management of individuals with BPSD. Behavioral and Psychological Symptoms of Dementia (BPSD) refers to a group of non-cognitive symptoms and behaviors that occur commonly in patients with dementia. They result from a complex interplay between various biological, psychological and social factors involved in the disease process. BPSD is associated with increased caregiver burden, institutionalization, a more rapid decline in cognition and function and overall poorer quality of life. It also adds to the direct and indirect costs of caring for patients with dementia. Available data indicate efficacy for some non-pharmacological and pharmacological treatment modalities for BPSD. However, the use of psychotropic medications for the treatment of BPSD has generated controversy due to increased recognition of their serious adverse effects. In this symposium, we will first describe the discuss the epidemiology and neurobiology of individuals with BPSD. Then we will describe the assessment of individuals with BPSD. This will be followed by an elaboration on the evidence-based management of individuals with BPSD. Finally, we will conclude with a review on the controversies in the management of individuals with BPSD.

On September 30, 2021, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced the launch of its Office of Recovery. This office has been established to advance the agency’s commitment to, and support of, recovery for all Americans. SAMHSA has a long history of advancing Recovery Support dating back to the 1980s with the Community Support Program and the 1990s, when the first Recovery Community Support Programs were funded. Mental health recovery support began in 1977 with the initiation of the Community Support Program. Launched by NIMH, this initiative supported community living for people with serious mental illness including holistic, consumer-centered care that incorporated self-help approaches. Beginning in the 1980’s, NIMH and then SAMHSA began funding consumer-operated service programs and requiring consumer involvement in the planning, delivery and evaluation of services. SAMHSA defines recovery as a process of change through which individuals improve their health and wellness, live self-directed lives and strive to reach their full potential. There are four major dimensions that support recovery: Health; Home; Purpose; and community. Cutting through these dimensions are the social determinants of health. The Social determinants of health (SDoH), defined as “the conditions in which people are born, grow, live, work and age, and which are shaped by the distribution of money, power and resources”, have a considerable influence on the health of the US population, and are thought to be the primary driver of health inequities. Many people in recovery have faced difficult SDoH, including Adverse Childhood Experiences (ACEs). Indeed, recent research demonstrates that there is a direct correlation between ACEs and the initiation of SUDs later in life. Other contributing factors include low educational attainment, which is associated with substance misuse later in life, as well as a host of other medical and socio-economic difficulties. SAMHSA has established recovery support systems to promote partnering with people in recovery from mental and substance use disorders. This presentation will expand upon this and also the role of the Office of Recovery.

International Medical graduates(IMGs) make up around a quarter of licensed physicians in the country. Up to a third of all psychiatrists in the USA and more than a quarter of psychiatry trainees are IMGs. The vast majority of IMGs is composed of non-US IMGs, with most coming from the global south. Many of the non-US IMGs also fall into the category of double minorities given their immigrant status in addition to racial/ethnic background, gender and sexual orientation. Immigration, in of itself, has been the topic of much debate in the psychiatric/psychoanalytic literature. However, little data exists on the immigration and acculturation of non-US physicians within the medical workforce generally or the psychiatric workforce particularly. At the start of training, non-US IMGs face a dual learning curve, both as immigrants and trainees. Often there is limited support and understanding of their struggles. Non-US IMGs have been shown to face bias and discrimination by patients, peers and supervisors. They are held to a different, tougher standard and come to accept limitations to career advancement as part of the package. During the session, we will summarize the existing literature on the stress faced by international graduates and the struggles of being an IMG of minority background. We will invite the attendees to reflect on case vignettes for challenges faced by such physicians. During the session, we will review the issues faced by specific groups: racial/ethnic minorities, women and those who belong to the LGBTQ community. The session will then highlight the various issues raised by intersectionality, with a focus on barriers to professional success and progression. We will also present models that assist in addressing these concerns. For example, for trainees at the beginning of training, the transition can be made easier by providing specialized orientation to both the medical and geographical culture while also providing logistical support as they settle into a new country. Efforts at cultural awareness should also extend to IMGs and institutional policies should be routinely reviewed to ensure a level playing field. Ally training, implicit bias training and anti- racism/sexism training may be helpful in fostering a better learning and academic environment. Peer as well as intergenerational mentoring can be a very vital tool to assist non-US IMGs career progression during training and beyond. As the numbers of IMGs matching in psychiatry declines, meeting their specific needs in academic psychiatry is vital. We hope to have a discussion that aims at identifying ways of assisting IMG in navigating American academia and reaching full career potential. Inviting institutions to optimize the environment for IMG.

CDC estimates indicate that 1 in 54 children in the U.S. is diagnosed as being on the autism spectrum. While most on that spectrum suffer from intellectual disability or borderline cognitive abilities, 44% on this spectrum have average or above average IQ. Those with relatively high IQ face many unique challenges in their schooling, social interactions, and employment. Moreover, about 3/4 of clinically-referred persons with Autism Spectrum Disorder (ASD) also suffer from significant ADHD-related impairments. Objective of this general session is to provide clinicians with information and strategies to improve clinical understanding, treatment, and support for patients with ADHD/ASD and their families. Methods will include lectures including relevant research data, a variety of case examples and outcomes from various interventions utilized with high IQ patients with ADHD/ASD and their families. Numerous successes and some failures will be reported. Presentations will cover: 1. Review of similarities and differences between ADHD and ASD, review of recent research on genetic heritability as well as quantitative and qualitative similarities and differences. 2. Adaptations of evaluation and treatment approaches for higher IQ children, adolescents and adults with both ADHD and ASD. Case examples will be used to highlight strengths and difficulties of those with high IQ as well as adaptations to help assessment and to sustain effective treatment for executive function impairments related to ADHD. 3. Selection and "fine-tuning" of medications for those with relatively high IQ, ADHD and ASD. Emphasis will be on "sensitive body chemistry" found in many with combined ADHD and ASD and on common comorbidities. Examples of dosing strategies and adaptations for medication will be provided. 4. Strategies for psychosocial support of high IQ children and adolescents with ADHD and their families. The PEERS program developed at UCLA for social skills training of teens and young adults will be described as well as case vignettes for addressing family dynamics and parent-child and sibling conflicts in daily life.

Bipolar Depression is a largely understudied area. Patients are frequently misdiagnosed as Major Depression Disorder, which leads to utilization of inappropriate treatments including antidepressant monotherapy. Recent studies have shown that Patients with bipolar disorder experienced longer periods in the depressed than in manic phase. Furthermore, episodes of depression are the most frequent cause of disability among patients with bipolar disorder. Polarity of the first episode has predictive value on long-term course of the condition, including the predominance of future episodes. Polarity of patients’ first reported mood episode suggests that depression-prone subtypes have a greater probability of suicidal acts. Patients with bipolar disorder who experienced a first episode of depression have a long-term predominant presentation of depressive episodes and subsyndromal depressive symptoms. Bipolar depression when accompanied by mixed features has higher risk of suicidal behavior and presence of comorbidity substance use disorder. Treatment resistant bipolar depression is highly prevalent. New pharmacological and Neuromodulation (e.g. ECT, TMS) treatments have improved the outcome of acute bipolar depression and the prevention of relapse to depression. Result from recent pharmacological treatments including Lurasidone, Cariprazine Lumateperone, and Ketamine; as well at those utilizing Neuromodulation approaches. Finally, the use of antidepressants in bipolar depression remains controversial, especially as monotherapy, however in combination with mood stabilizers or atypical antipsychotics they appear to be a treatment option. Risk factors for antidepressants causing emerging symptoms of mania have been identified.

Human sleep has redundant neurologic processes to ensure sleep/wake stability and satisfy sleep homeostasis. Inadequate sleep quantity, quality and continuity interfere with sleep homeostasis resulting in impairment of wake state to include symptoms of excessive sleepiness, fatigue, mood changes, cognitive impairment, impaired coping skills and altered pain threshold. Recognition of psychiatric disorders’ effect on sleep as well as prescription therapeutic intervention and the interaction of sleep disorders on psychiatric disease manifestations and therapeutic response are important considerations in the management of psychiatric disorders. We will discuss a practical approach for how to incorporate sleep medicine in psychiatric practice including a review of the evidence behind sleep interventions, when to refer to an outside specialist, and when/how to wrap up targeted sleep intervention.

After a decades-long pause, psychedelics are being tested as potential treatments for mood and substance use disorders. We will provide a brief review of the major findings from clinical psilocybin trials from the past two decades at Johns Hopkins and elsewhere. Taken together, recent and on-going clinical trials provide promising results. Such findings, however, must still be considered preliminary. Enthusiasm regarding the prospect of psychedelic treatments has, in many cases, gone beyond the available evidence. In this session, we will describe the recent past and present of psychedelic research and then then identify several pressing issues in the field: 1) clinical challenges, 2) research challenges, and 3) challenges in public science communication. Clinically, we will describe the safety guidelines and procedures currently in place for psilocybin studies conducted at Johns Hopkins. We will comment on various proposals for altering aspects of these procedures to expand access to psilocybin treatments. Additionally, an eclectic mix of psychotherapeutic approaches are currently being paired with psilocybin treatments in research contexts. We offer some comments in support of concepts from evidence-based therapies such as Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Dialectical Behavior Therapy (DBT), which have been historically less common in psilocybin research contexts. Research methods in psilocybin trials have been steadily improving, but challenges remain. Psychedelic studies are difficult to adequately control, due to issues with blinding. Extra-pharmacological factors such as expectations play a heightened role in psychedelic trials. Additionally, valid concerns about safety have resulted in strict exclusion criteria for previous and on-going psychedelic trials, but more heterogeneous samples must be included in future trials to improve generalizability. We provide several examples of recent improvements in the rigor of clinical trials on psilocybin and suggest ways forward. Public science communication about psychedelics has historically tended to be either overly alarmist or overly enthusiastic. We advocate for acknowledging the limitations of the available evidence as well as the inevitable risks and contraindications in clinical contexts. We believe it is incumbent upon researchers and clinicians to provide scientifically grounded and clinically sensible public messaging about psychedelic treatments, so as to temper a growing trend towards unrealistic expectations. We conclude by underscoring the myriad ways in which psilocybin research and clinical practice can be mis-managed in the coming years––while voicing a cautious optimism about the near-future of psilocybin research and potential treatments in psychiatry.

Alcohol use disorder (AUD) is chronically relapsing disorder that is characterized by a compulsion to seek and take alcohol, loss of control in limiting intake, and emergence of a negative emotional state (e.g., hypohedonia, dysphoria, anxiety, hyperalgesia, irritability, and sleep disturbances, defined as “hyperkatifeia”) when access to the drug is prevented. AUD can be framed as a three-stage cycle—binge/intoxication, withdrawal/ negative affect, and preoccupation/anticipation that has heuristic value for translating the brain changes associated with AUD to the clinical domain. Here, dysregulation occurs in three functional domains that reflect the three stages of the addiction cycle: incentive salience/pathological habits in the binge/intoxication stage, negative emotional states in the withdrawal/negative affect stage, and executive function deficits in the preoccupation/anticipation stage. These three domains and stages are hypothesized to be mediated by three major neurocircuitry elements: basal ganglia, extended amygdala, and prefrontal cortex, respectively, and an individual can enter the addiction cycle at any of these three stages. Among such multiple sources of motivational dysregulation, one, gaining significant traction, is negative reinforcement driven by the emotional pain of alcohol withdrawal and protracted abstinence. Negative reinforcement is defined as alcohol taking that alleviates the negative emotional state or hyperkatifeia that is created by drug abstinence. Compelling evidence exists to argue that hyperkatifeia triggered by acute excessive alcohol intake, is sensitized during the development of compulsive alcohol taking with repeated withdrawal, persists into protracted abstinence, and contributes to the development and persistence of compulsive alcohol seeking. Hyperkatifeia that drives negative reinforcement is hypothesized to derive from loss of function of key neurochemical circuits within the brain reward systems (dopamine and opioid peptide) in the basal ganglia and gain of function of the brain stress systems (corticotropin-releasing factor, dynorphin, norepinephrine, hypocretin, vasopressin, glucocorticoids and neuroimmune factors) in the extended amygdala. Significant overlap in the engagement in AUD of neural circuits mediating emotional pain and physical pain may provide insight into the development of medications and other treatments to reverse the allostatic changes to reward and stress circuits that drive and perpetuate AUD. Breaking this cycle is possible through the use of FDA-approved medications and other promising therapeutic agents. These interventions have distinct advantages for certain patient groups. Moreover, treatment of comorbid psychiatric disorders, often pre-existing or worsened by this addiction cycle, may be amenable to targeted pharmacologic strategies. A case presentation will elucidate potential treatment strategies for individuals with AUD and co-occurring psychiatric disorders.

Anxiety disorders are common, can be disabling and frequently begin during childhood. The work presented here is an overview of our in studies in nonhuman primates and children aimed at characterizing the early-life factors that predispose to the development of anxiety disorders and other stress-related psychopathology. This translational neuroscience approach enables cross species studies that have the potential to uncover the influences of heritable and nonheritable factors on the circuits and molecules that mediate maladaptive childhood anxiety. In this regard, we have been studying anxiety from a dimensional perspective in preadolescent children and young rhesus monkeys; ranging from anxious temperament (AT), a trait like phenotype characterized by high levels of persistent subthreshold anxiety to anxiety disorders. Anxious temperament is of particular interest as it is an early life disposition that markedly increases the later in life risk to develop stress related psychopathology such as anxiety and depressive disorders. Data from our work and that of others implicates alterations in prefrontal-limbic circuitry as being critical in underlying the dysregulated fear and anxiety responses that are typically associated with anxiety disorders. Using viral vector methods to overexpress specific genes and lesioning and chemogenetic methods to alter circuit function, we demonstrated a causal role for the dorsal amygdala and a regulatory role for the posterior orbitofrontal cortex in mediating pathological anxiety. Based on this work, we are performing proof of concept studies in NHPs with the goal of establishing new circuit based, molecular targets for treating human anxiety disorders. Ultimately, a better understanding of the factors related to the childhood onset of pathological anxiety has the potential to facilitate the development of more effective, and life course changing, interventions in individuals at risk to develop anxiety disorders and other stress-related psychopathology.

Methamphetamine use is a growing public health concern in the U.S., producing increasingly severe consequences including use disorder and overdose deaths (Twillman et al., 2020). Fewer than 32% of at least 1.6 million individuals who need treatment each year for methamphetamine use disorder receive any treatment (Jones et al., 2020), and a significant proportion have co-occurring psychiatric disorders or symptoms (Glasner-Edwards et al., 2009). The intersection of methamphetamine use with the U.S. opioid epidemic presents a specter for clinicians and policymakers struggling to address the growing consequences of these mutually deleterious conditions; inadvertent or intentional co-use of methamphetamine with opioids including fentanyl (and its analogues) yields potentially dangerous consequences (Ciccarone 2021; Jones et al., 2020). Comprehensive approaches are needed to reduce harms associated with methamphetamine use, including among individuals with OUD (Tsui et al., 2020), but significant barriers to treatment remain and are impacted by health disparities. Reduced healthcare services and other limitations resulting from the COVID-19 pandemic have exacerbated the difficulty of treating individuals with methamphetamine use disorder and other comorbidities. This symposium will first present the epidemiology and scope of the methamphetamine problem in the U.S. and its increasing prevalence among persons who use opioids, with additional impacts on the opioid crisis. It will then discuss evidence-based treatment approaches for methamphetamine use disorder, including behavioral and pharmacological treatment interventions. It will review social determinants of health (SDoH) that impact SUD treatment access and overdose deaths. Specifically, (1) Dr. Larissa Mooney will provide an introduction and overview of methamphetamine use in the context of the U.S. opioid epidemic and the COVID pandemic, medical and psychiatric consequences of co-use of methamphetamine and opioids, and provision of integrated treatment for both disorders. (2