Opioid use disorder during pregnancy

Shannon C. Miller, MD, FASAM, FAPA, Medical Director, Integrated Dual Diagnosis and Outpatient Addiction Psychiatry/Medicine, Program Director, VA Advanced Fellowship in Addiction Medicine/Research, Veterans Affairs Medical Center, Cincinnati, Associate Professor of Clinical Psychiatry, Associate Director of Education, Training, and Dissemination, Center for Treatment, Research, and Education in Addictive Disorders (CeTREAD),Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Lisa Fernandez, MD, Addiction Psychiatry Fellow, University Hospital/University of Cincinnati, CeTREAD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Roberto Soria, MD, Medical Director, Opiate Addiction Recovery Services, Assistant Professor of Clinical Psychiatry, Co-Director, Clinical Services, CeTREAD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Early identification of opioid use disorder (OUD) in pregnant women can be challenging. Self-reports underestimate use and shame, fear of prosecution or involvement of child welfare services, and guilt can further erode self-report. Women with OUD may have irregular menses and might not be aware of their pregnancy until several months after conception. Also, women with OUD who are maintained on opioid agonist therapies may misinterpret early signs of pregnancy—such as fatigue, nausea, vomiting, headaches, and cramps—as withdrawal symptoms and may respond by increasing their opioid dosing, thus exposing their fetus to increased drug levels. Finally, many women with OUD experience amenorrhea as a result of their stressful, unhealthy lifestyle, which may preclude pregnancy despite sexual activity. When these women later enroll in an opioid maintenance program, their endocrine function may return to normal, leading to unexpected pregnancy.

Screening for OUD in pregnant patients has not been well studied. An interviewer’s nonjudgmental, empathic attitude may be more important than the specific questions he or she asks. It may be best to begin with less threatening questions and proceed to more specific questions after developing a therapeutic alliance.

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How anxiety presents differently in older adults

Nazem Bassil, MD, Assistant Professor of Medicine/Geriatrics, Faculty of Medicine, Balamand University, St. George Hospital Medical Center, Beirut, Lebanon

Abdalraouf Ghandour, MD, Fellow, Division of Geriatric Medicine, University of Missouri, Columbia Columbia, MO

George T. Grossberg, MD, Samuel W. Fordyce Professor, Director of Geriatric Psychiatry, Department of Neurology and Psychiatry, St. Louis University School of Medicine, St. Louis, MO

Although anxiety disorders are common at all ages, there is a misconception that their prevalence drastically declines with age. For this reason anxiety disorders often are underdiagnosed and undertreated in geriatric patients, especially when the clinical presentation of these disorders in older patients differs from that seen in younger adults.

In older persons, anxiety symptoms often overlap with medical conditions such as hyperthyroidism and geriatric patients tend to express anxiety symptoms as medical or somatic problems such as pain rather than as psychological distress. As a result, older adults often seek treatment for depressive or anxiety symptoms from their primary care physician instead of a psychiatrist. Unfortunately, primary care physicians often miss psychiatric illness, including anxiety disorders, in geriatric patients.

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Adapting dialectical behavior therapy to help suicidal adolescents

Nicholas L. Salsman, PhD , Assistant Professor, Department of Psychology, Xavier University, Cincinnati, OH

Robin Arthur, PsyD, Chief of Psychology, Lindner Center of HOPE, Assistant Professor, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Treating suicidal adolescents is fraught with challenges. Antidepressants may be associated with increased suicidal ideation in adolescents, although some data suggest that increased adolescent suicide rates are correlated with decreases in antidepressant prescribing. Adolescents hospitalized after a suicide attempt are likely to attempt suicide again after they are discharged. Such patients might not attend outpatient psychotherapy; a study of 167 adolescents discharged after a suicide attempt found that 26% never attended follow-up appointments and 11% went once.

Emerging research supports the effectiveness of dialectical behavior therapy (DBT) for suicidal adolescents. DBT is a form of cognitive-behavioral therapy that combines individual therapy, skills training, and telephone coaching and is implemented by a therapist consultation team that meets weekly. This article reviews evidence supporting the efficacy of DBT for suicidal adolescents and describes principles of outpatient DBT for these patients as developed by Miller et al.

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Folie en masse! It’s so tempting to drink the Kool-Aid

Henry A. Nasrallah, MD

Editor-in-Chief

Psychiatrists occasionally encounter a case of folie à deux, where 2 persons share the same false belief. Paradoxically, it is more common for a large number of people to share a false belief (folie en masse) and uphold it as fact because the idea appears enticingly valid as an “explanation” for a problem or event.

“Conspiracy theories” abound in our society and yet conspiracy theory advocates would express shock and disdain at the infamous event when 918 followers of Jim Jones drank cyanide-laced Kool-Aid because they believed their leader’s irrational ideas. Apart from recognizable cults—some of whom claim to have their own “solutions” for mental illness—many ordinary people uphold beliefs that are not supported by evidence but widely “accepted” as true:

Persons with psychosis are dangerous. This incorrect belief was prevalent before the tragic events at Virginia Tech and Tucson, AZ (remember the “Son of Sam” in New York?) and was reinforced by them. Clinicians know that, similar to the general population, only a small proportion of persons suffering from a psychotic illness exhibit violent behavior. In fact, their illness renders them more likely to be victims than perpetrators of crime.

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