FDA's Expert Panel on Selective Serotonin Reuptake Inhibitors (SSRIs) and Pregnancy: Who Were the Key Players

The panelists at the start of the FDA's Expert Panel on Selective Serotonin Reuptake Inhibitors (SSRIs) and Pregnancy held on July 22, 2025.

The FDA had a panel discussion on the use of SSRI inhibitors in pregnancy the morning of July 22, 205 which was broadcasted via the FDA’s YouTube channel. Listed below were the selected members for this panel. It included 5 women and 8 men, 3 of which were from outside of the United States. Of the panelists 5 were psychiatrists, only 3 of them currently practicing, and only one was trained in perinatal medicine.

• Tracy Beth Hoeg, MD, PhD—PM&R, Panel Moderator, senior advisor at FDA

• Marty Makary, MD, PhD—FDA Commissioner, surgery, surgery oncology

• Anick Berard, PhD—Perinatal epidemiologist from University of Montreal, Canada

• Dorothy Fink, MD—Panel Moderator, Deputy Assistant Secretary for Women's Health, specializing in endocrinology (IM/Peds)

• Adam Urato, MD—Chief of Maternal Fetal Medicine at Metro West Medical Center, OBGYN

• Jay Gingrich, MD, PhD—Psychiatrist and Columbia researcher who focuses on schizophrenia, depression and anxiety

• David Healy, MD—psychiatrist/psychopharmacologist from Wales Department of Psychological Medicine

• Jeffrey Lacasse, PhD, MSW—social worker from Florida State University

• Roger McFillin, PsyD—psychologist Executive Director for Center for Integrated Behavioral Health

• Josef Witt-Doerring, MD—psychiatrist and previous medical director of the FDA, co-founder of the Taper Clinic in Palm Desert, CA

• Joanna Moncrieff, MD—London psychiatrist, professor

• Michael Levin, PhD—Biologist from Tufts, Director of the Allen Discovery Center

• Kay Roussos-Ross, MD—University of Florida Health, triple boarded on/gyn, psychiatrist, addiction medicine

Prior to the discussion, panelists were told to “speak from the heart.” Below you can click to be taken to the discussion. The panelists took turns presenting their perspectives on SSRIs. Some related to pregnancy, and others did not. For example, Dr. Moncrieff focused on whether antidepressants have efficacy for depression. Mr. Lacasse, a social worker, referenced an article he authored 20 years ago, and focused on the old chemical imbalance theory, which is widely known to be outdated. At least two of the panelists, Dr. Healy and Dr. Witt-Doerring, presented their known anti-psychiatry and anti-medication views. Dr. Healy, for reason not quite clear, made a reference to a man murdering his wife, before using the phrase “make doctors great again.”

There was only one perinatal psychiatrist on the panel, Dr. Roussos-Ross, whose work focuses on treating pregnant women with mental health and addiction issues. Notably, she was the only panelist who centered her discussion around the well-being of these women.

I will not further comment on this panel. My point is, when you don’t seek out the true experts on a topic, you will get misinformation, fear-mongering, and exposed to a hidden agenda. If only there were 10 perinatal psychiatrists discussing the risks and benefits of these medications, perhaps we could have had a nuanced and fruitful conversation about how to best treat and manage psychiatric disorders in pregnancy. Instead, we watched one expert in perinatal psychiatry and a dozen physicians and scientists who are perhaps experts in other areas, but not this, talk about a mishmash of topics that semi-related to SSRIs and pregnancy. I for one, hope that the FDA does better next time.

Adopting As a Child Psychiatrist: Lessons Learned

Over 100,000 children are adopted each year in the United States.

As a child and adolescent psychiatrist, I see children ages 2-18, adults with developmental disabilities, and specialize in the areas of trauma, neurodiversity, foster care and adoption. Finally, I am also an adoptive mother and used to be a foster mother. As an “expert” on adoption, trauma, and developmental disabilities, what advice do I have for adoptive or pre-adoptive parents? Listen to adoptees. As an adoptive mom to special needs children has prepared me in multiple ways. My medical training as a child psychiatrist has no doubt helped me in this journey. My own experiences as the daughter of an adoptee and as someone who is neurodiverse herself have helped me in this journey. However, the best thing I have ever done was listen. Through listening to adoptees and former foster youth, I come away with four significant opinions of adoption.

1. Adoption, the majority of the time, is unnecessary.

2. Even when it is essential, adoption always begins with trauma.

3. Adoptive and foster parents are not equipped to be trauma-informed parents.

4. Our children are not given adequate tools to navigate their feelings.

On this journey, I have come to understand the systemic issues that lead to a lot of needless adoptions (not exactly what people want to hear, but true). The fact is, that trauma begets trauma and that most foster care related adoptions are due to neglect (not abuse) and infant adoptions are due to lack of resources (not lack of wanting to be a parent). There are, of course, some cases where physical or sexual abuse leads to necessary removal or parents do not want to parent (regardless of resources or societal interventions), but those cases are a much smaller number than we are led to believe. Therefore, many adoptions are a result of a fundamental failure of society to take care of its’ people in treating their mental health and providing support. Becoming an adoptive and foster parent has opened my eyes to just how pervasive our systemic failures genuinely are. We know how to fix this. We have the research. We, as a society, must be willing to invest in children and families. However, this is a point that we, as a society, have not yet reached.

Adoption always begins with loss or trauma, oftentimes both. As adoptive parents, it is our childrens’ best interests to acknowledge this and hold space for this fact, even in infant adoptions. There is the loss of a mother they bonded to for nine months and even more so the loss of a family they are now legally no longer a part of. When we understand this fact, we will be able to serve our children so much better. We are not offended by the thought of open adoptions or the notion that the children will want to explore that loss, which can happen in multiple ways.

The amount of training that I had as a foster parent for trauma-informed parenting is laughable. The training I had was not necessarily useless; it was just extremely superficial. Foster and adoptive parents need to be taught the importance of the first family, the importance of being honest and open with your kids, the benefits of open adoptions and finally, how to parent in a trauma-informed manner. I learned some trauma-informed practices as a child psychiatrist, but even that was inadequate. A lot of this I have discovered myself through research and again listening to adoptees. Connected parenting and trauma-informed parenting is sorely lacking and is beneficial for all children, but especially for adopted children.

Our children are not given adequate tools to navigate their feelings about having two families, of being adopted and of transracial adoptions. They certainly are not taught how to manage their feelings around any history of trauma. Many therapists and psychiatrists are not trauma-informed or do not understand the nuances of adoptions. Lots of things are explained away as attachment issues that are trauma and need to be treated as such. A lot of adoptive parents are not aware or able to separate their feelings about adoption and allow themselves to be a safe space for their children.

We need to approach adoption with the understanding that: we need to do a better job of keeping families together, we need to listen to adult adoptees without defensiveness, we need to understand trauma and we need to allow our children the space to grieve what they have lost and work through their complicated feelings. When we utilize that approach, we can make the best of what is a less than ideal situation. If you are interested in becoming an adoptive parent, my recommendation is to join groups that are adoptee-centered. Follow adoptee activist. Listen, learn, honestly evaluate your reasoning and invest in learning about trauma. This list forms the building blocks to becoming a suitable adoptive parent.

Psychiatrist Shares Her First Day in Prison

“Ma’am, we can’t let you in!” These words rang like a loud tocsin as I was told that I had worn a forbidden color, a chambray blue denim ensemble. On my first day at work at the correctional facility, I quickly learned that orange and neon green were also among the many prohibited colors of clothing. Contraband included personal cell phones, earbuds, smart watches, an extra pair of shoes and anything made of glass and personal decorations for my cubicle. While I always knew that practicing psychiatry was never going to be boring, this took the novelty to an unexpected level.

In retrospect, it is notable that I was fascinated by the Australian television crime series Halifax f.p. as a teenager, where the protagonist was a female forensic psychiatrist. Though it was never my intention to become a correctional psychiatrist, work visa needs and geographical preference had brought me to this place. I was ready to start my practice as a trained geriatric psychiatrist…in an all-male prison.

To acquaint myself with the culture, I binge-watched Wentworth and Orange is the New Black on Netflix while awaiting my new assignment to begin. However, except for knowing that SHU meant Solitary Housing Unit, I was a complete novice when it came to correctional procedures.

Now feeling slightly more prepared, my first day began. As soon as I tentatively entered the premises, I heard the mandatory alarm, which I began to call my ‘posture-correction-device’ as it seemed to beep whenever I slouched or leaned back in my chair. Also mandatory were the multiple identity card and personal bag checks which would later serve to make my experiences with TSA more pleasant.

When I spotted the watch-towers above, I realized that my blue denim outfit made me difficult to differentiate from an inmate. Since it was technically shift change, there were groups of various types of staff members walking out to freedom after having spent the previous eight hours at work overnight. I smiled inwardly as I caught the sound of my mother-tongue while watching two staff members, who were dressed in scrubs try to finalize a shift swap. We ended up on the same unit a couple of years later and would often have lunch together.

Since I had been assigned to the acute inpatient unit, I showed up for the morning huddle and noticed the bulky, armless blue chairs in the room. They were difficult to lift, clearly resistant to punctures, tear and ligature tying. All of a sudden, the unit was swarmed by a group of custody officers who were responding to an alarm generated by a suicide-watch sitter as the patient had “boarded up” using his mattress. He was refusing to be discharged back to his assigned unit as he had reported safety concerns, fearing for his life. That’s when I learned that prison-gang politics were a reality and not just a part of Lockdown on National Geographic.

That day, after the huddle, I got my census list and went to the custody station so that the patients could be brought to the office. It was clear that no movement happened in the prison without the approval of custody as “safety first” was the motto. A few minutes later, a young, well-built man with multiple tattoos walked into my office. The accompanying custody officers made sure I had an alarm on me and gave me a thumbs up.

My first patient sat down across from me on the bland and unwieldy chair, smiled and said cheerfully, “Ah! You must be the new Psych! We’ve been expecting you!”

Humanity in Medicine: Relic or Right?

Racism and sexism are alive and well in medicine.

It was about two weeks ago, February 12, 2019 to be exact, when Neurology (the official journal of the American Academy of Neurology) published an article that caused what some would call a stir. This also happened to be the week that Valentine's Day fell on. Like so many other holidays usurped by corporations, Valentine's Day is often forcibly thrust upon us, even in academic circles. So it is unsurprising that many among us may have expected our inboxes and notifications to be filled with lighthearted content to this end, for example an editorial filled to the brim with cardiology puns. Or maybe an article about the chemical and neurologic changes that occur when a person falls in love. Predictable and light-hearted, but appropriate. What none of us were expecting, save for the individuals who wrote, edited and published the piece, was the dizzying reminder of the racist history, misogynistic  leanings, and toxic superficiality, that still plagues many of our “trusted” institutions.

Dr. William W. Campbell is a neurologist who submitted and published the piece called “Lucky and the Root Doctor.” The article has since been redacted. If you were to click on the article link, you would be redirected to another page with a short explanation and apology. The apology from the journal Neurology states:

“Lucky and the Root Doctor,” a Reflections piece.  Articles within our Humanities section of  Neurology® seek to edify; this article did not achieve that goal, and should not have been published.  We sincerely apologize for our error. This story, a recollection by a doctor of a former patient, contains racist characterizations.  This has prompted a re-evaluation of our peer review process for humanities articles, and we are re-doubling our efforts to make sure such material is never published again.

While the retraction and apology are certainly pertinent, one has to wonder how something like that could be published in the first place. There is a tone deafness that seems to have afflicted the writer of the piece as well as all those who gave it approval for publishing...in an academic journal. Who exactly were these peer reviewers and editors? I ask this not for the purpose of making them targets, but rather to point to why and how something like this was allowed to happen.

Representation matters. Both when thinking about your content and your audience. Dr.Campbell, a white neurologist raised in the southern United States, made a statement in response to the retraction:

It is unfortunate that sensibilities in our society now create an inability to transcend cultural barriers by telling true stories.

The sensibilities he is referring to include his readers reaction to his use of the word 'roly-poly' to describe a large woman. It appears that he is equally baffled as why readers would be offended by the following description:  

His wife's abundant rolls of fat jiggled as she giggled.

 and this one:

I once shared a table at a fried chicken fast food establishment with a nice African American lady. Immensely enjoying her fries, she sat with the shaker in one chubby fist and liberally salted each individual fry.

It seems what Dr. Campbell and his editors could not grasp, others quickly recognized. One reader on social media commented:

I just read this, and am astounded by it. As someone raised in the South for the majority of his youth and early adulthood, I recognize the “sweet condescension” of a white male trying to “humorize” the sociocultural experience of poor African-Americans. The purpose of this article eludes me…

Another commented:

Cringe-inducing. It’s like they dusted their archives from the 1950s and thought it would be neat to publish it. Unfortunately this was written in 2019…

Despite this unfortunate event, I cannot say that all white male baby boomers are as insensitive in how they "transcend cultural barriers." In fact, I've spoken to a few that were also horrified by the piece and its subsequent publication. What I can say, however, is that this embarrassing event (and events like it) likely took place because of a lack of diversity in medicine generally, and on the  Neurology  humanities peer review board specifically.This diversity includes that of race and gender. You may have noticed that the apology issued by Neurology mentioned nothing about the editorials crass and sophomoric characterization of women.  

When the racist lens is so obvious, it is not surprising that people of color question the motivations of gestures like Black History Month. There are some that feel maligned that Valentine's Day shares a month with Black History Month (in the U.S. anyway). I do not. While love is not synonymous with respect and equality, between them there exists an important conceptual and practical overlap. Somewhere within the intersection of these concepts is the notion of working in the other person's best interest and preserving their dignity. Among other things, Black History Month endeavors to remind us that the history of the U.S. is deeply steeped in the unlawful and systematic disenfranchisement of persons of African descent. Therefore, acting very much against their interests. The U.S. is not unique in this regard. Respect and equality is not something that comes naturally to nor easily enforced within large institutions, be it governmental, commercial or academic settings.  

Combatting this type of inequity requires an ongoing and layered approach. One way we can encourage the representation and dignity of minorities, is by ensuring that minorities are in leadership and decision-making roles. One commenter shared this sentiment:

This is why we need diversity in medicine! I just gave a grand rounds in neurology in gender bias and focused on their specialty—neurology is one of the worst in terms of diversity—they have had ONE female president of AAN since 1948 and surely the majority if not all have been white.

The medical field is not immune to racism. I recall an incident earlier in the year where it surfaced that in 1984 medical school administrators at Eastern Virginia Medical School allowed students (among those students the current Virginia Governor Ralph Northam) to wear KKK garb and blackface in photographs published in the medical school yearbook. Many blamed the lack of diversity within the student body and medical school administration at the time. As is the case for many professional spaces, women and people of color are underrepresented.  The deficit is made even more apparent when we look at positions of authority. This criticism cannot be reserved solely for the medical field though, many U.S. institutions continue to have issues addressing sexism and racism. This likely comes as a surprise to few: I struggle to think of one nation that does not suffer from this social affliction. 

Currently, we find ourselves at a time when government officials, media outlets, and public figures shamelessly use race and gender to divide the masses. It is imperative that physicians and others in positions of authority make efforts to prevent events that play into this toxic narrative. While we are all unique, one universal truth is that our identities and our interactions with others are informed by the societies and spaces in which we live. 

Naturally, all of these spheres have a history and subtext of their own. Since the end of the 19th century, African Americans have matriculated and graduated from American medical schools. They were restricted to serving mainly in their own communities, and little was done by the white establishment to acknowledge their presence or accomplishments in the medical field. Women have endured a similar struggle. 

No one person can be expected to be cognizant of the intersections of all these variables, however, knowledge and awareness is not enough: it must be actionable, not merely symbolic.

 The piece offered by Neurology was plainly sexist and racist. As one commenter aptly noted, it is reminiscent of publications from the 1950s: reinforcing and rekindling the legacy of Jim Crow, ignoring the dignity of women and infantilizing of the ill and infirm. Although one misguided individual can be forgiven, precisely how an entire editorial board approved such a publication is worrying. It begs the question of who is on the board, and whether they are truly capable of providing nuanced oversight on the variety of content that comes before them. Is it possible that the editorial board lacks the diversity in race and gender necessary to do so in this ever-changing landscape?

It is perhaps unfair to expect perfection in anticipating every single misstep of this nature. Mistakes happen, after all. What is unforgivable is the persistent refusal and resistance to make the changes necessary to avoid these unnecessary and harmful blunders. Given the breadth of the audience, and the pieces subsequent notoriety, one can only hope that going forward, the journal Neurology does its part in assuring its content is reflective of its diverse audience.

The Most Important Questions To Ask About Psychotherapy

Most physicians work in settings where psychotherapy is outsourced to other caregivers, leaving them to wonder exactly what transpires during therapy time.

In this post, I will share some thoughts about the role of psychotherapy in modern clinical practice and some questions that we should consider when third-party therapy is part of the picture.

The Void In Mental Health Care

The role of psychotherapy in psychiatry has diminished considerably as insurers have tried to contain costs by limiting face time between physicians and their patients.

This has created a worrisome void in mental health care because medication is an incomplete solution for many psychiatric patients. I have seen these patients. And they have not fared well.

The Problems I’ve Seen

Most of the patients I see have failed multiple prior treatments and have often seen several other physicians before coming to me. I am a second- or third-opinion consultant. And, mood and anxiety disorders are, by far, my most frequent consultation problem.

I routinely ask each of my patients: have you ever had treatment other than medications? Have you ever had psychotherapy? A dispiriting number have never had a psychotherapist.

Many more told me that they had been engaged in psychotherapy - or at least what they thought was psychotherapy. The most common response from this group of patients was: Yes, I've been seeing So-And-So for about several years now. Awesome!

Then I ask questions more detailed questions about the nature of the therapy:

“Has your counselor or therapist explained the psychological or social factors that contribute to your mood issues?”

“And how are those issues being addressed in your care?"

Oftentimes, these questions would confuse my patients. No matter how I phrased them, most of my 'treatment-resistant' mood disorder patients were apparently unaware that depression or anxiety often has specific psychological components that may be causative and that can be ameliorated by the practice of psychotherapy.

Most of the third-party-psychotherapy patients that I saw had never left their therapist’s office with a psychological explanation for their symptoms, and couldn't describe how their therapy was supposed to work. Their meds, though - they all had a good understanding of what they were supposed to be doing, even if they weren’t working all that well. The social narrative of the chemical imbalance dominates. Psychology is neglected, even though its explanations are more detailed and actionable.

The Original Breakthrough Treatment

Before psychiatry had its wonder drugs, the field took very seriously the concept of mind (psyche) and ultimately developed therapies specifically for the mind (psychotherapies).

The first of these breakthrough psychotherapies was Psychodynamics. The pre-pharmacology era also witnessed the formation of Jungian Therapy, Logotherapy, Gestalt Therapy, Behavioral Therapy, Cognitive Behavioral Therapy, and others. Each of these psychotherapies were based on a coherent theory of mind that could account for how various symptoms arose. Psychodynamics, for example, holds that symptoms arise from subconscious mental conflicts; treatment is designed to bring these conflicts to conscious awareness where reason can intercede. Cognitive Behavioral Therapy views symptoms as the result of inaccurate cognitions (e.g., I’m a failure) and its treatment seeks to reframe them more accurately (e.g., I sometimes make mistakes).

Through careful assessment and psychological formulation, the clinician could identify which facets of mental or social functioning were most relevant to the patient's symptoms. Specific therapies were chosen to work on the facets needing attention. At the same time, the clinician would recognize and build upon the facets that were healthy.

This approach was enormously successful. Though psychotherapy didn't work for everyone (neither do modern drugs, by the way), the psychiatrists and psychologists of the pre-pharmacology era helped many to recover.

Psychotherapy in those days was practiced solemnly. Statements made by patient or doctor were considered weightily. Occasionally, lawsuits were filed because of something a doctor said, or did not say, during psychotherapy.

Psychotherapy was taken as seriously then as drugs are now.

Psychiatry Leaves the Building

Psychiatry underwent many changes during the psychopharmacology revolution and emerged with a curiously narrow focus on medications. Psychotherapy training during most residency programs was shortened as attention began to focus on efficiently doing "the med piece."

A lot has happened in the therapy world since Psychiatry left the building. Specifically, there has been an explosion of educational programs that produce people who are licensed to do “therapy.” These include social workers, counselors, marriage and family therapists, members of the clergy, addiction specialists, and so on. So, the statement “I’ve been seeing a therapist for my depression” is actually not all that informative in these modern times.

The Key Questions To Ask

It appears that many of our patients are being referred to a black box labelled "therapy" or "counseling" and sometimes neither the patient nor the doctor really know what that entails. We need to know what is happening in that box if we are serious about getting our patients well.

Psychotherapy for mood disorders should follow the path of any other treatment. It should be based on an etiological hypothesis. Procedures should address the presumed cause. And (most importantly), the formulation and treatment should change if expected progress is not happening.

Patients switch drugs every few months if they are not getting results. They should similarly switch therapies (or therapists) if there is not clear evidence of progress toward recovery goals.

A lot of people confuse supportive/empathic listening for evidence-based psychotherapy. These elements can help some patients, and are prerequisites for effective care. But patients with complex mood disorders likely require more specific evidence-based interventions.

It pays to ask the questions of your patient:

• Based on your therapist's assessment, what do you understand to be the cause(s) of your symptoms?

• How will your therapy help you to address those factors?

• How do you feel you have been progressing (or how will you know you are progressing)?

• If you have not been progressing, what do you think is getting in the way?

Though these questions are no substitute for the value of speaking directly with the therapist, asking them of patients can help to reinforce that symptoms often have psychological or social causes which may require attention in order to achieve recovery. These psychological or social factors are often shortchanged. When present, they need to be acknowledged and actively addressed in treatment. Medications can’t solve everything.

Drowning in Shallow Waters: A Star is Born Shines a Light on Co-Dependency and Substance Abuse

With the Oscars just days away, the films that are nominated as the best of the year can illustrate much of the work we face each day as psychiatrists.

Due to its pervasiveness, the leaching landscape of substance abuse provides fertile ground to cultivate the dangerous seeds of co-dependency.  As professionals who chose to dive headfirst into all makes of dysfunction, psychiatrists and other mental health professionals likely encounter this behavioral and emotional phenomenon often. It may present itself as the overly avoidant patient who’s loved ones enable their misanthropic tendencies. Or perhaps you have enough self-awareness to recognize the patterns of co-dependency in your own life? Unfortunately, if we look at one particular subset of the population, it is obvious that the number of people who find themselves in such a dyad, far surpasses the number of mental health professionals there will ever be at one time.  According to the WHO, some 31 million people suffer from some form of substance abuse. Of that 31 million, it is estimated that about 4 million of them suffer from alcohol use disorder. 

As you can imagine the with diversity that exists amongst the millions of people who suffer from the disease, alcoholism can look different depending who you talk to. The illness can run the gamut from fairly inconspicuous to severely debilitating. While the media does not always do a good job at portraying the many facets of the illness, even fewer outlets do so while being honest and disturbingly entertaining. A Star Is Born, a film produced and directed by Bradley Cooper and starring himself and Lady GaGa, manages to do just that. This is the fourth remake of the film, which was first released in 1937 and originally starred Janet Gaynor and Frederic March. The 1954 versions cast Judy Garland opposite James Mason, and a later much acclaimed version starred musical powerhouses Barbra Streisand and Kris Kristofferson in 1976. 

This version, however, feels more befitting for our time. Not only does the film give us a front seat to the wild ride that is a viral rise to fame, but it also poignantly illustrates the mosaic of tenderness and cruelty that sustains co-dependent relationships. Although the term co-dependency is now broadly used to describe any type of unhealthy relationship that people can share with those close to them, it initially was reserved for partners of chemically dependent persons.  Although prior versions of the film touched on the issue of alcoholism, Cooper's film does so whilst acknowledging its place in the broader landscape of substances, specifically pharmaceutical drugs in the form of sedatives, hypnotics, and painkillers. According to the National Institute of Drug Abuse, eight to 12 percent of those who are prescribed an opioid will develop an opioid use disorder. Due to their similarly sedating effects, it is common to find the abuse of alcohol and pharmaceutical drugs in the same users. As the current opioid crisis has unfortunately reminded us, an individual's relationship to substances of abuse often start as a legitimate therapeutic modality. So is the backdrop of Bradley Cooper's character Jackson Maine, a now fading country music star who suffers from the untended emotional scars of generational trauma, and the physical scars of chronic pain and premature hearing loss. Littered throughout the film are a deluge of drug paraphernalia and problematic behaviors. Jackson maintains his limp grasp of fame on a regimen of alcohol, steroid injections, prescription pills, and self-loathing.  

A brief, but memorable moment, was when Bradley's character Jackson Maine used the weathered heel of his cowboy boot to crush an assortment of pills, which he promptly snorted, before sprinkling its remnants into a glass of dark spirit. Whilst the scene had the desired effect, I realized later the shock I felt was misplaced. His behaviors are neither far-fetched or uncommon, and as physicians we try to approach that cognizance without judgment. Similarly common, was a scene where for the first time Ally sees an inebriated Jackson black out drunk. The man who a moment ago was charming and quick witted, became pathetic and sad. It was foreboding. It should have served as a warning for her—every fiber in me wanted to grab Ally and yell RUN!  

But she didn't run. And I can't tell you exactly why. Of course, there are beautiful moments, like when Jackson coaches Ally through the jitters of her first recording studio session, or when he nursed her swollen fist with frozen packs of vegetables. But accompanying the tenderness was also darkness. While there was no instance of physical violence between them in the film, the trauma was there. It took the form of jealousy, self-sabotage, enabling and denial. Like many partners of people suffering from chemical dependency, Ally finds that an integral part of her identity and her happiness, are tied to Jackson. This fact can be lost on physicians, that addiction treatment must not only consider what the addiction does for the addict, but also what it can do for the recurring key players in an addict's life. 

As I said, I could not tell you exactly what Ally was thinking. But I can tell you that whatever she was thinking, it would have helped her to share those thoughts with someone. Psychotherapy, while almost globally recommended for those who suffer from substance use disorders, is often overlooked as a resource to their partners. In an environment where healthcare is not universal, assuring that these resources are affordable and accessible to populations that need them, is nearly impossible. Every effort should be made to offer resources and referrals that are not only clinically appropriate, but also economically feasible. Though we are not treating the family, frequently the notion of family or individualized therapy should be raised for partners and immediate family, as our patients are better served by a network of individuals that are themselves mentally robust and supported. In the film, the music seems to serve as a poor replacement for therapy for both of the main characters, with unfortunate consequences, reminding us that the movies are not always what we want to see in real life.

Resident Corner: A Day In the Life

As a third-year psychiatry resident in at SUNY Downstate, a university hospital in East Flatbush, Brooklyn, most of my training time is spent working at Kings County Hospital (KCH), a large community hospital across the street from Downstate, serving one of the poorest neighborhoods in this rapidly gentrifying borough of New York City. I am confident that all of you must have either read or heard of “physician burnout.” Maslach and Jackson define it as “a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who work with people in some capacity.” In health care settings, resident clinicians are known to be its most frequently affected victims and literature suggests highest prevalence in the surgical specialties. Although psychiatry is considered by many an “easy and relaxed” specialty, psychiatric trainees and other mental health staff are not immune to burnout. The assumption that mental health professionals can utilize their skills to handle and ‘cope’ with their problems is as wrong as thinking that oncologists have a lower risk of cancer.

I would like to familiarize you with a typical day in my life. My entire residency class has been working in the outpatient clinic since the beginning of the third year. We reach KCH by 8AM, spending 30-60 minutes commuting one way. We see around seven to 10 patients on any given day, some of them for weekly psychotherapy which requires a 45-minute visit. Our patients – mostly immigrants (sometimes undocumented) and citizens from low-socioeconomic status – present with a wide array of psychological, interpersonal, and socio-occupational problems. We all share the emotional “baggage” that our patients bring as in any human dyad transference, and countertransference is unavoidable. It is a challenge to maintain professional composure with our patients expressing suicidal thoughts and plans, mourning the death of loved ones, describing their traumatic events in grisly details, swearing at us, becoming increasingly animated and crossing boundaries in making threats and sexually provocative gestures. Apart from addressing their clinical issues, we perform the role of social workers and assist them in obtaining social security benefits such as housing, food stamps, employment and health aide services. In addition, rigorous documentation outreach phone calls to no-shows, liaison with insurance staff for pre-authorizations, pharmacies and patients’ families (to quell their anxieties), as well as mental and physical fatigue from excessive computer use can all make life quite difficult in the clinic. Apart from being tired, we often feel sad, angry, helpless, anxious, emotionally numb, disillusioned and incompetent. Some of us even experience nightmares involving our patients. There are numerous days when we feel completely drained and just want to go to bed after work. Based on an informal discussion with my colleagues, I estimate that 40% of us would meet the criteria for burnout.

All of us have our own ways of dealing with stress. We are a very diverse group of helping and caring residents who are always willing to support each other and lend an ear. I personally believe in the power of an popular Sanskrit verse from Bhagvada Gita that states: “karmaṇy-evādhikāras te mā phaleṣhu kadāchana mā karma-phala-hetur bhūr mā te saṅgo ’stvakarmaṇi,” which translates to “You have a right to perform your prescribed duties, but you are not entitled to the fruits of your actions. Never consider yourself to be the cause of the results of your activities, nor be attached to inaction.” Whenever I think about it, it provides equanimity and helps me to maintain a healthy distance from my patients’ stressors. I also unwind by listening to music and watching movies and TV shows. My classmates cope by going for personal psychotherapy, talking to friends and family, playing board games, watching funny videos on YouTube, cooking, exercising and taking vacations. They find these outlets rejuvenating and it gives them an impetus to continue their everyday work.

I would like to finish by confessing that not all our patient interactions bring negative emotions. Many of them fascinate us with their stories, inspire us with their resilience and reward us with their improvement. Despite the occupational hazards of psychiatry, there has never been a day in my brief career when I regretted embarking on this exciting journey that traverses the interface of medicine, psychology, neurosciences, sociology, anthropology, and philosophy. I feel extremely gratified and fortunate for being a lifelong student and practitioner of this subject.       

The One Medication Every Psychiatrist Needs to Know About

Getting to know metformin is one way child and adolescent psychiatrists can be more prepared to address metabolic side effects of atypical antipsychotic medications.  

Metformin (Trade names: Glucophage, Glucophage XR, Glumetza, Fortamet, Riomet)

Metformin is first-line treatment for overweight patients with Type II diabetes and is FDA approved for diabetic children age 10 and older. Metformin improves sensitivity to insulin and limits the production of glucose in the liver. Typical pediatric dosing of metformin starts at 500 mg per day for the first week with increases to a maximum dose of 1000 mg twice a day. Modest weight loss can occur in overweight youth at risk for diabetes (Park MH et al Diabetes Care 2009;32:1743-1745). Typical side effects of metformin include nausea, vomiting, gas, bloating, diarrhea, and loss of appetite.  

Practice parameters for the use of atypical antipsychotic medications in children and adolescents were published by the American Academy of Child & Adolescent Psychiatry (AACAP) in 2011. Weight management interventions are encouraged if medication-induced weight gain results in a BMI >90th percentile for age. Current practice guidelines do not address routine monitoring of insulin levels, but refer to checking hemoglobin A1c (HbA1c) as indicated. I personally follow fasting insulin levels in overweight patients as I worry that if I wait for an elevated HbA1C, it may be too late to intervene. Most of my patients on metformin stop gaining weight or even lose weight—up to 30 lbs.

This clinical observation is supported by the literature. Children who gained significant (more than 10%) weight within the first year of treatment with olanzapine, quetiapine, or risperidone were selected for a 16-week, double-blind, placebo-controlled study. BMI stabilized in the metformin treatment group while patients receiving placebo continued to gain 0.31 kg/wk (Klein DJ et al Am J Psychiatry 2006;163:2072-2079). Children and adolescents with autism spectrum disorder (ASD) also demonstrated a significant reduction in weight gain in a more recent randomized trial (Anagnostou E et al JAMA Psychiatry 2016;73(9):928-937). Metformin was reported to be well tolerated in the 60 patients with ASD who received doses of up to 500 mg twice a day (ages 6-9) or 850 mg twice daily (ages 10-17).

Case example

Charlie was a 17-year-old male with a longstanding diagnosis of ADHD when his impulsivity and irritability escalated to the level of a mood disorder. He was frequently suspended for fighting. Although he did not yet meet criteria for bipolar disorder, his family was desperate to try a mood stabilizer as he failed intensive behavioral therapies and several antidepressant trials. He started a risperidone trial following a discussion of risks of off-label prescribing. The conversation focused on lifestyle interventions to prevent weight gain given his body mass index (BMI) of 38.5 kg/m2. The improvement in his behavior was immediate but his BMI peaked at 42.1. At that time, his fasting metabolic labs revealed a normal glucose (92 mg/dl) but an elevated insulin level of 43.3 mU/L (normal range for reference lab 3-25 mU/L). Attempts to taper risperidone failed due to breakthrough irritability and his family resisted a major medication change in the middle of his senior year. The use of metformin 500 mg twice daily was supported by his pediatrician. No side effects were noted at his follow-up appointment and the dose was increased to 850 mg twice daily. Three months later his BMI had decreased to 40.7 and his repeat insulin level was 39.2. These numbers were far from ideal, but his family appreciated efforts to mitigate risks as he graduated from high school and transitioned to college.  

Weighing off-label prescribing

The stakes for patients like Charlie are high as effective treatment carries potential lifelong medical implications. Despite stronger labeling, antipsychotic drugs are still prescribed off-label for children with eating disorders, tic disorders, OCD, PTSD, and disruptive aggression. There is a lack of long-term data on the benefits of metformin for medication related weight gain. A fair number of patients can’t tolerate metformin due to GI side effects and parents often have difficulty administering two doses a day with food on school days. Lactic acidosis is rare but the muscle pain could be confused with dystonia or even neuroleptic malignant syndrome (NMS).

Metformin is not a “magic pill” for weight loss but appears to be clinically useful in children and adolescents who require long term treatment with atypical antipsychotics. Families that worry about weight gain will likely be glad that their prescriber “met” metformin.

One Psychiatrist’s Take on Managing Tardive Dyskinesia

I routinely order ECGs, check weights, and draw labs to assess metabolic status for my patients taking second generation antipsychotics (SGAs). Before 2017, I didn’t rigorously screen for tardive dyskinesia (TD). Effectively this meant I didn’t care about it. In my private practice, I hadn’t noticed anyone with obvious TD symptoms, and no one had complained of involuntary movements, so I assumed that TD was a “solved problem”.

However, in March 2016, I met a 27-year-old man who had schizophrenia and obvious evidence of TD, with dyskinesia in facial muscles, extremities, and even his trunk. The best option I could offer at the time was to remove one of the two SGAs he was on. His father (and legal guardian) adamantly refused any change in medications, because that was the only regimen that had ever kept his son out of the hospital. In January 2017, when excitement began to build about two new medications poised to become the first FDA-approved treatments for TD, my patient’s father tragically passed away from sudden cardiac death. Throwing myself into TD research was one way to overcome the sense of powerlessness I felt from my inability to help him and his mother with their grief.

My situation was analogous to the decades of powerlessness clinicians had felt in trying to treat TD with various off-label medications and supplements, none of which had ever merited more than a Level B recommendation by the American Academy of Neurology. The two investigational medications represented a great opportunity for the field, and I wanted to bring that hope to my patient and his family in their difficult time. I offered that if the first of the two VMAT2 inhibitors was approved, we would try it. I was surprised how deeply invested they were in this offer. To them it was more than simply a treatment for just another condition he had. It had become the fulfillment of a promise I wasn’t able to make to his father at that first appointment— that I could improve his TD without risking his hard-won psychiatric stability.

It had become that very beacon of hope I’d tried to ignite for him. When he was finally able to take the medication, it reduced his movements to what would be almost unnoticeable to the average person. Just a month after starting treatment, the young man who couldn’t walk a straight line down the hallway when I met him, became able to remain nearly as still as I did in session.

Over the next few months, I worked to make myself into a “DIY expert” on TD by reading Neurology journals and movement disorder textbooks. Armed with this knowledge, I found that I did have a number of other patients who had mild to moderate TD, to which I had simply been blind. I had inadvertently set my bar for diagnosing TD at the level of the severe, state hospital-level cases. The dyskinetic movements I began to notice might have been easy to miss in a short medication management appointment, but they were often the cause of significant functional impairments that I had totally overlooked before I made the effort to ask. For instance, a 67-year-old woman stopped singing in her church choir because of embarrassment over her facial movements, and a 59-year-old had to swallow her pride and ask coworkers to put on her earrings and necklaces because her hands had too many dyskinetic movements to make the precise movements.

Everyone in clinical practice today trained in an era in which there was effectively nothing we could do to address Tardive Dyskinesia, so we didn’t have much incentive to look for it. Our skills for diagnosing it withered, and many newer clinicians never learned them in the first place. I actually did have the opportunity to train under a renowned TD expert, so I really had no excuse, but I let myself become complicit in “la belle indifference” that seems to have overtaken the field since the advent of the SGAs. That era is over. Today, safe and effective VMAT2 inhibitors are available, and we need to collectively wake up and find every patient with TD in our practices. Now I’ve made assessing for TD a part of my standard mental status examination for every patient on any antipsychotic, during every visit.

The Sleep Disorder You Might Be Missing

Every living creature, from deep sea fishes to microscopic single-celled terrestrial organisms, has an innate biological clock. For us surface dwellers, our rhythms undulate to the beat of the earth’s dark and light cycles. Light is the most powerful zeitgeber, or time giver, that regulates the internal clock. In this era of breaking news and binge watching, we are bombarded with constant exposure to artificial light, resulting in disruption of our natural body rhythms. Disturbances in the circadian rhythm can result in metabolic diseases, obesity, cancer, and mental health disorders. Despite the growing appreciation of chronobiology, circadian disorders are frequently missed in clinical practice.

Delayed Sleep Phase Syndrome (DSPS), also known as Delayed Sleep-Wake Phase Disorder, is one of the most commonly encountered circadian rhythm disorders in clinical practice and is often misdiagnosed as sleep-onset insomnia. DSPS should be suspected in those who complain of consistent patterns of sleep onset significantly later than the desired or conventional time. Patients with DSPS may also complain of problems with social and occupational functioning such as chronic tardiness to work or school, impaired academic or work performance, conflicts with parents or partners regarding wake time, and sleep deprivation. Common psychiatric comorbidities include depression, seasonal affective disorder, bipolar I disorder, obsessive compulsive disorder, and attention deficit hyperactivity disorder. A higher degree of circadian misalignment may be correlated with more severe depression and poorer response to treatment with antidepressant medications. Furthermore, it has been shown that patients with DSPS have a threefold higher prevalence of comorbid seasonal affective disorder compared to controls.

So, how do we differentiate DSPS from insomnia? A good clinical history is the cornerstone of psychiatric diagnosis and the diagnosis of DSPS is no different.

Diagnostic criteria according to the third edition of the International Classification of Sleep Disorders (ICSD-3) is as follows:

• The phase of the major sleep episode shows a significant delay in relation to the desired or required sleep time and wake-up time, as evidenced by a chronic or recurrent complaint by the patient or a caregiver of inability to fall asleep and difficulty awakening at a desired or required clock time.

• The symptoms are present for at least three months.

• When patients are allowed to choose their ad libitum schedule, they will exhibit improved sleep quality and duration for age and maintain a delayed phase of the 24-hour sleep-wake pattern.

• Sleep log and, whenever possible, actigraphy monitoring for at least seven days demonstrate a delay in the timing of the habitual sleep period. Both work or school days and free days must be included within this monitoring.

• The sleep disturbance is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

Zeitgebers and lifestyle should be also assessed including use of caffeine and stimulants, diet, the timing of meals, exercise, work/school/activity schedules, evening light exposure, and use of screens. Sleep diaries are useful adjunct to the clinical history and are recommended to evaluate the sleep schedule. The AASM sleep diary is free to download and provides two weeks’ worth of data. Actigraphy provides an accurate measure of sleep-wake cycles but may not be readily available in clinical practice. Polysomnography is not indicated unless there is clinical suspicion for another sleep disorder such as obstructive sleep apnea.

Once a diagnosis is established, behavioral modifications should be initiated in order to facilitate advancement of the circadian phase. Patients should be advised to minimize use of stimulants, avoid daytime naps, reduce light and screen exposure in the evenings, and avoid stimulating activities at least 2 hours before the time of desired sleep onset. Along with behavioral changes, melatonin and light are powerful body clock regulators that may be considered in the treatment plan. Short-term (<3 months) use of melatonin at a dose of 0.5mg, timed strategically 1.5 to 2 hours before the desired time of sleep onset can “pull” sleep earlier. Morning light therapy with a light box is effective for “pushing” back the wake time. It is recommended that patients start with using the light box at their natural wake time, then advance use of the box by 15 to 30 minutes each morning until the target wake time is reached. Use of hypnotics or sleep aids is not recommended. Consistency in following these strategies is the key to successfully shifting the sleep-wake cycle to align with one’s work or school schedule.  

By recognizing and treating circadian rhythm disorders, we can help improve quality of life, reduce the risk of medical and psychiatric comorbidity and restore a natural, balanced body rhythm. Now, that’s something that will help us all sleep better at night.