All right, hello, everyone, and welcome. Thank you so much for joining the Third National Conference on Advancing Early Psychosis Care in the United States, presented by SMI Advisor. My name is Dr. Rob Cotez, and I'll be moderating today's session. I'm a psychiatrist at Emory University School of Medicine, where I direct a first episode psychosis clinic and a program that specializes in clozapine prescribing. So the title for today's talk is the psychopharmacology management of early psychosis during the COVID-19 pandemic. And now I'd like to introduce you to our distinguished faculty for today's session. We have Dr. Anne Hackman and Dr. Dost Unger. So to start with Dr. Hackman, she is the division director of community psychiatry at the University of Maryland School of Medicine. Her career has focused on the treatment of people living with schizophrenia. And if you could just go to the next slide. She has spent more than 25 years working on assertive community treatment teams, and for the past decade has been the lead psychiatrist on a race connection model EIP program. Dr. Hackman has received awards from medical student and resident teaching. She serves on the executive committee of the American Association for Community Psychiatry. Dost Unger is the William P. and Henry B. Test Professor of Psychiatry at Harvard Medical School and chief of the psychotic disorders division at McLean Hospital. His research focuses on the clinical trajectories of people with early psychosis, as well as neuroimaging studies of brain abnormalities in these conditions. He launched McLean OnTrack, a subspecialty service for early psychosis in 2012, and has an absolutely wonderful team with some folks that I know up there. So he has received awards for his teaching and mentoring, and is the editor-in-chief of JAMA Psychiatry and a fellow of the APA and ACMP. So the speakers report no relationships with commercial interests, nor conflicts of interest. And now I will turn the presentation over to Dr. Unger. Thank you very much, Dr. Cortes. It's really a pleasure to be here and to join this conference. As you can see, the learning objectives for us this afternoon are describing COVID-related changes in the physiology and psychopathology that may be seen in people with early psychosis, outlining principles for managing psychopharmacology in early psychosis, and describe the potential access and health disparities impacting people with early psychosis in the COVID era. So I'm going to start by providing a bit of a background on COVID-19 and society. The changes that we've all experienced in the past eight months have been so profound that any discussion of early psychosis care in this context really should start here. Almost overnight, the pandemic had a profound effect on society and psychiatry, including in early psychosis care. We've all experienced disruptions in all aspects of daily life, from school and work to interactions with friends and families. The economic environment has been profoundly altered. Tens of millions of people lost their jobs in the United States. Many more experienced income reductions through furloughs or uncertainty about the future of their employment and health insurance. There have been major changes in the landscape of medicine and medical care as well, including new policies to reduce social-physical interaction and cessation of many in-person medical visits. The pandemic and also our mitigation efforts to slow down or stop the pandemic and the economic downturn that followed have all raised the risk of homelessness, substance use, depression, anxiety, and suicide. Pandemic-induced distress is unusual in that individuals are experiencing it in isolation without the daily structure of work or school, and repeated over many months via exposure to the news and social media. In fact, daily news of large-scale COVID-19-related disease and death in the community over months or years is almost certain to elevate psychiatric burden in the population. I don't really think that anybody in the United States or around the world has really had has been able to escape the impact of the pandemic at all, so this affects all of us. But because of this sort of slow-moving and daily drip of bad news, the pattern of stress really resembles that experienced by refugees or others exposed to chronic violence rather than acute disasters like the September 11th terror attacks. So of course, there's some maybe positives and some negatives to this. It's just different from going through an acute disaster and then dealing with the aftermath. Instead, we really are all dealing with a slow-moving disaster, and every day some of the difficulties play themselves out. Because of these considerations, many are suggesting that there's a potential for a tsunami of psychiatric disorders brought about by the pandemic, along with a second wave of COVID-19 itself. Of course, when I was preparing these slides, the second wave was not quite in full swing, but in many parts of the U.S. and the world, now we can really say that a second wave has set in completely, and then the tsunami of psychiatric disorders in need is still playing itself out. There's a sustained increase in demand for psychiatric services, and this may well exceed the existing capacity of the system over time and may last for years, depending on the course the pandemic takes. So this is a little bit like, of course, what we're all concerned about with the healthcare system being overwhelmed with COVID-19 disease itself. Emergency rooms, ICUs around the country are grappling with increased numbers of patients with severe need. But other than those medical services, psychiatric services are also at risk of being stretched in. And of course, whatever the pattern that COVID-19 takes and the psychiatric need takes, this is a focused attention on gaps in knowledge about how to prevent the effects of traumatic stress. There's a lot of discussion about how to prevent the effects of traumatic stress when it plays out in this way. This is from the New York Times website, but it refers to a widely distributed paper that appeared in the Morbidity and Mortality Weekly reports, which is actually a publication of the Centers of Disease Control, CDC. It reported that young adults are reporting rising levels of anxiety and depression during the pandemic. On the next slide. So this CDC survey reported that in the 18 to 24 age group, 64% of the respondents reported that they were having depression slash anxiety symptoms that they attributed to the pandemic and to COVID-19. This is almost two-thirds of young adults talking about experiencing depression and anxiety. 25% had increased their use of alcohol or substances. The most remarkable finding in this survey for me was that 24% seriously considered suicide in the past month. This is not just having suicidal ideation, they really were seriously considering suicide. That number was 11% in the general population, but 24% in the young adult age group. So this tells you how hard hit young adults have been by the pandemic. This CDC survey, by the way, was conducted on a population representative sample. So this isn't just putting a survey online and seeing who responds to it. They actually selected a population representative sample, which makes this all the more chilling. The extent of psychopathology and difficulty that's out there among young adults. The numbers were also generally greater among black and Hispanic respondents. This once again highlights one of the many disparities that are experienced by people from minority populations. I already mentioned the use of alcohol and substances, but this report was based on a publication that appeared in the journal JAMA Network Open, and it reported in another representative population representative sample that Americans are drinking about 14% more often during the pandemic. So this is not just about problem drinking, but in general, the consumption of alcohol in the population has actually gone up significantly. The other thing that's going on is firearms purchases. This is from a report in the CNN website that firearms purchases have skyrocketed during the pandemic, according to FBI records. Of course, this may or may not be directly related to psychopathology. This is not a report on symptoms people are experiencing, but the concern about safety and well-being seems to be reflected in all aspects of life and society right now. Another question that really remains unanswered that we need to handle, we need to tackle is does COVID-19 infection result in psychiatric sequelae and by what mechanisms? At this point, many millions of people in the United States and then even more around the world have experienced COVID-19 infection. Of course, many have died, but there's many who survive. But individuals who survive intensive care unit stays and intubation, as well as their families may experience acute and longer term consequences of trauma. Survivors often require rehabilitation after hospitalization. And during this rehabilitation time, psychiatric and cognitive symptoms are being commonly observed. So the longer term sequelae of COVID-19 infection itself is another issue that we have to handle. The extent to which COVID-19 related coagulopathies, hypoxia, neuroinflammation, and direct viral infection of the brain may contribute to psychiatric morbidity remains to be defined. So there is, of course, the impact of the pandemic at the societal level. And it's the mitigation efforts to stop the pandemic at the societal level. Those are difficult enough. And then added to that, you have the survivors of COVID-19 infection who are having to tackle this. I think it's safe to say that future demand for psychiatric services are going to be greater than the current demands. Around the country, many of you know, I don't need to tell you, that services are poorly resourced and inadequate, even for normal times. Now superimposed on that, we have the COVID-19 pandemic and the demand that's hitting us. Potential measures to increase capacity for mental health care should include adequately funding existing psychiatric services and instituting measures to counteract staff turnover, burnout, and low morale. Collaboration between psychiatrists and other medical professionals need to be enhanced through collaborative care and support for primary care and other physicians to provide mental health services when it's appropriate have to be expanded. We also have to expand internet-based self-help and other scalable mental health interventions. These really shouldn't be seen as panacea. I'm seeing a lot in the lay press about internet-based self-help and, you know, simple interventions like mindfulness, breathing exercises, and so on. Of course, these can be very helpful, very useful at the societal level. But they really complement rather than replace careful psychiatric assessment and care. So we really have to be thinking of both kind of population-level interventions that are easier to implement, like internet-based self-help, but also be prepared with expanded psychiatric services. And actually in the longer term, expanding psychiatry training and medical school curricula and ensuring acceptance and integration of mental health services in all clinical settings are really going to be critical. Other things we have to start thinking about include screening and vaccination efforts, which are going to become widespread in the coming period. So people with early psychosis may be at higher risk of refusing preventive care or unable to access it. And, of course, this is not going to be a foreign theme to many of you who work with our patient population. It's already true in other aspects of medical care. Our patients systematically receive poorer care. Part of this is because of difficulties accessing care, insurance and family supports and others. And part of it is also due to refusal of preventive care. But this is going to become an even bigger issue in the coming period for our patient population. On the other hand, there is a discussion that is just starting to be had that we really need to be mindful of, and that is, what is the cost-benefit analysis of vaccinating populations of young people if there is a non-zero risk from the vaccine itself? In other words, if the vaccine itself is going to be associated with some low percentage of adverse events, but young people, for example, those with early psychosis are at lower risk from COVID-19 infection itself. So what is the risk-benefit analysis in this population? It's going to be different from an older population, especially a population with severe mental illness who have additional medical morbidities and are at higher risk of complications from COVID-19 infection. That population is really a different population where the risk-benefit analysis is different. But among young people with psychotic disorders, this discussion needs to be had. And going forward, we really need to have a concerted effort to remove barriers so people in our clinics can receive the care they need and deserve. This involves flu vaccination in this coming flu season in the fall and winter, preventive testing and contact tracing, which, of course, the United States has not done in sufficient numbers until now, but that's going to be important for containing the pandemic. And ultimately, COVID-19 vaccination when that becomes available. Again, when I prepared these slides, that was only a theoretical statement. Hopefully, we're moving into a period where COVID-19 vaccine or vaccines will become more available and then we're going to be able to protect society at a different level. I'm going to go into the psychopharm considerations in just a second. So setting the stage for that, we really have to be aware that COVID-19 impacts multiple organs. We've all heard of this as one of the severe acute respiratory syndromes or SARS. And that's, of course, true. But COVID-19 infection does not only cause a respiratory syndrome. There's liver damage, kidney damage, heart damage that can happen along with lungs, as well as for the immune and hematologic systems. And damaged organ systems may lead to pharmacokinetic changes that impact absorption, distribution, metabolism, and or excretion of psychotropic medications. So there's going to be an increased sensitivity to certain psychotropic adverse effects in people with COVID-19. So clinicians really need to be aware of the potential to make adjustments to existing psychotropic regimens or to avoid using certain psychotropic agents if such safety concerns are arising. This table is from a paper that appeared recently. It's Bilbo et al., and you'll see the citation at the end of the slide deck. And I want to highlight a few things on these tables. So Bilbo and colleagues prepared tables looking at the potential psychotropic safety concerns in COVID-19 organized by drug class. And they point out that clozapine is associated with increased risk of pneumonia and its complications. And clozapine levels can increase with acute infections leading to clozapine toxicity. So clozapine is actually one of the special cases that we have to be particularly concerned about COVID-19 infection. But of course, other antipsychotics come into the picture as well because there's concern for COVID-19 infection associated with tachycardia, cardiac injury, potential for several medications being used to treat COVID-19 can cause QT prolongation. And of course, antipsychotics can interact with other QT prolonging agents. And also, acute liver injury in patients with COVID-19 who are on antipsychotics, especially things like chlorpromazine, may actually lead to a potential for drug-induced liver injury. I also want to highlight lithium and benzodiazepines. With COVID-19, there's a potential for acute kidney injury. And lithium clearance through the kidneys could actually lead to acute renal failure. So we really have to be careful. And then benzodiazepines in people with COVID-19 may actually exacerbate delirium. And COVID-19 itself is in fact associated with a potential for delirium. So we really have to be cautious about this as well. Another aspect of this kind of care of the pandemic era and early psychosis care is that acute COVID-19 related medical concerns and the subsequent lockdown measures led to delays in patients seeking psychiatric care, just as patients delayed seeking care for cardiac and neurologic conditions. So there is now good evidence that emergency department visits and hospitalizations for psychiatric disorders were significantly reduced in April and May in the Northeast United States That's when cities like New York and also actually Boston, where I work, saw peak numbers of COVID-19 cases. The reduction in ED visits and hospitalizations has since abated in the summer months, but actually with the steady increase in numbers of new COVID-19 cases in the Northeast, we're starting to see new concerns about this delay in seeking care. Of course, elsewhere in the United States, this played out in different timescales. So in some of the Southern states and the Southwest, it wasn't April and May, but it was July, August, September when COVID-19 cases were peaking and ED visits and hospitalizations for psychiatric disorders were actually significantly reduced. In the Northeast, there was a rebound in hospitalizations as reopening progressed and patients became more comfortable seeking care. So there's been this sort of initial reduction and then the subsequent increase. And we really don't know yet what the implications are going to be of this delay in accessing care on a range of outcomes. For example, duration of untreated psychosis. In the world of early psychosis, we place a great emphasis on getting people the care they need as quickly as possible. And in an environment where people were simply not going to get care, and also family members who often are those who initiate accessing care for people with early psychosis may not have been comfortable reaching out and accessing care. How this plays out remains to be seen, but a lengthening in duration of untreated psychosis could in fact have very significant consequences for people with early psychotic disorders. This is where my half of the presentation formally ends. Normally, I would pass the baton on to Dr. Anne Hackman. And you heard about Dr. Hackman's work as a clinical leader in early psychosis care in her clinic in Baltimore. Unfortunately, Dr. Hackman is having some difficulty dialing in and joining the call. And in fact, some of us heard her interactions with the support staff. She's getting a lot of help, but she's apparently not yet in on the call. So what I'd like to do is go ahead and start presenting some of her material as well. I actually feel terrible doing this because this is Dr. Hackman's life's work. I mean, she's a clinical leader who's built this clinic, and her slides are presenting her material. But of course, her work deserves to be heard. So we're going to go ahead and start presenting. And of course, Dr. Rob Cortez is also an early psychosis expert. So some of the material that Dr. Hackman was going to talk about, he has a unique perspective on and can really contribute. So Dr. Hackman's clinic is in urban Baltimore. It began in 2010 as part of Lisa Dixon's RAISE Connection research. It is now part of a state consortium of early psychosis clinics in conjunction with also Pennsylvania first episode clinics. And now Dr. Hackman's clinic has become part of EPINET, the Early Psychosis Intervention Network. That's a network of clinics funded by the NIH. And in fact, our clinic at McLean in the Boston area and several other Massachusetts-based clinics are also part of EPINET. So her team members include a team lead, a recovery specialist, a supported employment and education specialist, a part-time psychiatrist, and a small amount of peer specialists as well. There are also up to 30 clients, ages 15 to 30, who receive care in this clinic. And there is a two-year critical time intervention that they practice. This is a slide of the RAISE team and the physical space. You can see the staff at the entrance and the main program area. Next slide. RAISE, before COVID-19, involved weekly in-person visits, technically for first two months, followed by visits every other week for at least the next six months. Meetings involved clients and families. There is a 24-hour on-call service. Many of the work in the community is done by the supported employment education specialist. They provide groups for clients and families on site. And then a monthly client community activities actually involve going out to the movies, restaurants and supporting events. Of course, with COVID-19, changes have, things have changed significantly. The clinic and raise program canceled almost all in-person visits during the first two weeks of the Maryland state emergency. There was a considerable phone contact with clients. And by mid-April, the team was readily available for in-person visits, but with COVID screening with masks and shields and sanitizing of space between clients. And the in-person visits include administering long acting injectables, meeting with new clients and for in-person visits as requested by clients. Dr. Cortez, I'm actually curious about your experience in Georgia with providing care in this new era. How much of your visits at this point are in-person and how much of them are virtual? Yeah, that's a great question. So we're probably about 15% in-person and the rest are virtual. I think that one of the things that really made a big difference for our program was the good fortune of connecting with this team called the mobile integrated health team. And this is a group of mid-level providers, mostly nurse practitioners that we partnered with that had adequate PPE and they would go into the community and they would meet with people. They would get vital signs. They would deliver medications. They would potentially even give long acting injectable medications. And they really helped to bridge this gap between having people to come in for things like that and allowed us to continue to really provide care, provide clozapine, long acting injectables. Without this team, I don't know what we would have done. And I would really like to, and I think having this experience, I would really like to advocate to figure out how we can have more of these teams available for other programs. I think it's one of the, you know, it's hard to call it a silver lining, but at least we're learning some things that hopefully we can take from this difficult period once we emerge from the pandemic that can actually allow us to improve care provision. Next slide, please. So in Dr. Hackman's clinic, phone meetings replaced some visits. Telepsychiatry was widely used with HIPAA approved platforms and clients adapted quickly to virtual platforms. Most clients like telepsychiatry sessions. Some stated that it was even better than in person and some are able to use telepsychiatry for screening referrals from inpatient units even. But they're also doing more community visits. Some services adapted to sessions with clients at their homes, like in front porches or in backyards. I think this is similar to what Dr. Cortes was talking about. Certainly we've seen something similar at McLean. Many clients have made the transition to virtual sessions actually quite seamlessly. And there was a lot of concern among our frontline clinicians and that concern kind of was replaced by a relief that a lot of the care can still be delivered. And then that relief gave way to, wait a minute, what are we going to do now about clozapine, about long-acting injectables? So then the teams had to actually develop kind of jerry-rig ways of delivering the care that still needed to happen in person, similar to what you're saying as well. Some interesting details, a supported employment education specialist is providing some clients with assistance around virtual learning, which of course has become necessary. And adapting job searches to work available during the pandemic, which is another difficult challenge that many of our clients who were going through the process of accessing employment resources and finding jobs, many of those jobs actually were frozen because of the pandemic. And some of the job searches had to be reconfigured to looking for work that's available during the pandemic. Some of the group care was converted to virtual groups. Staff are providing regular COVID education to clients and families and addressing the challenges of COVID-related stressors for clients and families, financial stressors, what might be called excessive family time, impact of isolation, particularly on teenagers and young adults, barriers to virtual learning, and finding safe recovery-oriented activities. Dr. Contes, I'm curious about your experience on this topic. Yeah, just to some of those points, with how the job market rapidly changed, a number of our clients that had worked really, really hard over years to get meaningful employment, some of them lost their jobs, unfortunately. It was very, very difficult, and the team really needed to provide a lot of support around helping people move towards searching for other jobs and sort of remaining optimistic and hopeful and helping people to move on. Fortunately, a lot of people have been connected to new opportunities, which has been really good, and I think is a testament to how effective the supported education and employment models actually are. And then regarding the virtual groups, I mean, there's really been a lot of room for creativity. I think one of our most popular groups is called a DJ for the day group, where somebody gets on Spotify and they sort of allow their music to be played over a group, and then they kind of play whatever they want, and people really find that empowering. Yeah. So, one of our clients found a service, a website, which provides virtual tours of museums and shared this with the rest of the group. So, one of our groups has turned into these museum tours, which is also, like you're saying, there's so much room for creativity. That's what we have to do to adapt and survive now. So, what about prescribing during the pandemic? So, of course, we're continuing to use first episode prescribing practices, including start low, go slow, medication education for clients and families, shared decision making, appropriate monitoring of laboratory values and weights. None of those have really changed with the pandemic. There is a recommendation to add actually a vitamin D level to all routine labs with replacement therapy when indicated. So, this can come into play with some of our clients, especially in climates in the fall and winter, where sunlight exposure will also go down and people are actually going to be more indoors, partly because of the pandemic and the lockdown measures as well. Some of the other principles, making sure clients have adequate medication available at home in the event of a quarantine or infection, for example. So, 60 or 90 day supplies are now commonplace when clinically appropriate. Of course, for some people, they may not be appropriate and then they should be avoided. And then judicious prescribing of PRN medications to address symptoms, including anxiety, insomnia or breakthrough symptoms of psychosis. These can be very useful because, you know, in many ways we can become less nimble in terms of seeing people quickly in an in-person visit, but being prepared for any of these symptoms that might need to be treated as needed is actually a really good idea. Long-acting injectables. There's been some increase in the use of long-acting injectable antipsychotics. This, of course, decreases the need for visits to the clinic and clients are often agreeable to this. So, when you have a meeting of the minds in the shared decision-making model, long-acting injectables can become a very useful tool in the pandemic era. One thing that should be considered is the availability of backup medication or oral antipsychotic medication should the client become unable to come in to receive their long-acting injectable administration or if the mobile team is not able to provide it where the client is. Dr. Kotez, what's your experience with long-acting injectables in the pandemic era? Well, you know, the addition of the mobile integrated health team has really been quite helpful. One thing that we have seen a little bit is perhaps some shorter length of stay on the inpatient units and many times the inpatient unit initiates a long-acting injectable. You know, for example, like with a medication like paliperidone palmitate, it has two loading doses that are usually given about seven days apart. And one thing that I've seen is people getting maybe the first dose on the inpatient unit and then in the pandemic, people are maybe needing to get the second dose as an outpatient, whereas kind of before people might try to give both of those doses on the inpatient unit. So, I mean, it varies for each individual person, but, you know, in the outpatient setting, we really have to be, you know, very flexible and mobile and really be able to get that person that second loading dose of the injection as soon as possible. Yeah, that's a good point. And that transition, of course, is often a time when people can fall through the cracks and the handoff of care can actually harm the patient. And it's actually good to be mindful of this challenge during the pandemic. Next slide, please. And clozapine prescribing, we already mentioned clozapine. It's playing a greater role, I would say, in early psychosis care with the growing awareness of the potential positive impact it can make on people's trajectories. So, following the recommendations of the April 2020 consensus guidelines, you want to be aware of concerns about clozapine and the immune response, providing education around the vital importance of medical evaluation for any signs of infection, educating clients and families around the current temporary changes, and trying to switch to less frequent blood draws if those are available. So, the consensus guidelines, you will see the citation, the reference to the paper at the end of the slide deck. But clozapine has been an area of special concern for multiple reasons during the pandemic, because people on clozapine may actually have negative interactions with the COVID infection if they do get infected. And then also, both providing clozapine and also having the blood draw counts, blood counts be readily available, have become challenges. Dr. Cortes, what are you experiencing with the clozapine? Yeah, I mean, I think I would make two main points. The first would be, you know, if someone, you know, hopefully it wouldn't happen, but if somebody comes into the emergency room, and they're on clozapine, and they have COVID, you know, suspicious for COVID symptoms, it's very important to obtain a clozapine level when that person is in the emergency room. Clozapine levels usually take, you know, if you have to stand off the lab, they take five to seven business days to get the results back. But sometimes when people develop, when people have COVID, their clozapine levels can increase significantly, and it can lead to a toxidrome, where people have altered mental status, and they can be at risk for all sorts of additional medical complications in addition to COVID-19. So we've really been stressing the importance of obtaining clozapine levels in the emergency room. And then I guess the second point I would make would be, if people develop a fever as an outpatient, that again can be another sign that someone may be experiencing symptoms of COVID-19. And sometimes, you know, we've almost, we've sometimes even considered empirically reducing the dose a little bit, obviously with very, with a great deal of caution around that. So those are some of the things that we've seen with clozapine. Are you continuing with the clozapine clinic model of having people come in and have their blood drawn regularly in the clinic? You know, as per the CISC guideline, that, you know, there were also a lot of other co-authors on that. And with the FDA deciding to not pursue, you know, people not putting the blood work into the REM system, you know, based on a combination of those factors, we've sort of taken an individualized approach for each person and their monitoring schedule. You know, interestingly, clozapine, the rate of agranulocytosis from clozapine after one year probably is comparable to other antipsychotics. So the need for the frequent monitoring may lessen somewhat. So obviously, people who are on weekly monitoring, we've done everything we can to continue the weekly monitoring. But people who are on monthly monitoring, we sort of spaced out to about every three months. Interestingly, after the pandemic hit, there was a lot of people that we then postponed the clozapine blood work for every three months. And then at that three months, there's a lot of people that needed blood work that we needed to figure out what to do. The mobile integrated health team came in. They were very helpful. Some people actually came into the clinic. Some people went into other labs and got blood work there. But it was, you know, three months has been sort of the maximum that we've tried to let people go without labs. But some people have lapsed longer than that. Yeah, yeah. We're very much in the same boat in our clinic, trying to provide, you know, as much good care as possible, spacing out the blood draws when it's needed, and taking an individualized approach. So some people can go to still their local phlebotomy service, you know, if it's open, if it's available. Some people come in actually to our clinic and have one of our clinicians even draw a blood sample. We've done that occasionally to try and keep things moving. But the traditional Clozapine system is really not a good match for the pandemic. So it's become much more individualized now. Next slide, please. And just to one more point about that, it's really unclear. And I think that there's, I'm hoping that some people are going to be looking at this about what has actually happened to Clozapine utilization during the pandemic. And if in fact, people will be started on Clozapine less frequently due to the pandemic. I think that my experience prescribing during this during COVID-19 has been, you know, whatever you were doing before, it takes a lot more effort just to continue the current, that previous level of care that you were providing. And I think sometimes starting Clozapine can be like something that's above and beyond for people, you know, unfortunately, and in the midst of the pandemic, it's just, you know, sometimes it may be too difficult to begin. So it's curious, I'm curious what's going to happen with that. Yeah, good point. You know, Clozapine, I think we would all agree, is underutilized in the best of times. And part of that is because of what are perceived as barriers, but it's really sort of, you know, a lack of proper education and training for getting started using Clozapine in many cases when it's appropriate. So we've often advocated for more Clozapine use in psychiatry. And during the pandemic, those barriers feel even higher. So it's a good point. So some of the prescribing challenges Dr. Hackman is pointing out, high dose medications are sometimes started with people during a first episode hospitalization. We've observed some increase in this during the COVID-19 pandemic. So we typically begin to cautiously deprescribe when symptoms are stable, and we have established relationships. And this can become more complicated with fewer face to face encounters. So this is a reality that I myself have observed that inpatient units and outpatient providers have different priorities. Inpatient units are about stabilization of acute symptoms and getting person to a less restrictive level of care, whereas the outpatient clinic then has to, you know, manage the prescription patterns long term and minimize the adverse outcomes that can be associated with overprescribing. So this is a common pattern of having people on higher doses of medications in the inpatient units, and then the outpatient clinic tries to lower the dose. And Dr. Hackman is making the point that this is actually becoming an even more acute issue during the pandemic. You know, it seems to me another prescribing challenge that comes up is often the evaluation of extrapyramidal side effects over the video technology. And this has been a reason that, you know, we have brought some people into clinic that we've been seeing mostly in a virtual way. And, you know, really doing a very thorough assessment for extrapyramidal symptoms and, you know, feeling for rigidity and watching the gait and watching the arm swing and doing all those things that we could do. You know, there's, of course, some things that you can pick up on Zoom, but there are some challenges, I think, over that modality. I'm curious, have you had similar experiences with that? Yeah, absolutely. This is a real challenge. And then, you know, the other thing that we've observed is the potential for loss of privacy and confidentiality when people are doing these, you know, telehealth visits and then asking somebody to, you know, try and do an EPS exam on themselves when there's others in the house and so on has actually complicated matters. So other prescribing challenges, Dr. Hackman points out, distinguishing behavior is related to frustration around COVID-related restrictions from psychosis-related symptoms. Particularly true with adolescent clients who may be frustrated and angry, but having a diagnosis, losing social outlets, virtual learning, parents may sometimes seek medical solutions, medication solutions for an angry and frustrated teenager. So this is, it's a tough challenge when people have been, you know, quarantining together at home during the lockdowns and then potentially afterwards as well. And distinguishing, you know, an exacerbation of a psychiatric disorder from the COVID-19 restriction-related problems. And one referral with the first psychotic episode that was apparently triggered by COVID-related stressors in Dr. Hackman's clinic. This is interesting. We haven't seen that in our clinic, but it doesn't mean it's rare. Dr. Cotes, I don't know if you've seen, you know, we were talking about COVID-19-related psychopathology, but a psychotic episode is sort of another step there. Yeah, that hasn't been something that I've seen, but I could definitely, I can definitely see that kind of thing happening. And I bet that our inpatient colleagues or our colleagues in the emergency room have probably seen that. Yeah. Another point that Dr. Hackman wanted to make that is definitely worth bearing in mind is dual diagnosis and substance use disorders. So during the COVID-19 pandemic, we already talked about the increasing rates of substance use, as well as the potential for worsening of substance use disorders. And this really needs to be addressed in our population as well. There has, there's already data suggesting that there's been an increase in opioid overdose deaths during the pandemic. Baltimore has seen increasing levels of fentanyl use, which is, of course, highly concerning because many opiate overdoses and overdose-related deaths are associated with fentanyl use. So providers in first episode programs should be able to prescribe buprenorphine and naloxone when appropriate. Dr. Cortes, is this something that you have instituted? The buprenorphine naloxone prescribing? Yes, absolutely. You know, in the setting that I practice in the metro Atlanta area, there's a lot of, there's geographic variation with the type of substances that are used. And, you know, oftentimes we, in the first episode population that we work with, we tend to see people who use more cocaine and sort of other amphetamines and less opioids. But we often, we do see some opioids, you know, lean is a pretty popular, is a pretty popular substance where we are, and it tends to go under-recognized by a lot of prescribers. And so we try to really monitor opioid use, and it's often not the first thing that people are thinking about. Yeah, yeah. Unfortunately, you know, it's interesting, some of the emerging data so far, there's concern about suicide, but suicide numbers are not yet documented to be shooting up. They might, they still might, but we don't have that data yet. But we do have data that opioid overdose deaths are in fact going up. So this is clearly kind of a proximate threat that we need to keep in mind, including in first episode clinics. Next slide. And then COVID-19 infection and people living with new onset psychosis. Little information is available on COVID-19 infection on people in first episode programs. People in treatment are receiving regular COVID-19 prevention education. And of course, I think we all know at this point that young people typically have less severe illness with COVID-19 and not the same risks as older adults who are living with schizophrenia. So that can be a mitigating factor that makes us somewhat less concerned, but it doesn't mean the risk is zero. It is something to be worried about. And certainly providing education and making sure that young people in our clinics are adhering to the social distancing, masking protocols as appropriate is going to be important. We actually conducted a survey among colleagues of five different first episode clinics asking how many of their patients had tested positive for COVID-19 and then how many had been hospitalized, how many had died. And we found that on average, first episode clinics had about one patient who had tested positive for COVID-19, one in each clinic. And then no hospitalizations and no deaths. So that was reassuring that the numbers are not huge, but certainly there's going to be an occasional patient who's going to be grappling with a COVID-19 infection. Yeah, I would just make one other point. I think that, you know, it's been really helpful to explore people's sort of ideas about the pandemic and social distancing and masking in a very nonjudgmental way, and then use a motivational enhancement framework to be able to help move people to change to more using social distancing and masking, because people have had a wide range of opinions in the program that I work in about whether they should be doing social distancing or not. And we have seen some people be successful using a motivational interviewing approach. So moving forward, Dr. Hackman closes with a plea for more data on outcomes in the early psychosis population in the COVID-19 era. They are still sparse, I agree with this, and they are urgently needed, I also agree with this. You know, we are looking at data in our own clinic, and with about over 100 active patients that we've been following in the McLean Clinic. And I can tell you that supported employment education has been a tough challenge. Many of our patients actually were not able to continue with schooling, even after the summer and, you know, returning back for the fall has been a challenge. And many people have lost jobs that they were working in, and have had to readjust just like we were talking about. So I think it's absolutely true that we need more systematic data on how people are doing, both with the medical complications around COVID-19, psychiatric sequelae of COVID-19 and mitigation efforts, and then the community functioning problems related to the pandemic. So Dr. Unger, thank you so much. The helpful people at Tech got me on just in time to hear you do my last slide, since it was a fairly idiosyncratic slide set and unique to some of what's going on in Maryland. I give you credit for even trying it. Thank you. And I do apologize for disruptions earlier. It's been a complicated hour and a half. Well, it's great to have you. It's great to see you. And thank you for preparing the slides. I said when we were starting that, you know, it really feels long because this is your life's work. You know, built this clinic and you've provided great care to so many people for us to try and fill in. But we did the best we could. And, you know, thanks to Dr. Koteskis. He also shared his experience in the pandemic with a lot of clinical hurdles. Thank you so much. And my apologies. All right, great. Well, welcome again, Dr. Hackman. We're so glad to have you here. I think that maybe what we can do now is maybe we can go to some of the questions that the audience raised. I think the audience had a lot of really great questions and comments, and we really appreciate all the participation from the audience. So why don't we go ahead and jump into some of these questions? There was a slide early on that you presented, Dr. Unger, where we were looking at the incidence of various mental illness in the midst of the pandemic. And we were talking about depression and anxiety, and someone was wondering about, do we know yet if there's going to be an increase in PTSD rates in the pandemic? Well, it's a great question. So I haven't seen hard data on that. And the slide that I presented was from this nationally representative survey. So it's not clinical data, but it's a survey of people in society. And the psychopathology rates are high. And it's really chilling to see 24% of young adults, 24% of young adults, have seriously considered suicide in the past month in the United States. PTSD, it's going to be interesting. There's some debate about whether the impact of the pandemic is going to lead to PTSDs I don't think we traditionally understand it since, again, it's a slowly unfolding drip of bad news that we're all grappling with. So it's going to be interesting to see. I think, you know, again, in the absence of hard data, we can speculate that I believe PTSD rates will rise, and some of it will also be from the COVID-19 disease itself, people who survive but have been traumatized by it. And beyond that, what other kinds of, you know, it might be sort of a soft PTSD or a PTSD plus, people who are experiencing a lot of symptoms that aren't classic PTSD symptoms, because they did not experience an acute trauma. But nonetheless, it's psychopathology. That's where my thinking is. Yeah, thank you so much. There was a, there was another question that came up that I think often comes up in first episode in sort of early psychosis conversations. And the question is about how do you support youth who do not want to take a daily antipsychotic medication due to side effects? And so I guess that would be probably where we would leave that question. It's sort of about the decision to take an antipsychotic medication or not. And I think sort of secondarily have opinions on that changed in the midst of COVID. Dr. Ackman, do you want to take this one? I will be happy to take a stab at that. Sure. So part of first episode work, and in the state of Maryland, we do not have outpatient commitment or assisted outpatient treatment. We're one of, I think, four states in the nation where that is still the case. So it's always been very much a matter of shared decision making, including watchful waiting as an option with shared decision making. Now, that doesn't mean that someone's mother can't say, if you're living in my house, you need to take medications. But I, as the psychiatrist, we as the treatment team have no civil mechanism for requiring people to be on medications. And during the pandemic, I think we have handled it in much the same way that we did before the pandemic, if people are choosing not to take medications, and obviously, this is after we've worked with them around their various choices and best side effect profiles, then we would continue to monitor closely, have very frequent contact, work with families around both safety plans and things that would suggest that they needed to be concerned. I typically encourage people to have medication on hand, even if they are currently on choosing not to take it, so that if something happens and things worsen, particularly with the potential for being in a state of lockdown, they have something there that they could start if they needed to. And I know there was a question earlier about my mention of the judicious use of benzodiazepines early on in the program, well before the pandemic. I had a young man who, from the very beginning, absolutely refused to take an anti-psychotic medication, had discontinued before he came to us, but we did discover that if he got particularly anxious and did not sleep, that his psychotic symptoms were exacerbated. And for him, he had 0.5 milligrams of lorazepam that he took very intermittently, and he had 0.3 if he was under considerable stress or had difficulty sleeping. And 15 of those would last him for several months. So that's kind of been my approach. All right, thank you. Another question came up from the audience, I think this one came up when we were talking about clozapine. The question is, how does clozapine affect behavioral habits such as smoking, and would adjustments in dosages mitigate or exacerbate substance use? So, you know, we know the interaction between smoking and clozapine levels and monitoring that. I'm not aware of specifics around clozapine dosage mitigating or exacerbating illicit substance use in my first episode population, but I can tell you that given years as an assertive community treatment psychiatrist, there's a man that I worked with for a very long time who actually had symptoms that were pretty refractory to treatment, long history of lots of substance use. When he was started on clozapine, and the symptoms were greatly decreased, he stopped using substances and was very clear in saying, I needed to do something to deal with these ongoing auditory and visual hallucinations that were incredibly difficult in nature. And now that I have the clozapine, I don't need that anymore. So that's an N of one. Right, there's good evidence that clozapine use reduces substance use disorder incidence in patients with psychotic disorders. The question about dose adjustments, I also don't have a good handle on that. I think our practice anyways is, you know, adequately treating the psychotic disorder. And then, you know, the substance use disorder sort of goes with that. Yeah, I think that that's a very important point is that, you know, just because someone has a substance use disorder, it shouldn't be a contraindication for using clozapine. In fact, the clozapine can actually help people to use less substances over time. So I thought that was a good question. And we are not sure if there is a dose dependent relationship on that one. Okay, another question here. This is sort of getting at the point that was made earlier about how can the field have more people outside of psychiatrists that can prescribe safely? And how can we increase that number? And there was some mention about having more primary care physicians have prescribed psychotropic medications. And then there was a question in there about at the medical school level to help promote more sort of knowledge and awareness of using psychotropic or using medications traditionally prescribed in psychiatry. I find in general that people who are not psychiatrists tend to be very reluctant to prescribe antipsychotics in most settings or to treat schizophrenia spectrum illnesses in most settings. I've certainly worked with some wonderful nurse practitioners who have done that. And I think I run the preclinical psychiatry block at the University of Maryland School of Medicine. And I think teaching students early and de-stigmatizing mental illness as much as possible. And we do that by having a lot of people with lived experience come in and talk to the students, including a former first episode client. So I think de-stigmatizing psychiatric illness is really a very important piece of it. I really agree with that. I think the priority should be to get clinicians to become comfortable working with people with psychotic disorders, especially early psychosis. I mean, I'm reminded that there is a few classes of psychotropic medications that are now prescribed by non-psychiatrists, the majority of them. SSRIs are like this, right? And benzodiazepines are approaching, if I remember correctly, and psychostimulants. But antipsychotics are not, just like Dr. Hackman said. And I think that's actually appropriate that treating people with psychotic disorders is team-based care and requires expertise. So I think, you know, the primary care docs, as long as they're comfortable being a primary care doc or a pediatrician, you know, or a family practitioner for our patients, that's really the best collaborative setup, I would say. Yeah, thank you. I really agree with all those points. And Dr. Hackman, I wanted to give the CAP program at Maryland a quick shout out, the combined accelerated psychiatry, something like that. But it's a wonderful program to get people, medical students, early exposure to psychiatry. Yeah, and I did that program as a medical student here, starting in 1986, and have been co-leading it for more than 25 years. So we continue to do that. And this is something that starts in the preclinical years, and it's very cool. And I think because of all of those efforts, really, the pipeline coming into psychiatry is quite strong. And medical students now are choosing psychiatry at greater rates than they had, you know, five or 10 years ago. And I think a lot of this is about efforts that people, you know, even in this conference have been making to reduce the stigma around, you know, people that have experienced, you know, people using services and people with mental illness. All right. So the next question here is an interesting one, wanted to get your thoughts on, are antipsychotics as effective in treating early episode psychosis as a result of substance-induced psychosis? I guess it's sort of like, how effective are antipsychotics in treating substance-induced psychosis? And is that similar to their effectiveness in treating people who have a diagnosis of schizophrenia? I think that when someone comes in with psychotic symptoms into a hospital, they are treated with antipsychotics, and for the most part, antipsychotics work. Often with first episode individuals, it can be very hard to tell. Is this a substance-induced psychosis? Did, you know, all the marijuana, or worse still, the synthetic marijuana, actually trigger trigger what is going to develop into a long-term psychotic illness? So I think particularly with synthetic marijuana that we are seeing people whose symptoms initially are psychotic symptoms are not as responsive to treatment as we would like them to be. But the approach is the same, I think. Yeah, I agree. And I would maybe turn it around and say, substance-induced psychosis, of course, you know, the DSM has a relatively narrow definition of it, but I think this question implies something a little broader than that. The challenge is not that the antipsychotics are less effective, but that if the substance use is ongoing, that interferes with care. So in fact, I would say in our early psychosis clinic, you know, one of the markers of a poor prognosis is somebody who is acutely psychotic and is still smoking a lot of weed. It's cannabis for us. That's a huge challenge. And, you know, when you see that patient, you know, that's not somebody who's going to recover quickly. But people who are able to stop smoking weed or never had a problem with cannabis, those actually tend to have a better prognosis. So it's sort of the substance is still in the picture, and that's a problem. Yeah, great points. And also, I would add that individuals who have had a diagnosis of substance-induced psychosis at a relatively high frequency actually end up developing something like schizophrenia. Maybe a third of people would. So it's sort of a risk factor, but I just also want to emphasize that diagnostic uncertainty early when someone comes to present for, you know, present for care. Another question that came up is, how has, or has it, I mean, has the approach to psycho education changed in the COVID-19 era? You know, I would say that the approach to psycho education, for me, has not changed a lot. I may be doing more of it over Zoom than in person, but that we also have the opportunity but that we also have the opportunity to do lots of COVID-19 education while we're at it. And that seems to me to have been useful kind of across the board and working with people who are living with psychiatric diagnoses. Yeah, I've not seen psycho education change a whole lot, except sometimes when it comes to helping parents and family members sort out what's a psychotic symptom in their teenager or young adult and what is a teenager or young adult who is profoundly frustrated with the fact that all their usual social outlets are gone or greatly limited and they're angry and yelling and occasionally, you know, throwing things and being aggressive. And I've had family members who are like, you need to give her medication for this. When I say actually, I think there are other things we can do, but more medication is not going to stop the person from being angry. And I'd like to add one thing. It's not really about psycho education, but it reminded me that one thing we're observing is, of course, a lot of our young people have different pathways to get to care and to get to the clinic. But there is one pathway, which is family raising concern and wanting to have kind of a consultation or just the first interaction to assess the situation. And that used to have a relatively high bar, you know, which young person wants to drop what they're doing and come to a hospital and see a psychiatrist, psychologist, what have you, social worker and so on. And now with Zoom, it's actually easier. It feels like less of a commitment and a lower bar to cross. So we've been able to get more young people to say, you know, all right, I'll just sit down and talk to you for a half hour. You know, and sometimes it leads to more of an attachment to the clinic and sometimes it doesn't. But at least that interaction has gotten easier for us. Yeah. So a question sort of related to the early identification. I'm curious how, I think, you know, some of the remarks that you were making earlier about the impact of COVID-19 on duration of untreated psychosis are very interesting. And I'm sort of, I'm curious how, you know, maybe prodromal teams or people that really focus on early identification, how that has changed in the pandemic. And, you know, because people aren't at, you know, they're not in classes physically, they're doing online school. I'm wondering if there may be any changes into the identification of people who may be at clinical high risk. You know, that's a great, I'm the one who made that comment. So I guess I should try to say something. But it's a great question. And I don't think that we have clear evidence yet. But I am concerned about this. At least in Boston, you know, when I talked to my colleagues who see more, you know, clinical high risk individuals, there was sort of a drying up of that phenomenon. Like you're saying, you know, schools, churches, community organizations, other settings where some of these youngsters would sort of raise some concern and they would come to some kind of attention. It's just not happening the way it used to. And then families set the bar higher for a lot of reasons. But now in the pandemic era, too, you know, there's a higher bar to say we got to go see somebody or at least we got to find somebody to help us. I really wonder if more people are going to wait until, you know, some kind of action has taken place, whether, you know, the youngster has, you know, had a behavioural outburst or something else has happened. So then finally the bar gets crossed. That's what I worry about. All right. Well, we really want to thank the audience. I think there were some some really terrific questions. And again, thank you to our speakers, Dr. Unger, Dr. Hackman, a really terrific presentation. We apologize to everyone about the technical difficulties, but hopefully we hope there were some things that I know I learned some new things in this presentation. So if you are claiming continuing education credits, either for psychology or social work, please be sure to complete the evaluation at the end of the session. And if you are claiming continuing medical education for physicians or certificate of participation, you'll be able to do so at the end of the conference. So again, I wanted to thank everybody and take care. Thank you.

psychopharmacology management

early psychosis

COVID-19 pandemic

psychiatry

moderator

faculty presenters

impact of pandemic

psychiatric disorders

increased psychiatric services

prescribing during pandemic