Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity – the presence of two or more chronic conditions in an individual – which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors – including trauma and racism – that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review

Under-Represented Populations Left Out of Alzheimer’s Disease Treatment with Aducanumab: Commentary on Ethics

Despite controversy about the efficacy and safety of aducanumab, the FDA's fast-tracking of this medicine is truly historic. However, structural problems leading to socioeconomic disparities and systemic racism in science, healthcare, and society have left out under-represented populations. This perspective outlines the racial and socioeconomic health disparities in aducanumab treatment: 1) Disparities in the risk of Alzheimer's disease (AD), 2) Limited participation from under-represented groups in AD trials raising concerns about the generalizability of the results, 3) Questionable applicability of the amyloid hypothesis in groups under-represented in AD research, and 4) Aducanumab's initial sticker price that unfairly singled out those with lower socioeconomic backgrounds. Potential solutions are discussed

Eliciting emotional expressions in psychodynamic psychotherapies using telehealth: a clinical review and single case study using emotional awareness and expression therapy

The COVID-19 pandemic and ensuing social distancing requirements resulted in an abrupt transition in the provision of most mental healthcare to telehealth; yet it was, at first, unclear whether patients' emotional expressions - of great import to the success of many psychodynamic therapies - could be facilitated using teletherapy. This article first presents a targeted literature review focused on emotional expressions in psychotherapy and implementing psychodynamic therapy over telehealth and then describes our clinical experience transitioning a psychodynamically-informed, evidence-based, and experiential group treatment for chronic pain, emotional awareness and expression therapy (EAET), to video telehealth at VA Greater Los Angeles Healthcare System. We discuss barriers we encountered in our implementation of EAET over video telehealth but also illustrate the ultimate success of the approach using verbatim excerpts from our therapeutic work, which aim to demonstrate the potential to facilitate powerful emotional expressions over video telehealth when conducting a psychodynamically-informed treatment. We examine the possible applications for video telehealth to maintain emotionally focused, psychodynamic psychotherapy administration and enhance its teaching and training. Although we describe limitations of our specific approach, ultimately, our experience supports the potential efficacy of experiential, emotion-focused psychodynamic therapies in a telehealth setting

The Mental Health of Older LGBT Adults.

There are approximately one million older lesbian, gay, bisexual, and transgender (LGBT) adults in the USA. Their mental health issues result from interactions between genetic factors and stress associated with membership in a sexual minority group. Although advancements in acceptance and equal treatment of LGBT individuals have been occurring, sexual minority status remains associated with risks to physical and mental well-being. Older LGBT adults are more likely to have experienced mistreatment and discrimination due to living a majority of their lives prior to recent advancements in acceptance and equal treatment. All LGBT adults experience one common developmental challenge: deciding if, when, and how to reveal to others their gender identity and/or sexual orientation. LGBT individuals have higher rates of anxiety, depression, and substance use disorders and also are at increased risk for certain medical conditions like obesity, breast cancer, and human immunodeficiency virus (HIV). Improved education and training of clinicians, coupled with clinical research efforts, holds the promise of improved overall health and life quality for older LGBT adults

The Physical and the Emotional: Case Report, Mixed-Methods Development, and Discussion.

There is a growing recognition that emotional problems are important to physical health outcomes. In response, primary care clinics have introduced self-report checklists to identify patients with emotional disorders such as depression or anxiety. Yet psychodynamic theory posits that certain emotional problems may be unconscious and unspoken, and thus not discernible on self-report checklists, and studies show that checklists do not identify every patient who needs treatment. New clinical tools are needed to identify subtle and complex presentations. We aimed to develop an innovative mixed-methods approach characterizing different types of verbal expression of feelings, drawing on psychodynamic theory and empirical research. We outline the development of the mixed-methods approach, including our theoretical framework and use of semi-structured interview data from Partners in Care (PIC), a randomized controlled trial of quality improvement for depression. We then illustrate the approach with one case: an older female PIC participant who screened positive for depression on all study self-reports. The approach delineates three qualitatively different categories of words-specific feeling words, vague feeling words, and physical words-that were quantified to define a measurable pattern for our participant. Clinicians could be trained to identify these categories of words in the context of a discussion of feelings to better detect and understand subtle emotional problems in patients who have difficulty talking openly about their feelings. Next steps include furthering face and construct validity and test-retest reliability, examining the prevalence of these patterns in a larger sample, and assessing correlates of patterns

The Mental Health of Older LGBT Adults.

There are approximately one million older lesbian, gay, bisexual, and transgender (LGBT) adults in the USA. Their mental health issues result from interactions between genetic factors and stress associated with membership in a sexual minority group. Although advancements in acceptance and equal treatment of LGBT individuals have been occurring, sexual minority status remains associated with risks to physical and mental well-being. Older LGBT adults are more likely to have experienced mistreatment and discrimination due to living a majority of their lives prior to recent advancements in acceptance and equal treatment. All LGBT adults experience one common developmental challenge: deciding if, when, and how to reveal to others their gender identity and/or sexual orientation. LGBT individuals have higher rates of anxiety, depression, and substance use disorders and also are at increased risk for certain medical conditions like obesity, breast cancer, and human immunodeficiency virus (HIV). Improved education and training of clinicians, coupled with clinical research efforts, holds the promise of improved overall health and life quality for older LGBT adults

The COVID-19 AAGP Online Trainee Curriculum: Development and Method of Initial Evaluation

ObjectiveOne effect of the COVID-19 pandemic is the disruption of in-person clinical experiences within geriatric psychiatry residency education. Online resources for trainees are needed to fill resultant gaps.MethodsThe American Association of Geriatric Psychiatry (AAGP) Teaching and Training Committee leadership collaborated with geriatric psychiatry experts to develop a web-based geriatric psychiatry curriculum for psychiatry residents and other learners. In addition, we planned to obtain initial self-report outcomes of the curricular modules.ResultsThe COVID-19 AAGP Online Trainee Curriculum (aagponline.org/covidcurriculum) consists of approximately 30 video-recorded lectures provided by AAGP member experts. A demographic survey and pre-/postsurvey attached to each module allow us to obtain learner characteristics and feedback on each module.ConclusionsThe Curriculum has the potential to supplement psychiatry residency education during the pandemic and potentially raise the profile of AAGP, with the goal of inspiring interest within geriatric psychiatry. Results of the initial self-report evaluation should be available in 1 year

Emotional awareness and other emotional processes: implications for the assessment and treatment of chronic pain

Emotional awareness (EA) is a key emotional process that is related to the presence and severity of chronic pain (CP). In this report, we describe primary and secondary emotions, discuss the distinction between emotional states and emotional regulation/processing, and summarize theory and research highlighting the significance of EA for CP. We describe ways to assess EA and diagnose centrally-mediated CP, for which emotional processes appear most relevant. We review several psychological interventions designed to enhance EA as well as several broader emotional processing treatments developed to address trauma and psychosocial conflicts underlying many patients' pain. We conclude by offering our perspective on how future integration of emotional processing into pain care could promote recovery from CP