Southern California PSYCHIATRIST December 2024

Cannabis: A Peril or a Panacea?

by Ruqayyah Malik, MD

Cannabis sativa is the annual dioecious plant–originally native to Asia–from which one of the most commonly used recreational substances in the world is derived (1,2,3). Cannabis sativa (C. sativa) contains over 500 chemical compounds, however, tetrahydrocannabinol (THC) is the main psychoactive compound that produces physiological and psychological effects. THC mainly acts on cannabinoid CB1 receptors in the brain to increase dopaminergic transmission. It can produce altered mind states such as euphoria, increased appetite, increased sociability, as well as altered sensory perceptions (2). Adverse effects of THC such as increased anxiety, paranoia, and psychosis are also possible in some users.

Cannabis–now commonly known as weed or marijuana–has been used for centuries in various cultures for spiritual and medicinal purposes (1). There are varying concentrations of THC that can be found in different strains of cannabis with different levels of psychoactive potency. For example, the fibrous stalk of the C. sativa plant typically has very low THC concentrations and can be converted into industrial hemp fiber that can be used for textile manufacturing, paper production, or construction materials. “The use of cannabis as a medicine by the ancient Chinese was reported in the world’s oldest pharmacopoeia, the pen-ts’ao ching which was compiled in the first century of this Era, but based on oral traditions passed down from the time of Emperor Shen-Nung, who lived during the years 2.700 B.C. Indications for the use of cannabis included: rheumatic pain, intestinal constipation, disorders of the female reproductive system, malaria, and others” (1). In terms of the modern medicinal value of the c. sativa plant, Epidiolex is an FDA approved anti-epileptic drug that contains cannabidiol and can be used to treat rare and severe forms of epilepsy such as Dravet syndrome or Lennox-Gastaut syndrome. Marinol and Syndros are also FDA approved antiemetic and anti-nausea medications that contain dronabinol and can be used for patients undergoing chemotherapy. Marinol and Syndros also have appetite-stimulating effects and can be used to treat anorexia and weight-loss in HIV/AIDS patients.

The long-term effects of heavy recreational cannabis use is still under investigation. Modern advances in horticulture have led to increased concentrations of THC in cannabis products with more powerful effects on the brain. Clinically, heavy cannabis users (e.g. daily use with notable tolerance and an inability to cut down use without withdrawal symptoms) can present with cannabis hyperemesis syndrome, psychosis, as well as negative alterations in mood, cognition and motivation. The legalization of the recreational use of cannabis in about 50% of US states has increased the access to and utilization of the substance. It is important that we continue to study the medical and psychiatric effects of cannabis so we can appropriately advise and guide our patients.

Cannabis has been shown to have a dose-dependent toxicity on CB1 brain receptors in animal studies. Human studies are more limited, however, Battistella et al. 2014 found that, “ regular cannabis use is associated with gray matter volume reduction in the medial temporal cortex, temporal pole, parahippocampal gyrus, insula, and orbitofrontal cortex; these regions are rich in cannabinoid CB1 receptors and functionally associated with motivational, emotional, and affective processing” (2). Indeed, cannabis use has been associated with a transient amotivational syndrome and decreased self-efficacy (3). Cannabis use in early adolescence has also been shown to affect the maturation of white matter tracts which can result in lower intellectual functioning and other neuropsychological deficits (4). Camchong et al. 2017 noted, “Previous studies investigating the effect of cannabis on development suggest that there is a persistent effect on cognition and neuropsychological performance in individuals who initiate cannabis use during adolescence. Longitudinal data show that individuals with more persistent cannabis dependence have a pronounced intelligence quotient (IQ) decline, with significant impact on overall IQ…Moreover, evidence suggests that overall IQ deficits do not fully recover after cessation of use (1 year), particularly in adolescent-onset cannabis users” (4).

The c. sativa plant has over 500 chemical compounds and, as has been shown, a multitude of applications. The increased concentrations of THC in recreational cannabis products however has led to more potent–and at times more deleterious–psychoactive effects. As cannabis continues to be more accessible to people all over the country it is important that we appropriately advise our patients on the risks and potential long-term effects of heavy recreational cannabis use on the developing brain as well as one’s baseline mood, anxiety levels and cognition.

Citations:

1. Zuardi, A. W. (2006). History of cannabis as a medicine: a review. Brazilian Journal of Psychiatry, 28, 153-157.
2. Battistella, G., Fornari, E., Annoni, J. M., Chtioui, H., Dao, K., Fabritius, M., … & Giroud, C. (2014). Long-term effects of cannabis on brain structure. Neuropsychopharmacology, 39(9), 2041-2048.
3. Lawn, W., Freeman, T. P., Pope, R. A., Joye, A., Harvey, L., Hindocha, C., … & Curran, H. V. (2016). Acute and chronic effects of cannabinoids on effort-related decision-making and reward learning: an evaluation of the cannabis ‘amotivational’ hypotheses. Psychopharmacology, 233, 3537-3552.
4. Camchong, J., Lim, K. O., & Kumra, S. (2017). Adverse effects of cannabis on adolescent brain development: a longitudinal study. Cerebral cortex, 27(3), 1922-1930.

A Comparison of Safety and Prescribing Practices between In-Person and Telehealth Visits

by Matthew Markis, DO

March of 2020 seems like ages ago, when an unfolding global pandemic took hold of our daily lives. So little was known about the virus; the risk of infection, who was vulnerable and how to respond. One certainty, however, was that in our line of work and with the existing technology, it was safer and more reasonable to shift our services online. Although some psychiatrists had previously utilized this method, often in service to rural populations, the pandemic rapidly accelerated the use of this technology in ways that made it standard practice.   Across all of medicine, a study of insurance claims data for 36 million working age individuals showed that telemedicine encounters increased 766% in the first 3 months of the pandemic, from just 0.3% in March to June 2019, to 23.6% for the same period in 2020.

Shortly after the lockdown, I started the process of converting a bedroom into my new office. I first moved in the dining room table, and then added new furniture and artwork, including my Zoom backdrop to make it my own comfortable workspace. I quickly noticed the satisfaction of my patients, appreciating the convenience of not having to commute for follow-ups, and not having to expose themselves to the unnecessary risk of infection. No one expressed any concerns about it impacting the quality of their care.

Now with the lockdowns long over, many of us in mental health have settled into this new routine. I enjoy a nice hybrid schedule, seeing patients mostly from home, but also going in once or twice a week to accommodate others who want to be seen in person. This also allows me to see office staff as well, not just communicating with them through Teams.

Despite my subjective experience, I wanted to see what the data shows regarding telehealth, both in terms of patient/provider satisfaction, and patient safety. One survey of 604 patients and 154 providers showed that 70% of both were generally satisfied with telepsychiatry. Interestingly, providers were more likely to favor in-person care after the pandemic compared to patients, 48% to 17%, respectively. In a survey of 3070 patients during the pandemic, 82.2% described their overall experience using telepsychiatry as either excellent or good. In a separate survey of 819 mental health care providers, 73% of them rated their experience as excellent or good.

While ensuring satisfaction for both patients and providers is significant, safeguarding patient safety remains the top priority, and evidence indicates that telehealth does not have a negative impact on patient outcomes across different patient populations. A meta-analysis of 20 trials including treatment for PTSD, depression, a mix of different disorders, and general anxiety disorder revealed that telemedicine is comparable with in-person treatment regarding treatment efficacy, patient satisfaction and attrition rates. Telehealth used for patients receiving medications for opioid use disorder was associated with increased odds of retention and lower odds of medically treated overdose. In a comparison of patients attending IOP and PHP programs, there were no significant differences in QIDS or Q-LES-Q discharge scores, or degree of change between admission and discharge scores between those attending in person and online.

A key area of concern has been individuals who are prescribed controlled substances, especially stimulant medications. This has been driven by a surge in prescriptions for ADHD medications during the pandemic, a 32% increase for non-stimulants and 10% increase for stimulants, whereas prescribing rates were flat prior to the pandemic. The increase in prescriptions was largely driven by adults between the ages of 20–39, and nurse practitioners who prescribed 57% more stimulants and 75% more non-stimulants compared to the two years prior to the pandemic. However, prescribing for benzodiazepines, buprenorphine and antidepressants remained flat.

The rise in stimulant prescriptions during the COVID-19 pandemic has been attributed to several interconnected factors. These include expanded access to telehealth and online pharmacies, increased awareness of conditions like ADHD, and disruption of work, social and family life during the lockdown that negatively impacted mental health. Yet the primary factors behind the increase remain uncertain, leaving questions as to whether it stems from overprescribing or a genuine effort to meet patient needs

Despite the increase in the total number of prescriptions for ADHD, evidence has shown there are similar prescribing rates between telehealth and in-person visits. An analysis of 205,065 initial visits for ADHD from January 1, 2020, through March 31, 2023 showed that within 30 days of the initial diagnosis, medication was prescribed roughly 60% of the time for both types of visits. Stimulants were initially prescribed 84% of the time for telehealth, and 87% for in-person. The high percentage of stimulants used is indicative of them being among the most effective and well-studied psychotropic medications.

With no clear evidence indicating harm from online prescribing and numerous documented benefits, the psychiatric community has strongly advocated for the continued use of telehealth. Last July, the American Psychiatric Association presented at the White House and urged the administration not to require in person visits as a requirement for prescribing stimulants. A near-record 38,000 comments from providers, patients and other advocates were made during public listening sessions held by the DEA in September 2023, urging it to include stimulants under telehealth prescribing.  It was advocating for patients who do not have access to local providers, and those who are having difficulty establishing care with a psychiatrist. The impact goes far beyond ADHD, given that as many as 80% of adults with ADHD are reported to have at least one other comorbid psychiatric disorder.

As the public health emergency has come to an end, questions about the future of telehealth and stimulant prescribing remain. Policymakers are considering whether to make telehealth flexibilities permanent, recognizing the benefits it has brought to patients and providers alike.

The pandemic served as a proving ground for telehealth’s potential, demonstrating that remote care can be both safe and effective. For patients managing conditions like ADHD, these innovations have not only preserved the standard of care but, in many cases, improved access and engagement.

The lesson is clear that the key to safe and effective stimulant prescribing lies not in restricting access but in ensuring evidence-based practices. With thoughtful policies and continued provider diligence, telehealth can remain a cornerstone of accessible, high-quality care—without compromising patient safety.

References:

1. Shaver J. The State of Telehealth Before and After the COVID-19 Pandemic. Prim Care. 2022 Dec;49(4):517-530. doi: 10.1016/j.pop.2022.04.002. Epub 2022 Apr 25. PMID: 36357058; PMCID: PMC9035352.
2. Morreale M, Cohen I, Van Wert M, Beccera A, Miller L, Narrow W, Schweizer B, Straub J, Zandi P, Ruble A. Determinants of experience & satisfaction in telehealth psychiatry during the COVID-19 pandemic for patients & providers. Front Psychiatry. 2023 Sep 1;14:1237249. doi: 10.3389/fpsyt.2023.1237249. PMID: 37720903; PMCID: PMC10502508.
3. Jones CM, Shoff C, Hodges K, et al. Receipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 Pandemic. JAMA Psychiatry.2022;79(10):981–992. doi:10.1001/jamapsychiatry.2022.2284
4. Shaker AA, Austin SF, Storebø OJ, Schaug JP, Ayad A, Sørensen JA, Tarp K, Bechmann H, Simonsen E. Psychiatric Treatment Conducted via Telemedicine Versus In-Person Modality in Posttraumatic Stress Disorder, Mood Disorders, and Anxiety Disorders: Systematic Review and Meta-Analysis. JMIR Ment Health. 2023 Jul 5;10:e44790. doi: 10.2196/44790. Erratum in: JMIR Ment Health. 2023 Sep 18;10:e52269. doi: 10.2196/52269. PMID: 37277113; PMCID: PMC10357375.
5. Bulkes NZ, Davis K, Kay B, Riemann BC. Comparing efficacy of telehealth to in-person mental health care in intensive-treatment-seeking adults. J Psychiatr Res. 2022 Jan;145:347-352. doi: 10.1016/j.jpsychires.2021.11.003. Epub 2021 Nov 3. PMID: 34799124; PMCID: PMC8595951.
6. Chai G, Xu J, Goyal S, et al. Trends in Incident Prescriptions for Behavioral Health Medications in the US, 2018-2022. JAMA Psychiatry.2024;81(4):396–405. doi:10.1001/jamapsychiatry.2023.5045
7. Choi WS, Woo YS, Wang SM, Lim HK, Bahk WM. The prevalence of psychiatric comorbidities in adult ADHD compared with non-ADHD populations: A systematic literature review. PLoS One. 2022 Nov 4;17(11):e0277175. doi: 10.1371/journal.pone.0277175. PMID: 36331985; PMCID: PMC9635752.
8. Bartelt K, EB, Butler S, Sandberg N. ADHD Medications Prescribed at Similar Rates During Telehealth and In-Person Visits. Epic Research. https://epicresearch.org/articles/adhd-medications-prescribed-at-similar-rates-during-telehealth-and-in-person-visits. Accessed on December 1, 2024.
9. Guinart D, Marcy P, Hauser M, Dwyer M, Kane JM. Patient Attitudes Toward Telepsychiatry During the COVID-19 Pandemic: A Nationwide, Multisite Survey. JMIR Ment Health. 2020 Dec 22;7(12):e24761. doi: 10.2196/24761. PMID: 33302254; PMCID: PMC7758084.
10. Guinart D, Marcy P, Hauser M, Dwyer M, Kane JM. Mental Health Care Providers’ Attitudes Toward Telepsychiatry: A Systemwide, Multisite Survey During the COVID-19 Pandemic. Psychiatr Serv. 2021 Jun;72(6):704-707. doi: 10.1176/appi.ps.202000441. Epub 2021 Feb 17. PMID: 33593104.
11. Fierce Healthcare. (n.d.). Advocates meet with White House to urge inclusion of stimulants in upcoming telehealth prescribing rules. Retrieved November 16, 2024, from https://www.fiercehealthcare.com/regulatory/advocates-meet-white-house-urge-inclusion-stimulants-upcoming-telehealth-prescribing

October Council Highlights

by Acting Secretary, Laura Halpin, MD

DR WILLS INTRODUCTION

Dr Wills shared goals for APA and as CEO.  She shared goals for strategic vision and clarity for the organization.  She shared goals for the financial future of the APA to support and enable a future for the organization.  She identified advocacy, mentorship, education and networking as core goals for the APA.   She is working to develop a strategic plan with this.  She also noted the importance of membership, including with early career members.

CA Advocacy Structure, legislative priorities and GAC                       Drs. Shaner and Wood

Dr Shaner provided an introduction regarding past successes with SB 1184.  He then gave an overview of the GAC structure and goals.  Dr Wood provided additional background on the California State Association of Psychiatrists.  Dr Wood reviewed recent bills sponsored and supported by SCPS and CSAP including SB 1184, SB 43, Prop 1, and changes to the incompetent to stand trial process and CARE courts.  Dr Wood also shared legislative goals for the coming year.

COMMITTEE REPORTS                                                                           Chairs

1. Unhoused Workgroup: Drs Chang and Koldobskaya provided information about the goals of the group and legislative recommendations for improving access to care for unhoused individuals
2. Stimulant Issues Workgroup: Drs Wood and Halpin provided updates about concerns about ADHD diagnosis and stimulant shortages as we as specific goals for interfacing with the APA.
3. Private Practice: Dr Goldenberg Provided goals of the private practice committee as concerns about stimulant shortage, tele-prescribing, parity, liaising with other members. He also brought up question of a Private Practice Component
4. Diversity and Culture – Dr. Malik provided background around decreasing the stigma for mental illness and moving the practi and past work on anti-racism, the progress on the repudiation of the Moynihan report action paper.
5. Alternatives to Incarceration –Drs. Wood and Bindra Committee is working on improving the diversion system and connecting patients to care with limited carceral system involvement
6. Access to Care–The committee is developing a program on October 30^th at 7 pm to address working with managed care and then clozapine and LAIs. Dr Burchuk provided additional updates about the functioning and goals of the committee

APA Representation Workgroup–Drs Red and Silverman, the workgroup is forming to develop improved representation within the APA.  Dr Red discussed goals for improving SCPS efficiency within the APA, specifically with Action Papers, Representation on APA Components, and concerns about Executive Direct training and leadership development.

Dr Wills then engaged in conversation about all of this.  She noted goals to improve communication and transparency and how important this is.  She has goals to continue to listen to members and find solutions to improve this.  She also continued to discuss goals and possible ideas to invest in new business lines to support the future of the organization.  There was also discussion about not relying on the Annual Meeting to provide as much revenue and finding new partnerships.

MINUTES OF THE PREVIOUS MEETING(S)                                 Dr. Halpin

– A motion was made to approve the September minutes with correction, and passed unanimously. Dr Halpin will fill in as secretary for this meeting.

ASSEMBLY REPORT                                                                          Assembly Reps

Dr Silverman provided update about Area 6 Council meeting.  Assembly takes place the first weekend in November, they have been reviewing action papers.

GAC ACTION ITEMS                                                                           Drs. Shaner and Wood

Report from monthly meeting was provided.  Additional specific actions were presented:

Motion 1: That the SCPS Council endorse a letter to APA in support of the candidacy of Emily Wood, MD,PhD, for membership in the APA Council on Advocacy and Government Relations (CAGR), and that it request that CSAP Board members make a similar motion for CSAP. Approved

Motion 2: That SCPS Council endorse in principle the current list of suggested CSAP advocacy initiatives for consideration among potential CSAP advocacy initiatives for 2025. Approved

Motion 3: That SCPS Council approve the draft CSAP Budget for2025.(provided in Council dropbox) Approved

Motion 4: That SCPS endorse a CSAP PAC contribution in the sum of $1500 to a CMA-hosted event featuring Assemblymember Mia Bonta. Approved

Motion 5:  That SCPS endorse three action papers authored by Area 6 Council members (SCPS and SDPS) and previously endorsed by the Area 6 Council during its meeting of 10/7 Approved

PRESIDENT’S REPORT                                                                    Dr. Rees

1. Dr. C. Freeman Endorsement. Dr C Freeman is running to be president-elect of the California Medical Association.

Motion Approved : SCPS endorsed Dr Freeman for president-elect of the CMA.

1. BSCC Letter and Endorsement: The EC voted to sign on to a letter to the Board of State Community Corrections about concerns about the conditions of Juvenile Halls in Los Angeles.

Motion Approved: Approved signing on to the letter

1. APA funding Executive Director to APA Assembly: The APA is not funding this travel or programming for this year. We are concerned and this is being discussed, Area 6 is addressing as well.
2. Telehealth prescribing letter: The COVID-exemptions to the Ryan-Haight Act allowing for flexibilities in telehealth prescribing of controlled substances would be set to expire at the end of the year. Multiple SCPS committees contributed to a letter that was drafted by the APA to express concerns about this and support for extensions of these flexibilities due to concerns for patient access to care and safety.

Motion Approved: Letter was approved by council to forward to the APA

PRESIDENT-ELECT’S REPORT                                                      Dr. Kelly

1. Newsletter Updates were provided. Dr Kelly recognized recent contributors and reviewed next month’s contributors.  New web based format was reviewed, interaction and clicks have increased with new format. October contributors were viewed.
2. Nominating Committee: Traditional roles is nominations for positions with SCPS. There was been some discussion about expanding role to promote SCPS members in external organizations engaging in advocacy with goals for organized psychiatry.  The committee may meet an additional time to do this.   Others interested can reach out to Dr Kelly.
3. SCSCAP Joint Meeting: Annual meeting will occur late Nov or Dec. Dr Wood and Dr Sid Puri will be presenting about stimulants
4. The NAMI meeting will occur in January. It will be occur on a night separate from the Council meeting to make sure we can full prioritize this important meeting.

TREASURER’S REPORT                                                                    Dr. Wood

1. September Financials and Cash on Hand Report

Dr. Wood reviewed various financial metrics, year-to-date. Overall, SCPS is in good fiscal health.

MEMBERSHIP REPORT                                                                    Dr. Ijeaku

1. Membership Report

Current Active Membership –844

Membership report was approved

1. NEW BUSINESS- none                                                            Dr. Rees

XVI.      OLD BUSINESS                                                                     Dr. Rees

SCPS Career Day will be Sunday December 8^th 2024 9:30 AM-3:00 PM Kaiser Permanente West LA 6041 Cadillac Ave Ste 503 Los Angeles CA 90034.  Booths and speakers are coming together.  If anyone has suggested for exhibitors, please share with Ms. Thelen.  PMRS will be sponsoring lunch.

George L. Mallory Diversity, Culture and Social Justice Award Guidelines

Please see the following guidelines to apply for the George L Mallory Diversity, Culture and Social Justice Award.
Please send materials to socalpsychiatric@gmail.com

Award Description: The Diversity and Culture committee is very excited to announce the George L. Mallory Diversity, Culture and Social Justice Award. This award recognizes a Southern California psychiatrist for their exceptional contribution to advocacy, teaching, research and/or leadership aimed at countering structural racism and advancing our understanding of culture and diversity in psychiatry.

This memorial award is named in honor of Dr. George L. Mallory, a prominent educator, psychiatrist and civil rights activist who dedicated his life to treating the underserved in Los Angeles County. Dr. Mallory was one of the first staff members of Martin Luther King Jr./Drew Medical Center, a president of the Black Psychiatrists of Southern California, and the recipient of numerous awards. The purpose of the George L. Mallory Award is to honor current psychiatrists who are continuing this important work in reshaping public mental health to be more inclusive and equitable to all. The Committee encourages SCPS members to send in nominations (self-nominations accepted) for consideration for this award. For more information including past awardees please visit: https://www.socalpsych.org/about/diversity-culture-committee/

Application opens: November 1, 2024
Application closes: January 15, 2025
Nomination Process: Self-nominations and 2nd party nominations welcomed
Application Requirements: Description of the nature of your commitment to justice, equity, diversity and inclusion (1-2 pages). A copy of your CV (1-5 pages).

Selection Criteria:

● Award recipient should demonstrate a historical contribution and ongoing commitment to advocacy, teaching, research and/or leadership aimed at countering structural racism and advancing our understanding of culture and diversity in psychiatry
● Award recipient must be a psychiatrist serving in the SCPS regions
● Award recipient must submit their application materials by the published deadline in order to be considered

Award Recipient selected by: February 25, 2025

Awards Ceremony: Spring 2025. The award recipient is strongly encouraged to attend the SCPS Installation and Awards Ceremony to be recognized in person.