Tuesday, December 1, 2015

Media Often Frame Opioid Analgesic Abuse as Criminal Justice Issue, Not a Health Condition

Evidence-based treatments for opioid analgesic abuse are well known, but a study of U.S. media coverage appearing today Psychiatric Services in Advance suggests the news media more often frame the problem as a criminal justice issue and not a treatable health condition.

Over the past two decades, the rates of opioid abuse, addiction, and overdose have climbed steadily in the United States. According to most recent estimates, some 4.5 million Americans use prescription pain relievers (the majority of which are opioid analgesics) for nonmedical purposes, and 1.9 million nonmedical users are dependent on these drugs. Additionally, about 16,000 people are believed to die each year from overdose deaths involving these drugs—more than deaths caused by heroin and cocaine combined.

To better understand how this issue has been framed in public discourse, Emma McGinty, Ph.D., an assistant professor of health policy and management and mental health at the Johns Hopkins Bloomberg School of Public Health, and colleagues analyzed 673 print and television news stories from 1998 to 2012.

About 57% of news stories that mentioned a cause for opioid abuse said that illegal drug dealing was the main cause. Physician-related causes were also frequently mentioned: 45% of news stories that noted any cause mentioned that it was easy to get a prescription for an opioid analgesic from a doctor, and 28% mentioned that doctors prescribe painkillers at inappropriately high doses or prescribe more pills than necessary.

Just over half (51%) of the news stories mentioned possible solutions to opioid analgesic abuse, with law enforcement efforts to arrest and prosecute drug dealers mentioned most frequently (64% of new stories). Only 3% and less than 1% of news stories mentioned expanding substance use treatment and harm-reduction policies, respectively, as potential solutions.

However, the authors noted, attitudes appeared to change over time. “The proportion of news stories mentioning law enforcement solutions decreased over the study period, from 70 percent in 1998–2000 to 57 percent in 2010–2012, and the proportion of stories mentioning prevention-oriented solutions increased from 10 percent in 1998–2000 to 55 percent in 2010–2012,” wrote McGinty and colleagues. “The findings underscore the need for a concerted effort to reframe opioid analgesic abuse as a treatable condition addressable via well-established public and behavioral health approaches.”

For more in Psychiatric News about opioid abuse, see “Opioid Use Found to Be Decreasing, While Opioid-Related Deaths Increase.” For additional information, read the recent blog post “How the APA Is Helping Address America’s Opioid Crisis,” by APA CEO and Medical Director Saul Levin, M.D., M.P.A.

(Image: David Smart/Shutterstock.com)

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Monday, November 30, 2015

Youth Seeing PCPs for Mental Health Problems More Likely to Get Medication

More than one-third of U.S. children and adolescents receiving outpatient care for mental health conditions from 2008 to 2011 saw only a primary care physician (PCP) for their care—a proportion that exceeded those treated by only a psychiatrist—according to a study in Pediatrics.

To determine how the proportion of youth seen and/or prescribed medications for mental health conditions by PCPs compared with other mental health providers, researchers from MassGeneral Hospital for Children and Brigham and Women's Hospital in Boston examined data from the Medical Expenditure Panel Survey (MEPS). The analysis incorporated data collected from 2008 to 2011, which included 43,235 U.S. children and adolescents aged 2 to 21 years.

The researchers found that 1,778 children and adolescents aged 2 to 21 were reported to have had an office-based or outpatient visit for a mental health condition, with a mean of 5.4 visits per child with any mental health visits. Of those who had a visit for any mental health condition, 34.8% saw only a PCP, 26.2% saw only a psychiatrist, 15.2% saw only a psychologist or social worker, and 23.8% saw multiple providers. A greater proportion of youth with attention-deficit/hyperactivity disorder (ADHD) versus youth with anxiety/mood disorders saw a PCP only (41.8% vs 17.2%).

The study also revealed that youth who had a visit with a PCP were more likely to be prescribed a psychotropic medication than those who saw a psychiatrist: 70.2% versus 63.0% of children for any mental health condition, 73.7% versus 61.4% for ADHD, and 59.7% versus 45.9% for anxiety/mood disorders. Youth with ADHD seen by PCPs had 1.5 times the odds of receiving a medication than did those seen by psychiatrists.

“This study suggests PCPs alone care for a greater proportion of children receiving mental health care than do psychiatrists or psychologists/social workers, especially in the treatment of ADHD. However, fewer than half of children had any involvement from their PCP, and comanagement with other mental health specialists, especially psychiatrists, appears uncommon,” the study authors noted. “[I]n an effort to assist PCPs in their involvement in pediatric mental health care, further emphasis should be placed on collaborative care models with psychotherapy and programs that provide point-of-care advice to PCPs from mental health experts.”

For related information, see the Psychiatric News article “Pediatricians Urged to Adhere Better to ADHD Care Practices.”

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Wednesday, November 25, 2015

Asenapine Found to Be Safe, Effective in Youth With Manic or Mixed Episode of Bipolar I Disorder

The second-generation antipsychotic asenapine may help to reduce mania and the severity of illness in youth with bipolar I disorder within days, according to a study published in the December issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Robert Findling, M.D. (pictured left), the director of the Division of Child and Adolescent Psychiatry at Johns Hopkins University School of Medicine, and colleagues randomly assigned 403 youth (aged 10 to 17) displaying manic or mixed episodes of bipolar I disorder to receive placebo or asenapine (2.5 mg, 5 mg, or 10 mg) twice daily for three weeks.

The researchers found that all three doses of asenapine led to statistically significant improvements in Young-Mania Rating Scale (YMRS) scores and Clinical Global Impression scale for use in Bipolar Illness (CGI-BP) from days 4 and 7 onward. By day 21, a positive drug response (greater than 50% reduction in YMRS scores from baseline) was achieved by 42% to 54% of those taking asenapine compared with 28% among youth taking placebo. There were no significant differences in YMRS total score between the asenapine groups versus the placebo group in patients with and without attention-deficit/hyperactivity disorder, with and without concomitant stimulant use, or with respect to age and gender.

The incidence of clinically significant weight gain at 21 days was statistically significant versus that of placebo in all three asenapine groups (asenapine range 8.0%–12.0% versus placebo 1.1%). Mean changes from baseline in lipid parameters, glucose, and fasting insulin were also greater in patients treated with asenapine compared with those who took placebo. Other treatment-emergent adverse events reported by patients taking asenapine included somnolence, sedation, increased appetite, and numbness and tingling of the mouth.

“These results suggest the potential for substantial long-term metabolic changes in pediatric patients treated with asenapine. Because of the known metabolic side effects that occur in children and adolescents prescribed atypical antipsychotics, baseline and period monitoring of metabolic parameters including BMI, lipids, and glucose levels is recommended,” Findling and colleagues wrote.

To read more about pharmacological treatment of pediatric bipolar disorder, see the Psychiatric News article “Experts Make Strong Case for Lithium in Youth With Bipolar Disorder.”

(Photo Courtesy of Johns Hopkins University SOM)

Tuesday, November 24, 2015

Participation in Mental Health Courts May Lessen Future Arrests

Criminal defendants who enter mental health court programs may perceive their treatment as significantly less voluntary than those not participating in such programs, but they appear to experience better outcomes, according to a study published in Psychiatric Services in Advance.

Woojae Han, M.S.W., of the University of Albany, and Allison Redlich, Ph.D., of George Mason University compared the treatment outcomes of 357 defendants in mental health courts with 384 people with mental health problems who had recently entered the legal system, examining the impact of community mental health and substance abuse treatment on recidivism at the time of court entry and six months later.

Analysis of interview data with the participants and national arrest data revealed significant increases in treatment motivation and use of community mental health and substance abuse services among participants in the mental health courts compared with the others; however, the perceived voluntariness of treatment decreased in the mental health court group. Increased medication compliance and mental health service use were associated with a significant decrease in arrests for the mental health court group, but not the control group, the authors reported.

“This finding suggests that treatment itself may not lead to meaningful criminal justice outcomes (for example, reduced arrests) but that treatment combined with court monitoring decreases arrests for offenders with mental illness,” the study authors wrote.

For more in Psychiatric News about mental health courts, see “Mental Health Courts: An Effective Alternative to Incarceration” and “MH Court Cuts Violence, Even in Felony Cases.”

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Monday, November 23, 2015

Meta-Analysis Finds Stimulants Reduce Quality, Quantity of Sleep in Youth With ADHD

Stimulant medications appear to reduce the quantity and quality of sleep for children with attention-deficit/hyperactivity disorder (ADHD), according to a meta-analysis published online today in Pediatrics. The findings suggest that clinicians should carefully monitor sleeping behaviors of children taking these medications and adjust treatment to promote optimal sleep.

Previous studies examining the effects of stimulants on sleep in youth with ADHD have produced contradictory findings, with some suggesting that stimulants impair sleep while others propose the medication leads to relief from ADHD symptoms and improvements in sleep.

For the current study, researchers from the University of Nebraska, Lincoln, conducted a meta-analysis of nine randomized, controlled studies involving 246 children and adolescents who were diagnosed with ADHD, had been randomly assigned to stimulants (methylphenidate and amphetamine), and had sleep assessed using objective measures.

The researchers found that youth with ADHD who took stimulants took a longer time to fall asleep, have worse sleep efficiency, and sleep for shorter periods of time. The analysis revealed that the more times a day a stimulant was taken, the longer it took for the youth to fall asleep. Additionally, while the findings revealed that stimulants had a negative effect on sleep efficiency regardless of how long the youth took the medication, sleep efficiency appeared to improve over time.

“The results of the present meta-analysis highlight the importance of carefully weighing the potential benefits and adverse effects of stimulant medications when prescribing to children,” the study authors wrote. “Pediatricians are also encouraged to provide referrals for behavioral treatment of ADHD and sleep, either in addition to or as an alternative to prescribed medications.”

For related information, see the Psychiatric News article “Children With ADHD Benefit From Sleep-Focused Treatment.”

(Image: Donskaya Olga/Shutterstock)

Friday, November 20, 2015

Judge Awarded for Work on Decriminalization of People With Mental Illness

In a ceremony yesterday evening at the United States Supreme Court, Florida Judge Steven Leifman, J.D., was honored with the 2015 William H. Rehnquist Award for Judicial Excellence from the National Center for State Courts for his work on behalf of people with mental illness in the Miami-Dade (Fla.) County criminal justice system.

Leifman, who also serves on the board of directors of the American Psychiatric Association Foundation, has both advocated for and implemented programs to divert from county jails into treatment and community support people with mental illness who do not pose a risk to public safety.

“It is important to recognize a larger American problem: the rising presence of people with mental illness in our jails and prisons even as the general prison populations declines,” said Leifman. The intersection of the criminal justice and mental health systems is “fragmented, underresourced, and outdated.”

Solving this problem cannot be accomplished by one person, one level of government, or one party, he said. “We are used to an adversarial criminal justice system, but we need to reach across boundaries.”

APA President RenĂ©e Binder, M.D., who attended the ceremony, noted that the award to Dr. Leifman highlights the national recognition by the judicial system of the inappropriate criminalization of persons with mental illness. 

"Chief Justice John Roberts listened carefully while Dr. Leifman gave an elegant and passionate speech of his experience as a sitting judge and seeing defendants with obvious mental illness and confusion who had committed minor offenses and were being sent to jail inappropriately," she said. "APA is working collaboratively with Judge Leifman and with other stakeholders to highlight this problem and address solutions."

For more in Psychiatric News about Judge Leifman’s work in Miami, see “Program Prepares Defendants for Return to the Community” and “Defendants With Mental Illness Diverted to Social Security System.”

(Image: Rick Reinhard)

FDA Extends Deadlines for Clozapine REMS Program

The Food and Drug Administration (FDA) is extending deadlines for provider and pharmacy certification for participation in the Clozapine Risk Evaluation and Mitigation Strategy (REMS).

In an announcement issued this week, the FDA said it is indefinitely extending the deadlines due to technical and other problems associated with the Clozapine REMS. New deadlines will be issued after further evaluation by the administration. “We are also carefully evaluating next steps regarding the December 14, 2015, pre-dispense authorization (PDA) launch,” the FDA said in a statement. “We will communicate the revised certification deadlines and additional information about the PDA launch as soon as possible.”

The Clozapine REMS Program replaces the individual clozapine patient registries that had been required previously for monitoring neutrophil counts in patients receiving the antipsychotic, which has been associated with a risk for agranulocytosis. The new REMS program was initiated this year in an effort to ease burdens on clinicians and pharmacies and to make clozapine—one of the most effective antipsychotics and the only drug approved for treatment-resistant schizophrenia—accessible to more patients.

The administration said the deadlines are being extended to help ensure that health care professionals have sufficient time to complete this process and that patient access to clozapine is maintained. “Health care providers should prioritize the medical needs of their patients and, as appropriate, continue prescribing and dispensing clozapine to patients with an absolute neutrophil count (ANC) within the acceptable ranges while the issues are being resolved by the Clozapine REMS program administrators,” the administration said. “Prescribers and pharmacies should continue to work with the Clozapine REMS Program administrators to resolve any issues and continue their efforts to complete certification and update patient information to meet the requirements of the program.”

APA is continuing to discuss concerns related to implementation of the Clozapine REMS program with the FDA. For information on the Clozapine REMS, click here. For further information in Psychiatric News, see “Why Won’t Clinicians Use Clozapine Despite Proven Superiority?”


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