Wednesday, October 1, 2014

Therapy With Horses Appears to Lessen Violent Incidents

A horse is only a horse, of course, unless the horse is an adjunctive psychotherapist.

Researchers at New Jew Jersey’s Greystone Park Psychiatric Hospital, a 500-bed state facility, tested the relative effects of animal-assisted therapy on violent behavior among a group of 90 patients randomized to receive either therapy with horses, dogs, enhanced social skills training, or usual care, reported Jeffry Nurnberg, M.D., and colleagues online today in Psychiatric Services in Advance. Most of the patients were diagnosed with schizophrenia or schizoaffective disorder and had been hospitalized for an average of 5.4 years.

Dogs have been used for therapeutic interventions, but studies using horses are rare. Nurnberg and his colleagues used “two or three therapy horses tested and credentialed as suitable for direct patient contact in clinical environments.” Patients did not ride the horses but led them around a course under the instruction of therapists. Comparing before-and-after incident reports, the researchers found decreases in violence and aggression for patients working with horses but not for the other cohorts.

“Unique effects from therapy horses may come from interacting with physically imposing animals that appear quite capable of causing harm but do not,” wrote the authors. “Equine interactions may model nonviolent behavioral strategies, resulting in patients’ greater tolerance of provocative interpersonal stimuli.”

For more in Psychiatric News about using animals as an adjunct to traditional therapies, see “Farm Has Spent 100 Years Helping Those With Serious Mental Illness.”

(Image: Auremar/
APA's Next Twitter Chat: Join your APA colleagues in responding to questions and comments from the public and patients in this week's #YourMH @TWITTER chat on Friday, October 3. The topic is bullying, in observance of National Bullying Prevention Month. To join, use #YourMH (stands for "Your Mental Health"), @APAPSYCHIATRIC, or #stopbullying. If you haven't created a Twitter account yet, click here to do so now. And during the chats, don't just sit on the sidelines—be a part of the conversation!

Tuesday, September 30, 2014

'Sunshine Act' Database Now Open for Public Review

The public now has access to the first round of data reported by the pharmaceutical and medical-device industries regarding payments that physicians and teaching hospitals may have received from them. The database, managed by the Centers for Medicare and Medicaid Services (CMS) and known as Open Payments, was established in accordance with the Physician Payment Sunshine Act (PPSA) as part of the Affordable Care Act. According to CMS, its purpose is to increase transparency and accountability in health care.

The database lists consulting fees, research grants, travel reimbursements, and other gifts provided to physicians and teaching hospitals. It contains 4.4 million payments valued at nearly $3.5 billion paid to 546,000 physicians and almost 1,360 teaching hospitals. Forty percent of the records do not carry personally identifiable information because they did not meet CMS’s integrity standards for consistency of information when matched across other databases.

The data available today were collected from August to December 2013 and were available for review and dispute for a total of 45 days ending September 11.

Beginning in June 2015, reports will be published annually and will include a full 12 months of payment data. Physicians still have until December 31 to dispute 2013 data, but disputes will not be flagged in the public database until the next publication cycle.

APA members are encouraged to visit the public Open Payments database and review any data that may have been reported about them. Those who have not yet registered on the physicians' Open Payments database should do so now. For more information, click here.

Monday, September 29, 2014

ACA Increased Access to Care for Young Dependents, Study Shows

Extended dependent coverage for young people under the Affordable Care Act appears to have produced modest increases in general hospital psychiatric inpatient admissions and higher rates of insurance coverage for young adults nationally.

And in California, the new coverage under the ACA appears to have lowered rates of emergency department visits, according to the report “Effect of the Affordable Care Act’s Young Adult Insurance Expansions on Hospital-Based Mental Health Care” in today's AJP in Advance.

The ACA requires insurers to permit children to remain on parental policies until age 26 as dependents. Researchers from multiple institutions sought to estimate the association between the dependent-coverage provision in the ACA and changes in young adults’ use of hospital-based services for substance use disorders and nonsubstance use psychiatric disorders.

They conducted a quasi-experimental comparison of a national sample of non-childbirth-related inpatient admissions to general hospitals and California emergency department visits with psychiatric diagnoses, using data spanning 2005 to 2011. Analyses compared young adults who were targeted by the ACA dependent-coverage provision (19- to 25-year-olds) and those who were not (26- to 29-year-olds), estimating changes in utilization before and after implementation of the dependent coverage provision.

They found that dependent coverage expansion was associated with 0.14 more inpatient admissions for psychiatric diagnoses per 1,000 for 19- to 25-year-olds (targeted by the ACA) than for 26- to 29-year-olds (not targeted by the ACA). The coverage expansion was associated with 0.45 fewer psychiatric emergency department visits per 1,000 in California. The probability that inpatient admissions nationally and emergency department visits in California were uninsured decreased significantly.

"It is gratifying when the putative benefits of a major policy change, such as the ACA, actually are realized in better access to services for individuals with behavioral health conditions,” said Howard Goldman, M.D., editor of Psychiatric Services and an expert on the ACA who is past chair of an APA work group on health reform. “In this instance, we hope that the observed increase in inpatient use and the decline in emergency visits reflect appropriate use of health care services. The inpatient increase surely reflects improved health insurance coverage--with benefits on par with those for general medical and surgical services."

More information on the Affordable Care Act appears in the Psychiatric News article "Lieberman Sees Promising Future for Psychiatrists, Patients" by Jeffrey Lieberman, M.D.

NOTE: Join your APA colleagues in responding to questions and comments from the public and patients in this week's #YourMH @TWITTER chat on Friday, October 3. The topic is bullying, in observance of National Bullying Prevention Month. To join, use #YourMH (stands for "Your Mental Health"), @APAPSYCHIATRIC, or #stopbullying. If you haven't created a Twitter account yet, click here to do so now. And during the chats, don't just sit on the sidelines—be a part of the conversation!

Friday, September 26, 2014

Targeted Psychotherapy Approach Effective for Older Adults With Bereavement Disorder

A grief-targeted therapeutic approach works twice as well as standard depression psychotherapy in older adults experiencing a prolonged and debilitating bereavement known as complicated grief (CG), finds a new study published in JAMA Psychiatry.

Also referred to as persistent complex bereavement disorder, CG involves prolonged mourning over a lost loved one coupled with intense yearnings and frequent thoughts of the deceased. CG shares characteristics with major depression and is often diagnosed and treated as such, but this may be hindering optimal care for these patients.

A team at Columbia University led by M. Katherine Shear, M.D., enrolled 151 adults aged 50 and up classified as having CG and compared a targeted CG therapy (CGT) to interpersonal psychotherapy (IPT), a well-known and proven depression treatment. CGT combines elements of IPT along with other techniques aimed at engaging and motivating the patient.

CGT proved quite effective, with over 70 percent of participants showing a response after 16 treatment sessions, compared with 32 percent who received IPT. CGT also lowered the overall illness severity, with only 35 percent of CGT participants remaining moderately ill or worse after their sessions, compared with 64 percent of IPT patients.

The authors noted that CG remains an underrecognized public health problem, and one that will continue to grow as the U.S. population ages. A recent analysis found that around 9 percent of bereaved older women will experience CG.

The DSM-V lists persistent complex bereavement disorder under its "Conditions for Future Study."

To read more about the potential for mental problems following the loss of a loved one, see the Psychiatric News article “Bereavement Can Set Stage for Several Mental Illnesses.”


Thursday, September 25, 2014

Child and Family Focused CBT Improves Symptoms of Pediatric Bipolar Disorder, Study Shows

A form of cognitive behavior therapy that involves the child with the family may be efficacious in reducing acute mood symptoms and improving long-term psychosocial functioning among children with bipolar disorder, according to a report appearing online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Previous studies have found that family-based psychosocial treatments are effective adjuncts to pharmacotherapy among adults and adolescents with bipolar disorder (BD).

Amy E. West, Ph.D., of the University of Illinois-Chicago, and colleagues, randomly assigned 69 youth, aged 7 to 13 with bipolar I, II, or not otherwise specified (NOS) disorder (according to DSM-IV-TR) to either child and family focused CBT (CCF-CBT) or standard psychotherapy. CFF-CBT integrates principles of family-focused therapy with those of CBT and actively engages parents and children.

Both treatments consisted of 12 weekly sessions followed by six monthly booster sessions delivered over nine months. Independent evaluators assessed participants at baseline, week 4, week 8, week 12 (post-treatment), and week 39 (six-month follow-up).

They found that the CFF-CBT participants attended more sessions, were less likely to drop out, and reported greater satisfaction with treatment than controls. CFF-CBT demonstrated efficacy compared with standard psychotherapy in reducing parent-reported mania at post-treatment and depression symptoms at post-treatment and follow-up. Global functioning did not differ at post-treatment but was higher among CFF-CBT participants at follow-up.

For more on bipolar disorder in adolescents, see the Psychiatric News article "Link Found Between Glutamate, Adolescent Bipolar Disorder."

NOTE: The topic for APA’s #YourMH @TWITTER chat tomorrow is traumatic brain injury. #YourMH chat takes place every Friday from noon to 1 p.m. ET. To join, use #YourMH (stands for "Your Mental Health"), @APAPSYCHIATRIC, or #TBI. If you haven't created a Twitter account yet, click here to do so now. And during the chats, don't just sit on the sidelines—be a part of the conversation!

(Image: Lisa F. Young/

Wednesday, September 24, 2014

Psychiatrists Urged to Review HCP Prescriptions to Patients

On October 6—less than two weeks away--hydrocodone combination products (HCPs) will no longer be classified as Controlled Substance Schedule III (C-IIs), but rather as Controlled Substance Schedule II (C-IIs), in accordance with the Drug Enforcement Administration's (DEA) final rule to reschedule such products. The new requirements that will impact prescribers are as follows:
  • Prescriptions for HCPs must be written on a hard copy, original prescription or electronically transmitted where e-prescribing of C-IIs by certified e-prescribers is allowed by state law and the pharmacy is certified to accept electronically prescribed controlled substances. Fax transmission is not allowed.

  • Prescriptions for HCPs cannot be called into a pharmacy.

  • Prescriptions issued after October 6 for HCPs cannot be refilled.

The DEA notes that prescriptions issued before October 6 that have authorized refills may be dispensed in accordance with DEA rules for refilling, partial filling, transferring, and central filling Schedule III through Schedule V controlled substances until April 8, 2015. However, certain states and pharmacy systems may not honor this exemption, and therefore will not allow remaining refills to be dispensed for HCP prescriptions written prior to October 6.

In the meantime, APA members should seek out information concerning their respective state laws as it relates to the new prescription practices for HCPs as a Schedule II substance and notify patients with HCP prescriptions of the new federal requirements to obtain prescriptions after October 6. To avoid the possibility that medically necessary refills will not be dispensed between October 6 and April 8, 2015, members should consider providing patients with new Schedule II-compliant prescriptions.

Read the DEA’s final ruling in The Federal Register at

Tuesday, September 23, 2014

Genomic Analysis Yields Eight Distinct Types of Schizophrenia

Schizophrenia appears to be “heterogenous”—that is, comprising a group of related disorders each of which present with distinct clinical syndromes; and those syndromes now appear to be associated with eight separate networks of genetic mutations.

That’s the finding from a remarkable genetic analysis titled “Uncovering the Hidden Risk Architecture of the Schizophrenias: Confirmation in Three Independent Genome-Wide Association Studies,” appearing in AJP in Advance.

In a large genome-wide association study of cases with schizophrenia and controls, researchers with the Molecular Genetics of Schizophrenia Consortium (an international group of researchers) examined single nucleotide polymorphisms (SNPs) that grouped or clustered together and assessed the risk for schizophrenia by comparing the cases and noncases. They then looked at relationships between the SNP clusters and various ways that patients present symptomatically across three separate studies.

The authors identified 42 SNP sets associated with a 70 percent or greater risk of schizophrenia and confirmed 34 (81 percent) or more with similar high risk of schizophrenia in two independent samples. These SNP sets or genotypic networks were linked to the different ways that patients present with schizophrenia, yielding eight distinct clinical syndromes varying in symptoms and severity.

“We found that some genetic pathways increasing susceptibility involved deficient control of healthy brain development, and other pathways involved increased susceptibility to brain injury and toxicity," Claude Robert Cloninger, M.D. (pictured above), a study coauthor and a professor of psychiatry at Washington University School of Medicine, told Psychiatric News. “Regulation of the plasticity of glutamate receptors was important in some classes of schizophrenia and not others.

“The main take home message is that there are many pathways to schizophrenia, which converge on eight classes of the disorder,” he said.

Full coverage of this study will appear in a future issue of Psychiatric News. For more information on psychiatric genetics, see the Psychiatric News article, "Revolution in Psychiatric Genetics Rapidly Gains Steam."


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