Dialectic Behavioral Therapy May Lead to Improvements in Children With Disruptive Mood Dysregulation Disorder

There are no established treatments for disruptive mood dysregulation disorder (DMDD), a disorder characterized by chronic irritability and severe, recurrent outbursts in children. A study in the Journal of the American Academy of Child and Adolescent Psychiatry suggests dialectical behavioral therapy for children (DBT-C) may offer an advantage over individual therapy for preadolescent children with the disorder.

“Emotion regulation, defined as intrinsic capabilities individuals use to modulate the experience and expression of emotions based on internal or external demands, appears to be a core deficit in DMDD,” wrote Francheska Perepletchikova, Ph.D., of Weill Cornell Medical Center in New York and colleagues. “DBT is an empirically validated therapy designed to treat emotional regulation, suicidal thoughts, and non-suicidal self-injury associated with borderline personality disorder.”

For the study, Perepletchikova and colleagues randomly assigned 43 children aged 7 to 12 to DBT-C or treatment as usual (TAU) over 32 weeks. DBT-C consisted of weekly, 90-minute sessions conducted individually with each family; sessions were divided into child counseling, parent training, and skills training with parents and children. Children in the TAU group received up to 32 weeks of individual therapy, with each clinician determining session duration, frequency, and treatment approach. Assessments were conducted at the beginning of the study, followed by every 8 weeks until the end of 32 weeks, and again at a follow-up three months later.

After 32 weeks, the rate of positive response (“much improved” or “very much improved” on the Clinical Global Impressions Improvement Scale) was 90.4% for children receiving DBT-C and 45.5% for those receiving TAU. Children receiving DBT-C also showed higher rates of symptom remission (52.4% vs. 27.3%) and lower use of psychiatric medications (19.1% vs. 54.4%). 

The DBT-C group also had much higher retention than the TAU group, though the authors noted this may have been due to the fact DBT-C was provided free of charge while TAU participants had to pay through insurance. 

“A confirmatory efficacy trial is needed with a more structured TAU, with built-in strategies for retention and without requirement for payment,” the authors wrote. “Further research needs to examine the effects of DBT-C on specific outcomes, including depression and anxiety, as well as ... mediating factors, including emotion regulation, creation of validating environment, and treatment duration.”

For related information, see the Psychiatric News article “How to Diagnose and Treat Disruptive Mood Dysregulation Disorder.”

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Poor Vision May Be Associated With Worse Cognition in Older Adults

Poor vision appears to be associated with worse cognitive function in older U.S. adults, according to a study published today in JAMA Ophthalmology.

“This is the first evidence, to our knowledge, of a strong, clear association between self-reported [visual impairment] and cognitive impairment in a large-scale, broadly representative sample of the U.S. population,” senior author Suzann Pershing, M.D., M.S., of the Stanford University School of Medicine and colleagues wrote. This association remained after adjusting for demographics as well as age-related predictors of cognitive decline including hearing and physical function impairments, the authors noted.

To examine the relationship between visual impairment and cognition in older U.S. adults, the researchers analyzed two national data sets, the National Health and Nutrition Examination Survey (NHANES), 1999-2002, and the National Health and Aging Trends Study (NHATS), 2011-2015. Vision was measured at distance and near and by self-report in the NHANES and by self-report alone in the NHATS. The NHANES measured Digit Symbol Substitution Test (DSST) score and relative DSST impairment (DSST score ≤28, lowest quartile in study cohort), and the NHATS measured possible or probable dementia (based on self-report and performance on cognitive tests).

The NHANES included 2,975 respondents aged 60 years and older who completed the DSST measuring cognitive performance. The NHATS included 30,202 respondents aged 65 years and older with dementia status assessment. In the NHANES, distance visual impairment (odds ratio [OR], 2.8) and subjective visual impairment (OR, 2.7) were both associated with lower DSST scores and higher odds of DSST impairment. The NHATS data corroborated these results, with all vision variables associated with higher odds of dementia (distance visual impairment: OR, 1.9; near visual impairment: OR, 2.6).

The authors cautioned that “the results presented in this cross-sectional analysis are purely observational. A causative relationship between [visual impairment] and cognitive dysfunction cannot be established without longitudinal studies.” 

Nonetheless, they concluded that “should causality be established, this may contribute to the value of vision screening, not only to identify patients who may benefit from treatment of correctable eye diseases but also to suspect broader limitations in function from cognitive and directly visual tasks.”

Numerous questions remain, wrote Jennifer Evans, Ph.D., of the London School of Hygiene and Tropical Medicine in a related editorial. “If the results of this investigation are not a measurement artifact and not confounding, and visual impairment and cognition are indeed associated, then the next question is: which came first? … Would successful intervention for visual impairment (where possible) reduce the risk of cognitive impairment? Or is sensory impairment an early marker of decline?”

For related information, see the Psychiatric News article “Dual-Task Gait Testing Identifies MCI Patients Likely to Develop Dementia.”

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Billing for Psychotherapy Drops After 2013 Changes to CPT Psychiatry Codes

The proportion of psychiatric visits billed as psychotherapy declined significantly in the period following the 2013 update of Current Procedural Terminology (CPT) codes used for psychiatry, according to an analysis appearing in Psychiatric Services in Advance. Moreover, the most frequently billed psychiatric codes were those for evaluation and management (E/M).

“Given that the majority of visits to psychiatrists included E/M services only, efforts and incentives could be used to increase care coordination, treatment in teams, and colocation of mental health services to support the provision of mental health care,” wrote Tami L. Mark, Ph.D., of RTI International, William J. Olesiuk, Ph.D., of Truven Analytics, and colleagues at the Substance Abuse and Mental Health Services Administration.

On January 1, 2013, the Centers for Medicare and Medicaid Services (CMS) implemented significant revisions to the CPT code set for psychiatry and psychotherapy services, eliminating more than 30 of the most commonly used psychiatry CPT codes and introducing several new codes. The 2013 CPT revisions, formulated by the American Medical Association CPT Editorial Board, were designed to improve the ability of the codes to account for varying levels of work involved in psychotherapy and medical management, among other factors.

For the analysis, Mark, Olesiuk, and colleagues used 2012–2014 data from the Truven Health Analytics MarketScan Commercial Claims and Encounters (MarketScan) database. The MarketScan database reflects the entire claims experience of approximately 30 million individuals with private insurance annually. The sample in this study was restricted to office visits to psychiatrists in 2012 (prior to the CPT code changes) and in 2013 and 2014 (the two years after the CPT code changes).

After controlling for factors related to the patient, practice, and health plan, the authors found that the percentage of visits billed as psychotherapy dropped from 51% in 2012 to 41% in 2013, and 42% in 2014. In 2013, the most common CPT code was the E/M code 99213 (established patient office visit, low to moderate severity), followed by the E/M code 99214 (established patient office visit, moderate severity), and the 90833 add-on code (individual psychotherapy, 16–37 minutes).

“The change in CPT psychiatric billing codes resulted in a significant decline in documented psychotherapy by psychiatrists among privately insured patients,” the researchers stated. “Whether this was due to a change in actual treatments provided or a clarification of the extent to which psychotherapy was actually being provided … is an issue that requires further investigation.”

For questions and answers about CPT coding, see the Psychiatric News article “CPT Coding Q&As From Helpline.”

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Process Open for Submitting Proposals to Update DSM

The publicly accessible portal on the APA website for submitting proposed changes and updates to DSM-5 will turn a year old soon, and past APA President Paul Appelbaum, M.D., chair of the DSM Steering Committee, wants to be sure clinicians, researchers, and members of the public know they have a role to play in making DSM a “living document.”

The portal, which was launched in December 2016, was the first step in a process meant to allow incremental updates as new research evidence accumulates. Instead of engaging in an extremely expensive and time-consuming process that characterized the development of past editions of the diagnostic manual, the DSM Task Force wanted to seize on the opportunity afforded by digital communication by creating a process for changes to be made incrementally, as they become warranted by the weight of new evidence. Since the portal opened late last year, however, proposed revisions have been very few and relatively minor—for example, an editorial correction to the criteria for acute stress disorder and the addition of ICD-10-CM codes for substance use disorder in remission.

Appelbaum said he believes it is most likely that clinicians and researchers are not sufficiently aware that the process exists. "We want to make an effort to spread the word and publicize the existence of this process,” he said.

Visitors to the portal are guided through steps to submit proposals for the following specific kinds of revisions:

• Changes to an existing diagnostic criteria set that would markedly improve its validity.
• Changes to an existing diagnostic criteria set that would markedly improve reliability without an undue reduction in validity.
• Changes to an existing diagnostic criteria set that would markedly improve clinical utility without an undue reduction in validity or reliability.
• Changes to an existing diagnostic criteria set that would substantially reduce deleterious consequences associated with the criteria set without a reduction in validity.
• Addition of a new diagnostic category or specifier.
• Deletion of an existing diagnostic category or specifier/subtype.
• Corrections and clarifications, including changes aimed at improving the understanding and application of an ambiguous diagnostic criterion, specifier, or text.

For more information, see the Psychiatric News article “Process for Updating DSM-5 Is Up and Running.”

Regular Phone Check-Ins With Mental Health Clinician May Reduce Symptoms of Postpartum Depression

A telephone-based depression care management (DCM) program is effective at improving the symptoms of postpartum depression, particularly in women who experienced childhood sexual abuse, reports a study in the Journal of Clinical Psychiatry.

“Childhood maltreatment confers life-long risk for general and mental health disorders and affects the development of stress-responsive neuropsychiatric symptoms,” wrote Katherine Wisner, M.D., of Northwestern University and colleagues. “The regular (and crisis) telephone availability of a supportive clinician is a comforting and empowering resource that appears to be particularly therapeutic to women with childhood sexual abuse.”  

The trial involved 628 women who screened positive for depression (a score of 10 or greater on the Edinburgh Postnatal Depression Scale) four to six weeks after giving birth. The women were randomly assigned to receive either DCM or enhanced usual care (EUC). The DCM program involved regularly scheduled calls from a clinician who provided ongoing education, assisted with decisions about medication use during breastfeeding, monitored patient symptoms and progress, facilitated access to mental health services, and more. Women in the EUC group were given educational materials, encouraged to contact their health plan to facilitate treatment, and received one follow-up call.

Independent evaluators followed up with women in both groups at three, six, and 12 months postpartum to assess their health, functioning, and use of health care services. At 12 months, both groups showed significant improvements, with SIGH-ADS (Structured Interview Guide for the Hamilton Depression Rating Scale with Atypical Depression Supplement) and function scores significantly improving by at least 50% from baseline. Women in both groups reported similar health service use as well.

Women with a history of childhood sexual abuse (about 20% of the participants) responded more favorably to the DCM program compared with the EUC condition. For example, the SIGH-ADS scores of women with a history of childhood sexual abuse decreased by about 1 point during the follow-up period in the DCM group, but rose 1.7 points in the group receiving EUC.

“Why might monthly telephone contact with a mental health clinician benefit women with childhood sexual abuse significantly more than nonabused depressed postpartum women? Women with childhood sexual abuse may have difficulty coping with pregnancy due to the need for intimate examinations and birth, which may trigger traumatic memories,” the authors wrote.

For related information, see the Psychiatric News article “Researcher Discusses Goals and Challenges of Perinatal Mental Illness” and the Psychiatric Services article “Incremental Benefit-Cost of MOMCare: Collaborative Care for Perinatal Depression Among Economically Disadvantaged Women.”

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CBT Improves Functioning in Parents of Children With ASD

Parents of children with autism spectrum disorder (ASD) can benefit from involvement in their children’s cognitive-behavioral therapy (CBT), according to a pilot study posted online August 1 in the Journal of Autism and Developmental Disorders.

“Treatment effects occurred across all parents in depression, emotional regulation, perceptions of their children, and mindful parenting,” wrote Andrea L. Maughan and Jonathan A. Weiss, Ph.D., of York University in Toronto.

Investigators examined changes in the parents’ mental health, parenting skills, and expressed emotion following participation with their children in a randomized, controlled trial of 10 sessions of a CBT program developed to improve emotional regulation in children with ASD. CBT has emerged as an effective treatment for anxiety disorders in children with ASD who do not have an intellectual disability, the researchers noted.

Participants included 57 children with ASD and one parent of each child. Of the 57 parents, 80.7% were mothers of children with ASD (91.2% males). The children’s IQ scores ranged from 79 to 140. About 70% of parents had undergraduate university degrees. More than 90% of the children met criteria for at least one mental health problem on the Anxiety Disorders Interview Schedule for DSM-IV. Parent psychopathology and stress were measured using the Depression Anxiety Stress Scale. Child psychopathology and improvement were measured by the Clinical Global Impression Scale–Severity and Improvement.

Of the parents who had depression, their symptoms from pre- to post-intervention were significantly reduced, and overall the parents’ emotional regulation improved. 

“It may be that helping children to practice the emotion regulation strategies from the CBT program also resulted in parents learning strategies that are relevant to their own coping approach,” the researchers noted. 

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High-Risk Drinking, Alcohol Use Disorder Rises Significantly Over Past Decade

Between 2001-2002 and 2012-2013, the percentage of U.S. adults who engaged in regular high-risk drinking increased by almost 30%, and the percentage of people meeting criteria for alcohol use disorder (AUD) grew by 49.4%, according to a report published today in JAMA Psychiatry.

“Increases in all of these outcomes were greatest among women, older adults, racial/ethnic minorities, and individuals with lower educational level and family income,” Bridget F. Grant, Ph.D., of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and colleagues wrote.

Grant and colleagues compared information collected during face-to-face interviews from two nationally representative surveys of U.S. adults: NIAAA’s 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and the 2012-2013 NESARC-III. Survey participants were asked identical questions regarding 12-month alcohol consumption and how often they engaged in high-risk drinking (four or more standard drinks containing alcohol [for example 12 oz. beer or 5 oz. wine] on any given day for women; five or more standard drinks for men); for this study, high-risk drinking was defined as exceeding the daily drinking limits at least weekly. Participants were considered to have a DSM-IV AUD diagnosis if they met criteria for alcohol dependence or abuse in the past 12 months.

The study sample included 43,093 participants in the NESARC and 36,309 participants in the NESARC III. Between 2001-2002 and 2012-2013, alcohol use in the United States increased from 65.4% to 72.7% (11.2% increase), high-risk drinking increased from 9.7% to 12.6% (29.2% increase), and the prevalence of DSM-IV AUD increased from 8.5% to 12.7% (49.4% increase). 

“While the prevalence of AUD among both 12-month alcohol users and 12-month high-risk drinkers increased, the prevalence of AUD among high-risk drinkers (46.5% in 2001-2002 and 54.5% in 2012-2013) was much greater than the prevalence of AUD among 12-month users (12.9% in 2001-2002 and 17.5% in 2012- 2013), highlighting the critical role of high-risk drinking in the increase in AUD between 2001-2002 and 2012-2013,” the authors wrote. 

In a related editorial, Marc A. Schuckit, M.D., a professor of psychiatry at the University of California, San Diego, described the costs associated with alcohol-related problems and noted that the populations that appear to be at greatest risk may also be least likely to have access to care.

The article “makes a compelling case that the United States is facing a crisis with alcohol use, one that is currently costly and about to get worse,” he wrote. It is also a reminder that “the chilling increases in opioid-related deaths reflect a broader issue regarding additional substance-related problems.”

The findings “highlight the urgency of educating the public, policymakers, and health care professionals about high-risk drinking and AUD, destigmatizing these conditions, and encouraging those who cannot reduce their alcohol consumption on their own, despite substantial harm to themselves and others, to seek treatment,” Grant and colleagues wrote.

For related information, see the Psychiatric News article “Why Treat Alcohol Use Disorders in Primary Care?” and the AJP article “Vulnerability for Alcohol Use Disorder and Rate of Alcohol Consumption.”

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