Tuesday, April 25, 2017

APA Urges Senate to Confirm McCance-Katz for Asst. Secretary for Mental Health, Substance Use


APA strongly supports the nomination of Elinore McCance-Katz, M.D., Ph.D., to be the first Assistant Secretary for Mental Health and Substance Use in the Department of Health and Human Services and is urging the Senate to swiftly confirm her nomination. 

President Trump announced last Friday that he intends to nominate McCance-Katz, an APA member psychiatrist, to the position. It would be a win for APA, which had been advocating for McCance-Katz’s selection in discussions with the White House. Staff of APA’s Division of Government Relations told Psychiatric News that McCance-Katz brought to the table the skills and experience that the White House—and APA—hoped to see in the position: a strong scientific and medical background with a focus on substance use and experience working at the federal level. 

If confirmed, McCance-Katz would be the first Assistant Secretary for Mental Health and Substance Use and will replace Kana Enomoto, the Acting Assistant Secretary of Health and Human Services. At press time, it was anticipated that the Senate hearing on McCance-Katz’s nomination would take place within the next couple of months. APA members are urged to contact their senators to support her nomination. 

“Dr. McCance-Katz has a wealth of experience in academic and public sector settings in addressing mental health and substance use disorders,” said APA President Maria A. Oquendo, M.D., Ph.D. “She is an accomplished physician, and APA strongly supports her nomination.”

The assistant secretary post was created in the 21st Century Cures Act, a bipartisan bill that passed late last year. The Assistant Secretary is charged with overseeing the Substance Abuse and Mental Health and Services Administration (SAMHSA) and coordinating mental health and substance use programs at other agencies across the federal government. McCance-Katz served in SAMHSA as the first chief medical officer of the agency; her experience there will pay off in her new role, said APA leaders.

“We urge the Senate to confirm Dr. McCance-Katz as soon as possible,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We look forward to working with her to improve the quality of care of mental health and substance use disorders.”

In a letter delivered today to Senate leaders, Levin and Oquendo emphasized the strengths McCance-Katz would bring to the new position. “To overcome the pervasive opioid addiction in our country, we need a strong leader who can lead the collaboration between primary care and mental health to drive the nation’s recovery,” they wrote. “Dr. McCance-Katz is preeminently qualified to carry out the important responsibilities that need to be undertaken by the Assistant Secretary.”

McCance-Katz is currently the chief medical officer for the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals. She is also a professor of psychiatry and human behavior and professor of behavioral and social sciences at the Alpert Medical School at Brown University. 


Monday, April 24, 2017

Controlling Elevation of Estradiol, Progesterone May Reduce PMDD Symptoms


Previous studies suggest reproductive steroids play a role in premenstrual dysphoric disorder (PMDD)—a disorder characterized by distressing mood and behavioral symptoms that occur during the luteal phase of the menstrual cycle that disappear shortly after menses begin. It is unclear, however, whether these symptoms are triggered by the rapid rise in hormone levels at the start of this phase or the sustained exposure to elevated hormone levels.

A recent study in AJP in Advance suggests that the changes in estradiol and progesterone levels from low to high trigger the onset of PMDD symptoms. 

“Although the mechanisms underlying the mood-destabilizing effects of ovarian steroids in PMDD remain to be better characterized, as does the source of susceptibility to this trigger, our findings provide a new target for interventions,” Peter Schmidt, M.D., chief of the Section on Behavioral Endocrinology at the National Institute of Mental Health, and colleagues reported.

This discovery came from an assessment of 22 women with PMDD, aged 30 to 50, who were given monthly injections of leuprolide to suppress the production of ovarian hormones. Following two to three months of leuprolide alone, 12 of 22 women reported PMDD symptom remission (as determined by self-reported improvement confirmed by Rating for Premenstrual Tension scale scores <5 and the absence of symptom cyclicity on the Daily Rating Form). Women who responded to leuprolide then received one month of placebo followed by three months of estradiol/progesterone replacement therapy.

The women receiving estradiol/progesterone reported a rise in some PMDD symptoms during the first month of therapy, but there were no significant differences in symptom severity during the subsequent months when plasma levels of these sex hormones were stable, Schmidt and colleagues reported.

“[O]ur findings suggest that there is a ‘half-life’ of the affective state that is triggered, following which it remits,” Schmidt and colleagues wrote. “[T]reatment strategies to attenuate or eliminate the change in estradiol and progesterone (or their metabolites) could effectively target the hormonal trigger in this condition.”

For related information, see the Psychiatric News article “Researchers Uncover Cellular Pathway That May Contribute to PMDD.”

(Image: pio3/Shutterstock)

Friday, April 21, 2017

President Trump Nominates Psychiatrist to Serve as Assistant Secretary of Mental Health


President Donald Trump announced on Friday his intent to nominate Elinore McCance-Katz, M.D., Ph.D., a psychiatrist with a subspecialty in addiction psychiatry, to serve as the Assistant Secretary for Mental Health and Substance Use in the Department of Health and Human Services.

McCance-Katz, M.D., Ph.D., is currently the chief medical officer for the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals. She is also a professor of psychiatry and human behavior and professor of behavioral and social sciences at the Alpert Medical School at Brown University.

McCance-Katz previously served as the first chief medical officer of the federal government’s Substance Abuse and Mental Health Services Administration (SAMHSA). A long-time member of APA, McCance-Katz led the Physicians' Clinical Support System for Buprenorphine, funded by SAMHSA grants, in collaboration with APA’s Council on Addiction Psychiatry. The program has helped train physicians to prescribe buprenorphine for opioid-dependent patients using distance-learning tools.

“Dr. McCance-Katz possesses a unique blend of academic and public sector experiences squarely focused on mental health and substance use disorders, having served in SAMHSA in the past,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.

“As an accomplished physician,” said APA President Maria A. Oquendo, M.D., Ph.D., “she will bring a wealth of knowledge in the prevention, treatment, and recovery of substance use disorders which currently challenges the United States. APA strongly supports her appointment.”

McCance-Katz obtained her Ph.D. from Yale University with a specialty in infectious disease epidemiology and is a graduate of the University of Connecticut School of Medicine. She is board certified in general psychiatry and in addiction psychiatry.

Adults With Serious Psychological Distress Are More Likely to Experience Barriers to Care


Adults with serious psychological distress (SPD) face more problems accessing and paying for health care than those without SPD, according to a study published this week in Psychiatric Services in Advance.

Using data from the 2006-2014 National Health Interview Survey conducted by the Centers for Disease Control and Prevention, Judith Weissman, Ph.D., J.D., and colleagues from New York University School of Medicine examined 11 indicators of access, utilization, and function among 207,853 adults. Among the indicators were presence or absence of health insurance coverage, insufficient money for health care and/or medications, delay in health care, insufficient money for health care, visiting a doctor 10 or more times in the past 12 months, limitations in ability to work, limitations in activities of daily living, insufficient money for mental health care, and having seen a mental health care provider.

The researchers found that adults with SPD were significantly more likely than those without SPD to experience barriers to care—including no health coverage, delays in care, lack of money to buy medications and to pay for mental health care services, and change in usual place of health care because of insurance. Although a lack of health coverage and money to buy medications worsened for all adults between 2008 and 2011, the study revealed that the proportion of adults with SPD who lacked money to buy medications continued to climb into 2014.

At the same time, the study found that adults with SPD were more likely than those without SPD to visit a doctor 10 or more times in the past 12 months.

“It is paradoxical that although SPD is associated with several indicators of poor utilization and access, as well as relatively poor general medical health, it is also associated with high utilization of expensive outpatient care,” the authors wrote. “[E]mbedding mental health care providers within the primary care setting and embedding PCPs within the mental health setting … may facilitate better treatment of both mental health and general medical conditions. Moreover, integration of care may reduce chaotic health care utilization, including frequent changes in the location of health care.”

For related information, see the Psychiatric Services article “Characteristics of Individuals With Behavioral Health Conditions Who Remain Uninsured After Full Implementation of the ACA.”

(Image: iStock/sturti)

Thursday, April 20, 2017

Patients Taking Psychotropic Medications Found to Be at Elevated Risk of Fractures


Psychotropic medication use increases risk for fractures—a heightened risk that may be missed by a commonly used fracture prediction tool, report the authors of a study published Wednesday in JAMA Psychiatry.

Among adults aged 40 years or older, the study found the risk of a major osteoporotic fracture was 1.43-fold higher in people taking selective serotonin reuptake inhibitors (SSRIs), 1.43-fold higher among people taking antipsychotics, and 1.15-fold higher in people taking benzodiazepines than people not taking these medications. 

“Osteoporosis and mental disorders are highly prevalent conditions, and, as such, these findings have substantial implications for mental health care workers and primary care practitioners,” wrote James Bolton, M.D., of the University of Manitoba (Manitoba, Canada) and colleagues in the paper.

Bolton and colleagues used the Manitoba Bone Density Program database (which contains information on all individuals in the province of Manitoba who have received bone mineral density scans) to assess how mental health influences the risk of major osteoporotic fractures—including hip, arm, and vertebrae fractures. The study cohort included 62,275 women and 6,455 men (average age of 64). Of the 68,730 individuals in the study, 12,982 (18.9%) had been diagnosed with a mental disorder. Psychotropic medication use was recorded in 11,938 (17.4%) of the sample, and 2,468 of these individuals (20.7%) were taking multiple psychotropics. 

The authors found that while a diagnosis of depression, anxiety, or schizophrenia was associated with a higher risk of major osteoporotic fracture, these associations were not significant once adjusted for medication use, suggesting the associations were driven by psychotropic use. Among the medications assessed, SSRIs, antipsychotics, and benzodiazepines increased the risk of both major osteoporotic fractures as a group and hip fractures alone. Tricyclic antidepressants and lithium did not increase the risk of either fracture type, while other antidepressants and mood stabilizers increased overall major osteoporotic fracture risk. 

When the study authors compared the total number of fracture incidents in adults taking psychotropic medications with the expected number based on a common fracture evaluation tool known as FRAX, they found that FRAX significantly underestimated fracture risk in this population. FRAX underestimated the 10-year risk of major osteoporotic fracture risk by 29% for those with depression, by 36% for those exposed to SSRIs, by 63% for those using mood stabilizers, by 60% for those using antipsychotics, and by 13% for those using benzodiazepines. 

“Diagnosed mental disorders and psychotropic medications identify subgroups at increased risk for fractures, and where this excess risk is not fully captured by the FRAX tool,” the authors concluded. “Broader public health initiatives and advocacy may be required to achieve better recognition and management of this elevated risk of fracture given that patients with psychiatric illness may not receive optimal treatment for comorbid physical health conditions.”

For related information, see the Psychiatric News article “Psychotropic Medication and Osteoporosis,” by Sylvia Karasu, M.D.

(Image: iStock/fotostorm)

Wednesday, April 19, 2017

Few Child Psychiatrists Follow Guidelines for Metabolic Monitoring of Youth on SGAs


Few child psychiatrists monitor children treated with second-generation antipsychotics (SGAs) in accordance with treatment guidelines, even though most are aware of those guidelines and agree with them, according to a survey published Monday in Psychiatric Services in Advance.

“The low rate of monitoring, despite high levels of awareness of and agreement with the need to monitor, suggests that obstacles interfere with adopting these guidelines,” Jennifer L. McLaren, M.D., of Dartmouth-Hitchcock Medical Center and colleagues wrote. The findings of the survey suggest family resistance to monitoring may be one such barrier to compliance.

Youth treated with SGAs are known to be at a greater risk of weight gain, developing type II diabetes, and elevated cholesterol. In 2004, APA and the American Diabetes Association published guidelines on screening and monitoring of patients on SGAs, which were endorsed by the American Academy of Child and Adolescent Psychiatry (AACAP) in 2011. The guidelines specify routine monitoring of fasting blood glucose, fasting lipid profiles, body mass index (BMI), and abnormal involuntary movements (AIMs) prior to and periodically after initiating SGAs.

McLaren and colleagues sent the survey to 4,144 working email addresses of child psychiatrists throughout the United States who were registered members of the AACAP, excluding psychiatrists in training, between December 2012 and February 2013.

Among responders (N=1,314, 32%), over 95% were aware of the guidelines for monitoring children and adolescents on SGAs. Fewer respondents agreed with the recommendations, with agreement rates ranging from 69% for fasting lipids to 80% for glucose, 89% for AIMs, and 91% for BMI monitoring. Less than 20% had adopted and adhered to most guidelines.

Additional analysis revealed that psychiatrists who were in academic practice had greater monitoring of glucose, lipids, BMI, and AIMs. In contrast, a physician’s length of time in practice was inversely related to monitoring glucose, lipids, and BMI. Many of the psychiatrists surveyed (82%) reported that parents who forget to obtain laboratory tests were a barrier to obtaining fasting glucose and lipids. Other commonly cited barriers were parental resistance (52%) and children’s refusal to obtain the tests (63%).

“Potential interventions to improve adoption include education with audit and feedback directed at specific providers who have not adopted recommended monitoring practices, monitoring reminder systems, and family education to improve knowledge and attitudes about monitoring,” the authors wrote.

For related information, see the Psychiatric News article “Recent Rise in Youth on Antipsychotics Raises Concerns Among Experts.”

(Image: iStock/Jovanmandic)

Tuesday, April 18, 2017

APA Joins Medical-Scientific Community in Support of March for Science


APA has joined 24 other medical and scientific organizations in a statement of support for the March for Science taking place Saturday, April 22, in Washington, D.C., and in other cities around the country.

APA and the other groups said support of scientific education and research is vital. “As the world's leading organizations representing clinicians, laboratory researchers, and physician-scientists committed to improving patient care, we support the March for Science and its nonpartisan call for the appreciation of scientific evidence, education, and investment,” the groups state. “Science has no political agenda but gives us the tools to find the truths about our world and then implement informed policies to enrich our communities.

“Science is vital to our health, as an understanding of human biology is essential to stimulating discoveries that lead to cures for diseases. Every day, physicians make the best patient-care decisions they can by relying on science-based tools. Clinicians prevent disease by administering immunizations, and they manage disease by providing therapies that have been thoroughly and scientifically vetted for optimal outcomes. This science-based care saves lives, decreases human suffering, and reduces unnecessary costs.

“Therefore, it is critical that we protect federal investment in our health. Over the past several decades, research supported by the National Institutes of Health (NIH) has yielded significant advances across all fields of medicine. Today, diseases with previously grim prognoses are treatable. We have powerful therapies that engage the patient’s own immune system to conquer cancers and non-malignant diseases. And, genome editing is showing early promise in curing and even preventing debilitating genetic conditions.

“We rely on evidence from the [federal] Agency for Healthcare Research and Quality to address patient safety, quality of care, efficiency, and access in our health care system. Research supported by the agency has prevented the spread of infections in hospitals and improved access to health care for patients in rural areas. And, through its surveillance programs, the Centers for Disease Control and Prevention (CDC) has played an important role in preventing and controlling inherited and communicable disease as well as dangerous outbreaks. Without the CDC, outbreaks would spread, food-borne illness would go undetected, and chronic diseases would have a higher human and monetary cost.”

The statement concludes, “We hope patients, their families, and everyone committed to advancing health care will join us in celebrating the value of scientific evidence in our everyday lives.”

The text of the group statement and a list of all signatories is posted on the website of the American Hematology Association.

(Image: iStock/BraunS)

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