Friday, October 24, 2014

Child Psychiatrists Discuss Impact of Marijuana Legalization

With legislation loosening restrictions on marijuana use becoming more prevalent in the U.S., researchers are investigating how its commercialization can impact society, especially youth.

Yesterday, at the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers from the University of Colorado School of Medicine presented comparative studies on the trends in cannabis use among adolescents and negative consequences associated with such use among individuals during the pre- and post-commercialization eras of medical marijuana in Colorado.

The first study, presented by Christian Hopfer, M.D. (pictured above), an associate professor of psychiatry, showed that of 560 adolescents being treated for polysubstance use disorder from 2007 to 2013, those who entered treatment after 2009 (after commercialization of medical marijuana) were more likely to have higher amounts of delta-9-tetrahydrocabnnabinol—an active ingredient in marijuana—in their urine and more polysubstance use at admission, compared with individuals who accessed treatment for polysubstance abuse during the pre-commercialization era. In a study lead by Stacy Salomonsen-Sautel, Ph.D., a postdoctoral fellow, data showed that commercialization of medicinal marijuana in Colorado also correlated with an increase in fatal motor vehicle crashes among drivers aged 16 and older who tested positive for marijuana use, whereas no change was seen among this category of drivers living in states without laws legalizing sale of marijuana for medical purposes.
"Commercialization of marijuana is definitely in process throughout the nation,” Hopfer pointed out. “There is a lot of capital going towards this substance…[as well as] efforts to remarket it as a more ‘upscale’ product." During an interview with Psychiatric News, Hopfer stressed that because marijuana legalization and commercialization are bound to have a substantial impact on society, it is crucial for parents, adolescents, and psychiatrists to educate themselves on the “policy changes regarding marijuana, the pharmacology of marijuana, and the effects of marijuana on adolescent development and safety."
To read more about youth and marijuana use, see the Psychiatric News articles "Research Review Prompts NIDA Warning About Marijuana Use" and "Marijuana Legalization and Young Brains: Time for Serious Study."
(Image: Psychiatric News/Vabren Watts)

Thursday, October 23, 2014

Psychiatrists Urged to Increase Awareness of Domestic Violence

October is National Domestic Violence Awareness Month, focusing national attention on a problem for which physicians and other health care workers—including psychiatrists—may be first responders. Psychiatrist Gail Robinson, M.D., points out that domestic violence can include physical, sexual, emotional, and verbal assault (including denigrating language and blaming the partner) and violence against objects such as punching the wall beside the partner. Robinson, who is APA’s minority and underrepresented trustee, is at the University of Toronto as director of the Women’s Mental Health Program, senior psychiatrist of the University Health Network, and a professor of psychiatry.

Robinson said risk factors for being a victim of domestic violence include observing violence between parents in the home when young; having attitudes that accept violence and gender inequality; and experiencing marital conflict or disruption. “Substance abuse and low self-esteem have been noted as increasing vulnerability to domestic violence; however, they may be a consequence of the violence rather than a cause of the violence,” she said. “Physically there may be outward signs of violence, such as bruises or fractures. If a woman is pregnant—violence continues to occur during pregnancy, often directed to the women’s abdomen—there may be at increased risk of miscarriage, premature deliveries, or small-for-date babies.”

Robinson’s advice to clinicians: “Always ask about the presence of conflict in the family when taking a history, as women find it difficult to report unless they get the sense that they will be heard and not ignored or blamed. Having pamphlets or posters about domestic violence in the waiting room can provide an atmosphere that encourages women to report. It is important for the psychiatrist to have some practical information about safety measures such as domestic violence hotlines and where to go if the woman has to leave.

Domestic violence is not exclusively a problem between heterosexual couples. A recent study found that same-sex domestic violence affects one-quarter to nearly three-quarters of lesbian, gay, and bisexual individuals—figures that equal or exceed those for straight couples. “Domestic violence can occur in LGBT families with the same frequency as it does in straight ones,” said psychiatrist Jack Drescher, M.D., past president of the Group for the Advancement of Psychiatry. “Clinicians need to be alert to domestic violence presentations in their clinical practices and to understand what kind of interventions may be helpful to their patients and their families."

Expressing support for education and outreach efforts on domestic violence, APA President Paul Summergrad, M.D., stressed that, "Domestic violence can lead to serious health problems, including anxiety, depression, posttraumatic stress disorder, and substance abuse, as well as an increased likelihood of general medical problems such as headaches, chronic pain, and poor physical health. Domestic violence is not limited by economic status, race, national origin, religion, gender, or sexual orientation.... APA strongly advocates for prevention and better detection of domestic violence, improved treatment of victims and offenders, and expanded research into causes, consequences, and prevention.” APA has posted domestic violence resources at

APA's is holding its next #YourMH @twitter chat in observance of Domestic Violence Awareness Month. Join your APA colleagues in responding to questions and comments from the public on Friday, October 24, from noon to 1 p.m. ET. To join, use #YourMH (stands for "Your Mental Health"), @apapsychiatric, or #DVAM14. If you haven't created a Twitter account yet, click here to do so now. Here's your chance to share your knowledge and insights.

Wednesday, October 22, 2014

Forensic Psychiatrists Discuss Factors That Can Increase Violence Risk in Those With Mental Illness

Predicting violence among psychiatric patients “remains an inexact science,” a bit like predicting the weather, said forensic psychiatry experts Charles Scott, M.D., a professor of clinical psychiatry at the University of California, Davis, and Philip Resnick, M.D., a professor of psychiatry at Case Western Reserve University School of Medicine. While most people with mental illness are not violent, certain factors increase the risk of violence for people with psychosis or mood disorders, wrote Scott and Resnick in the October issue of CNS Spectrums.

“[I]ndividuals who suffer from persecutory delusions and negative affect are more likely to act on their delusions,” they said. Angry affect is a critical variable, especially when coupled with feelings of being spied upon, followed, plotted against, or being under external control. They pointed out as well that depression may be a risk factor when accompanied by a recent history of violence and/or alcohol use. Active manic symptoms are also associated with increased risk of engaging in a violent crime, but mostly when associated with comorbid substance abuse.

Scott and Resnick suggest using structured risk assessments to help gather appropriate data and reviewing research findings to identify violence-related risk factors associated with psychotic and mood disorder symptoms. “Like a good weather forecaster, the clinician does not state with certainty that an event will occur,” they concluded. “Instead, he or she estimates the likelihood that a future event will occur.

For more in Psychiatric News about assessment of risk for violence, see the article, “Experts Discuss Factors That May Lead to Violence Among Mentally Ill People.”

(Image: Lisa F. Young/

Tuesday, October 21, 2014

Don't Miss Your Chance to Hear Lectures From National Experts

There is still time to make plans to attend the APA Institute on Psychiatric Services (IPS) October 30 to November 2 in San Francisco and take advantage of a program that will explore in depth critical topics in mental health care today. One of the highlights will be a forum on Thursday, October 30 from 6 p.m. to 8:30 p.m., devoted to issues affecting the mental well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals.

Titled "Achieving Wellness in the LGBT Community: Mind, Body, and Spirit," the free forum will be open to the community and features a keynote address by Darlene Nipper, deputy executive director to the National Gay and Lesbian Task Force. Among the roster of speakers and panelists are Annelle Primm, M.D., M.P.H., deputy medical director of APA; Dan Karasic, M.D., a clinical professor in the Department of Psychiatry at the University of California, San Francisco (UCSF); Robert Cabaj, M.D., medical director of San Mateo Behavioral Health and Recovery Services; Dr. Jei Africa, health equity initiatives director of San Mateo Behavioral Health and Recovery Services; Jamison Green, Ph.D., president of the World Professional Association for Transgender Health; and Lori Thoemmes, L.M.F.T., director of the UCSF Alliance Health Project. The forum is being organized by the APA Division of Diversity and Health Equity.

The IPS program will also feature lectures by some of the mental health field's nationally recognized experts who will address critical issues in patient care and psychiatric practice. The impressive lineup includes Howard Goldman, M.D., Ph.D., on "Implementing First-Episode Psychosis Services: Policy Issues," Tanya Luhrmann, Ph.D., on "Hearing Voices in Three Cultures: A Comparison With Implications for Recovery," Charles Marmar, M.D., on "How Biomarkers for PTSD Will Advance Diagnosis and Treatment," David Pollack, M.D., on "Doin' the Community Waltz: A Saging and Raging Trip With the Walts: i.e., Whitman to White (With Visits to Kelly and Cronkite on the Way)," and Altha Stewart, M.D., on "Blacks and American Psychiatry: After 170 Years of APA and 50 Years of Civil Rights, What's Next?"

Click here to learn more about IPS program highlights and registration information.

Monday, October 20, 2014

FDA Approves New Abuse-Deterrent Labeling for Opioid Analgesic

The U.S. Food and Drug Administration (FDA) approved new labeling for Embeda, an opioid analgesic to treat severe pain. The new labeling includes a statement indicating that Embeda has properties that are expected to reduce oral abuse of the drug when the product is crushed.

Embeda becomes the third opioid analgesic to be approved with an abuse-deterrent label, in line with the FDA’s 2013 draft guidance, Abuse-Deterrent Opioids – Evaluation and Labeling.

Embeda, which is manufactured by Pfizer, is a combination of morphine sulfate and naltrexone hydrochloride. These agents have competing actions on the opioid receptor; when capsules are swallowed intact, only the morphine is released, producing pain relief but creating the risk of abuse and addiction. When crushed, the naltrexone is also activated, blocking some of the euphoric effects of morphine. This reduces the risk of abuse, though not completely preventing it, for people who improperly use the drug such as by inhaling it.

Though the new labeling is approved, the FDA will require additional postmarketing studies of Embeda to further assess the effects of the abuse-deterrent features on the risk—and consequences—of abuse, particularly in regard to intravenous use. The agency is also holding a public meeting on October 30-31 in Silver Spring, Md., to further discuss the development of abuse-deterrent opioids.

To read about initiatives and recommendations for reducing opioid abuse, see the Psychiatric News article, "Caution Urged for Clinicians Who Prescribe Opioids."

Friday, October 17, 2014

Pipeline and Innovation for Psychotropic Drugs Are Limited, Study Finds

As development of drugs to treat psychiatric disorders lags behind that of drugs for other illnesses, a recent study published in Psychiatric Services in Advance sheds light on why the pipeline for psychotropic medicines is nearly empty.

Researchers from Brandeis University and Truven Health Analytics led an investigation of the current state of psychotropic drugs in the pipeline and potential barriers that may keep these drugs from reaching distribution in the United States. Sifting through industry reports, company press releases, and the National Institutes of Health clinical trials website, the researchers gathered information on phase 3 trials for drugs being developed to treat major psychiatric disorders, including alcohol use disorder, schizophrenia, and depression. All studies involved adults aged 18 or older.

The analysis showed that the pipeline for psychotropic drug development—99 clinical trials were included—is limited, with little product innovation evident. Most of the examined drugs were a combination of existing of U.S. Food and Drug Administration-approved medicines or individually approved medicines that were being tested for new indications or delivery-system approaches (such as an injectable version that is similar to an approved oral form). Only three drugs differed substantially from existing drugs.

Among the barriers that hindered development of psychotropic drugs were incentives that encourage firms to focus on incremental innovation—such as a new version with fewer associated side effects—rather than taking risk on radically new molecular approaches, the failure of animal studies to translate well to human trials, and drug-approval thresholds set by the FDA that developers and manufacturers may perceive as too high to attain.

In an interview with Psychiatric News, Alan Schatzberg, M.D., a professor of psychiatry at Stanford University and former APA president, said that the departure by pharmaceutical companies to develop innovative psychotropic medicines could result in serious problems for the field of psychiatry, especially for patients.

“There is a number of initiatives by various organizations to help with this problem, including the European College of Neuropsychopharmacology, which is working with companies to provide investigators with compounds that have been shelved, and NIMH's Research Domain Criteria [RDoC], which promotes research on specific [and new] biological targets," he said. Schatzberg emphasized that it will take a concerted effort on the parts of governmental agencies, industry, as well as APA to advocate for investment and innovative psychiatric drug development. “Silence will not be helpful to our patients,” he concluded.

To read more about psychotropic drugs in the pipeline and initiatives to steer drug development and innovation, read this month's "Med Check" in Psychiatric News.

(Image: Florianopulopulos/

Thursday, October 16, 2014

Psychiatry Appointments Often Difficult to Obtain, Study FInds

Considerable attention is being focused on the unmet need for mental health care in this country and how critical it is to improve insurance coverage so more people can enter treatment. But a new study finds that expanded insurance coverage might not be the answer, since even with insurance, treatment for mental illness can be hard to obtain.

Researchers at Maimonides Medical Center in Brooklyn, N.,Y., and Harvard Medical School examined the availability of outpatient psychiatric appointments in three large cities—Boston, Chicago, and Houston. As they reported yesterday in the study "Availability of Outpatient Care From Psychiatrists: A Simulated Patient Study in Three U.S. Cities" in Psychiatric Services in Advance, "Obtaining an outpatient appointment with a psychiatrist was difficult in the three cities we surveyed, and the appointments given were an average of one month away. Our findings add to the growing evidence that the mental health system is difficult for consumers to access. The findings are in line with national data demonstrating that two-thirds of primary care physicians cannot obtain outpatient mental health services for patients who need them."

Posing as patients, researchers called 120 numbers in each of the cities that were listed for individual in-network psychiatrists (as opposed to psychiatric clinics) in a Blue Cross/Blue Shield (BCBS) database. For each city, 40 callers each said they had either BCBS PPO insurance, Medicare, or were self-pay. Only 40% of the calls were answered in the first round of calling, and 16% of the numbers were found to be incorrect. After two rounds of calling, the callers obtained appointments with only 93 psychiatrists, or 26% of the sample. The differences between being in the BCBS PPO, Medicare, or self-pay were insignificant when it came to lining up the psychiatric appointment. There was, however, a significant difference in "success rate" for appointments among the cities, with psychiatrists in Boston least likely to offer an appointment (18%), while in Houston appointments were obtained 34% of the time. Chicago was in the middle at 25%.

The researchers concluded that "Expanding health insurance coverage through the Affordable Care Act may thus do little to change the conditions that made it difficult for us to obtain outpatient appointments with psychiatrists—or worse, expansion of coverage might further overwhelm the capacity of available services from these providers." As remedies, they suggest ways in which psychiatry might be made more attractive to medical students and urge an increase in insurance reimbursement for psychiatric care.

For more on these issues, see the Psychiatric News articles "Knocking Down the Barriers to Care" and "Shift to Population Health Called Critical to Psychiatry's Future."

(image: Anton Prado Photo/shuttterstock)


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