Monday, December 22, 2014

Benzodiazepine Prescriptions High Among the Elderly, Study Finds


A new surveillance study has found that benzodiazepine usage increases with age, with nearly 9 percent of adults aged 65 to 80 filling a benzodiazepine prescription in 2008, compared with around 7 percent of adults 51 to 64, 5 percent of adults aged 36 to 50, and less than 3 percent of adults aged 18 to 35.

Adults over 65 were also more likely to have a long-term prescription for a benzodiazepine and were more likely to have their prescription written by a nonpsychiatrist; psychiatrists wrote less than 6 percent of benzodiazepine prescriptions for those aged 65 to 80.

These findings were published in JAMA Psychiatry on December 17.

Benzodiazepines can be effective in the short-term for treating anxiety or insomnia, but their risk of dependence and adverse effects such as cognitive impairment and loss of balance has led to expert recommendations to limit their use, especially in elderly people.

“It was alarming to find the highest rates of benzodiazepine use among the group with the highest risks,” said study author Michael Schoenbaum, Ph.D., of the Office of Science Policy, Planning, and Evaluation at the National Institute of Mental Health. “Given that safer, effective options are available for anxiety and insomnia, it’s hard to make a clinical argument for these results.”

Schoenbaum proposed that clinicians should restart a dialogue on the usage of benzodiazepines in the elderly, though a commentary accompanying the study suggested even stronger changes.

“It may be time to act, perhaps first by restricting the prescription of benzodiazepines to psychiatrists. In the study, psychiatrists seemed to prescribe them properly. The next step is to consider them the same as other dangerous addictive substances and put them on a tight dispensation schedule using limited-duration prescriptions with no refills,” the commentary authors wrote.

To read about the potential cognitive harm of benzodiazepine use, see the Psychiatric News article "Long-Term Use of Benzodiazepines May Be Linked to Alzheimer’s.

(shutterstock/khemporn tongphay)

Friday, December 19, 2014

Hyperactivity of Caudate Nucleus May Be An Underlying Factor of OCD Symptoms, Study Finds


A study published in today’s American Journal of Psychiatry suggests that misfiring of the brain’s control system for habits may be a reason for compulsions in obsessive-compulsive disorder (OCD).

Researchers in the departments of psychiatry and psychocology at Cambridge Behavioural and Clinical Neuroscience Institute and New York University performed MRI scans on the brains of 70 people, with and without OCD, to determine whether an association existed between symptoms of OCD and abnormal brain activation in the caudate nucleus, a structure in the basal ganglia that must fire correctly for one to control their habits. While receiving scans, the patients were asked to press a pedal, a part of a pedal pressing behavioral test, to avoid shock to the wrist. In the final stage of testing, the shock block was removed to assess whether the pedal-pressing behaviors of the patients could be discontinued.

The researchers found that patients with OCD were less capable of stopping their pedal-pressing habits than the control group. In addition, individuals in the OCD cohort were more likely to have hyperactivation in the caudate nucleus, compared with those without OCD.

The study’s lead author, Claire Gillian, Ph.D., a professor of psychology at the New York University, stated that the findings may not be specific to OCD and that in fact habits may underpin symptoms of many psychiatric conditions. “There are a range of human behaviors that are now considered examples of compulsivity, including drug and alcohol abuse and binge eating. What all these behaviors have in common is the loss of top-down control, perhaps due to miscommunication between regions that control our habits and those such as the prefrontal cortex that normally help control volitional behavior. As compulsive behaviors become more ingrained over time, our intentions play less and less of a role in what we actually do,” she concluded.

To read about other studies investigating possible pathophysiologies of OCD, see the Psychiatric News article “Study Looks at Association Between OCD, Schizophrenia.”

(Image: Fedorov Oleksiy/shutterstock.com)

Thursday, December 18, 2014

Preliminary Study Shows Primary Care Provider Training Can Improve Prescribing for Children


A New York state initiative to provide psychiatric consultation to pediatric primary care providers about prescribing psychotropic medication shows promise for enhancing providers' comfort with prescribing, according to the report “Detection and Treatment of Mental Health Issues by Pediatric PCPs in New York State: An Evaluation of Project TEACH” published online in Psychiatric Services in Advance.

Researchers in the Department of Child and Adolescent Psychiatry at New York University School of Medicine and colleagues at other institutions evaluated Project TEACH (PT), a statewide training and consultation program for pediatric primary care providers (PCPs) on identification and treatment of mental health conditions. The project is part of a collaboration between the REACH Institute (Resource for Advancing Children’s Health) and five academic departments of psychiatry. The curriculum consists of 15 hours of in-person training, a tool kit, and Web-based learning tools, along with a six-month distance learning program that includes 12 one-hour consultation calls with child psychiatrists.

Researchers compared an intervention group of 176 PCPs who volunteered for PT training with a stratified random sample of 200 PCPs who did not receive PT training. Data on prescription practices, diagnoses, and follow-up care were from New York State Medicaid files for youths seen by the trained and untrained PCPs. They found that the percentage of children prescribed psychotropic medication increased after PT training (from 9% to 12%), a larger increase than in the untrained group (from 4% to 5%).

“Our findings suggest potential benefits of training PCPs to identify and treat children’s mental health conditions," the researchers said. "Provider training and consultation may be a meaningful way to help reduce the number of children who do not receive treatment for mental health conditions, but further research is necessary to determine whether this type of model will be useful as the responsibility for mental health care and outcomes shifts under health care reform.”

For more about this program, see the Psychiatric News article, "New York Child Psychiatry Divisions Fill Gap in Collaborative Care Model."

(Image: Lisa F. Young/shutterstock.com)

Wednesday, December 17, 2014

Health Coaching Intervention Effective for Obesity in Those With Serious Mental Illness, Study Finds


A health coaching intervention for obesity appears to be effective in achieving and sustaining clinically significant reductions in cardiovascular risk for overweight and obese individuals with serious mental illness.

That’s the finding of a replication trial of the In SHAPE program in the report “Pragmatic Replication Trial of Health Promotion Coaching for Obesity in Serious Mental Illness and Maintenance of Outcomes,” published in AJP in Advance.

In SHAPE is a 12-month program consisting of individual weekly meetings in the community with a health-promotion coach, a fitness club (YMCA) membership, and nutrition education adapted for people with serious mental illness that was found in a previous study to contribute to clinically significant reduction in cardiovascular risk in overweight or obese adults with serious mental illness.

In the new study, Stephen Bartels, M.D., of the Department of Psychiatry and the Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth and colleagues randomly assigned 210 individuals with serious mental illness and a body mass index greater than 25 receiving services in three community mental health organizations either to the 12-month In SHAPE program or to fitness club membership alone. The primary outcome measures were weight and cardiorespiratory fitness (as measured with the 6-minute walk test) assessed at baseline and at 3, 6, 9, 12, and 18 months.

At 12 months, the In SHAPE group had greater reduction in weight and improved fitness compared with the fitness club membership group. Primary outcomes were maintained at 18 months. Approximately half of the In SHAPE group achieved clinically significant cardiovascular risk reduction, defined by a weight loss greater than 5 percent or an increase of greater than 50 meters on the 6-minute walk test.

“By comparing In SHAPE to an active comparison condition (a fitness club membership), we were able to test the specific contribution of having a health-promotion coach,” the researchers stated. “Having a health-promotion coach was associated with more than two-and-a-half times the mean amount of fitness club attendance, which in turn was associated with greater weight loss and improved fitness.”

For more on this subject, see the Psychiatric News article, "Health Mentors Prove Valuable For Those With Serious Mental Illness."


(Image: Shutterstock)

Tuesday, December 16, 2014

Senator Blocks Passage of Veterans' Suicide Prevention Bill


The legislative battle went down to the wire, but a lone recalcitrant senator ultimately blocked passage of a bill to help reduce suicides among veterans by enabling the Veterans Health Administration (VHA) to hire more psychiatrists. APA, veterans’ service organizations, and the Department of Veterans Affairs had strongly backed the Clay Hunt Suicide Prevention for American Veterans Act, which the House of Representatives approved unanimously last week.

The Senate vote was blocked by a “hold” placed on the bill by retiring Sen. Tom Coburn (R-Okla.), who objected to the allegedly dysfunctional management of the VHA. A hold permits a single senator to block a vote on the Senate floor.

In reply, Sen. Richard Blumenthal (D-Conn.) noted that the act included provisions for annual evaluations of the VHA’s mental health care and suicide prevention programs, in addition to encouraging recruitment of “not less than 10” psychiatrists per year into the VHA in part through use of a medical school loan repayment program. Psychiatrists entering the program would agree to a minimum of two years of service with the VHA in return for a $30,000 per year loan repayment.

There is hope for passage early next year, however. “Veterans groups have assurances from Senators John McCain (R-Ariz.) and Richard Burr (R-N.C.) for a quick reintroduction in January,” said Lizbet Boroughs, deputy director of APA’s Department of Government Relations. “A bipartisan group of 20 senators currently supports the bill, and Representatives Jeff Miller (R-Fla.) and Tim Walz (D-Minn.) will act quickly on the House side, as well.”

For more in Psychiatric News about psychiatrists and mental health care in the VHA, see the article “Psychiatrists’ Pay to Rise at Veterans Health Administration.”

(Image: Susan Montgomery/Shutterstock.com)

Monday, December 15, 2014

Patients Should Know Their Rights Under the Parity Law


December 15 is Bill of Rights Day, a time to recognize and reflect on the freedoms and protections that people in this country have, for it is critical to know your rights to protect those rights.

Among the mental health community, an important right was established in 2008 with the passing of the Mental Health Parity and Addiction Equity Act (MHPAEA). This law made it clear that insurers cannot discriminate against patients with a mental illness, including a substance use disorder.

However, the MHPAEA can be truly effective only if it is properly enforced, and to that end, APA created a poster to help educate patients about mental health parity and their rights under the MHPAEA.

Titled “Fair Insurance Coverage: It’s the Law,” this poster clearly and simply explains the 10 key elements of the law and the steps to take when a violation is suspected.

APA hopes its members and partners join in the effort to protect mental health patients and ensure that all insurers play by the rules. Physicians and therapists should print a copy and post it their office or waiting room, and any other interested parties are likewise encouraged to display the poster in their workplace and/or share the link. Patients and members of the public are invited to download and review the poster as well. Subscribers of Psychiatric News will find a color copy of the poster in the December 5 print edition of the paper.

Learn more about the MHPAEA and find resources related to the law here.

To read APA President Paul Summergrad’s column on this subject, see the Psychiatric News article “Parity Enforcement: A Top Priority.”

(Image: Michelle Holland)

Friday, December 12, 2014

FDA Warns That Ziprasidone May Lead to Potentially Fatal Skin Reaction


Yesterday the Food and Drug Administration (FDA) released a warning stating that the use of ziprasidone (marketed as Geodon), intended to treat schizophrenia and bipolar disorder, may increase risk for a rare but serious skin reaction that can result in death.

The skin reaction, known as drug reaction with eosinophilia and systemic syndromes (DRESS), may start as a rash that can eventually spread to all parts of body. The condition causes a higher-than-normal number of eosinophils, which can lead to fever, swollen lymph nodes, and inflammation of organs such as the heart, kidney, liver, lungs, and pancreas.

The FDA released the warning statement after the agency reviewed information from six patients in whom the symptoms of DRESS appeared between 11 and 30 days after initiating treatment with ziprasidone. Based on this information, the FDA is requiring Pfizer, the drug's manufacturer, to add a new warning for DRESS to the Warning and Precautions section of the drug labels for the capsule, oral suspension, and injection formulations.

The FDA is urging health care professionals to stop patient treatment with ziprasidone if DRESS is suspected. They are also asking physicians, as well as patients, to report any side effects involving ziprasidone in the “Contact Information For Voluntary Adverse Event Reporting” section of the FDA MedWatch website.


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