The criminal-justice system often has a hard time understanding defendants with Asperger’s syndrome because of the nature of their verbal and psychiatric symptoms, maintains Madelon Baranoski, Ph.D., M.S.N., an associate professor of psychiatry at Yale University School of Medicine. “There is a disparity between their verbal capacity and their practical behavior,” she said at the annual meeting of the American Academy of Psychiatry and the Law in Montreal last week. “They don’t get idioms or context, and this ‘odd-yet-normal’ presentation is seen by the court as arrogant and defiant.” An obsessive focus on vocabulary coupled with mood lability and a vulnerability to anxiety, depression, and paranoia can present a serious problem if judges, prosecutors, and defense attorneys are unaware of Asperger’s manifestations. A better understanding by courtroom participants (including the defendant) of Asperger’s and other autism spectrum disorders might lead to disposition at lower levels of charges and better outcomes for the patient/defendant, she said.
Read more in about Asperger’s syndrome and other autism spectrum disorders in Psychiatric Newshere and here.
Quickly assessing survivors to see who needs immediate mental health services could benefit victims and better allocate scarce mental health resources in the immediate aftermath of major disasters, such as the devastation Hurricane Sandy wreaked over a large portion of the East and Midwest on Monday and Tuesday, leaving thousands of people without homes to live in and jobs to go to.
Researchers tested 59 emergency medical technicians, nurses, mental health workers, public health workers, and laypersons using two screening tools, the Fast Mental Health Triage Tool (FMHT) and the Alsept-Price Mental Health Scale (APMHS). The respondents evaluated 10 vignettes involving disaster victims at baseline and then another 10 using one of the tools. The FMHT flowchart proved significantly more useful than the APMHS and was better than using no tool in correctly triaging the medically cleared survivors to the correct mental health services, wrote Donald Brannen, M.H.S.A., M.S., of the Greene County Medical Reserve Corps in Xenia, Ohio, and colleagues in the journal Disaster Medicine and Public Health Preparedness online October 29. The flowchart raised baseline mental health triage scores from 51.5% to 67.3%. The tools were designed to improve mental health triage and not to replace treatment for mental health sequelae of a disaster, wrote Brannen and colleagues. “Mental health triage is a separate set of skills, knowledge, and abilities that benefits from a [screening] tool.”
Three papers discussing the results of the DSM-5 field trials were posted online today by AJP. These papers describe the methods and results of 23 diagnoses that were assessed.
In these first analyses of data from the field trials, 14 of the 23 adult or child psychiatric diagnoses had “very good” or “good” reliability. Among these were autism spectrum disorder and ADHD in children and posttraumatic stress disorder and binge-eating disorder in adults. The papers also report on tests of a number of “cross-cutting symptoms” that appear across many psychiatric disorders, and these were also generally found to have good to excellent reliability. The cross-cutting symptom measures are proposed to appear as supplemental material to the DSM to help clinicians conduct a more comprehensive assessment.
Six of the diagnoses had relatively low reliability scores, which the report characterized as “questionable” but acceptable; among these diagnoses were major depressive disorder and generalized anxiety disorder, two of the most common psychiatric diagnoses. Task Force Chair David Kupfer, M.D., said, “We believe at least some of the reason why the scores were not at the level of previous field trials is the attention we devoted to new diagnoses and criteria sets that are often comorbid with depression and anxiety. Moreover, depression and anxiety represent symptom clusters that can fluctuate during several weeks, and the rigorous trial design of the field trials—employing a test-retest design requiring two separate clinicians to evaluate the same patient on different days—may have contributed to a lower reliability score than was found in previous field trials.”
Just three diagnoses had “unacceptable” rates of reliability, and these have been substantially revised or are no longer proposed for inclusion in the manual.
The proposed DSM-5 criteria are still under review and will not be final until they are approved by the APA Board of Trustees. The criteria were tested October 2010 through February 2012 by 279 clinicians at 11 academic centers in the in the United States and Canada. A second set of data from small group practices and private practices will be reported early next year.
Kupfer said that the field trials provide critical new data for the ongoing review of proposed diagnostic criteria for DSM-5. “We accomplished what we set out to do—which was to look at a limited group of diagnoses in which either a new disorder was being proposed or there were significant changes to existing criteria and to test both reliability and clinical acceptance,” he said. “The good to very good reliability of most diagnoses underscores that clinicians are comfortable using these new criteria.”
If you've experienced mental illness during the past year, you also may have had more than your share of colds. So suggests a study headed by Roselind Lieb, Ph.D., a professor of clinical psychology and epidemiology at the University of Basel in Switzerland and reported in the Journal of Psychosomatic Research. The study was based on a representative population sample of more than 4,000 German adults aged 18 to 65. The researchers found that having a DSM-IV mental disorder was associated with a 44% higher risk of having had a cold during the previous year. The reasons for the link are unclear, but Lieb told Psychiatric News that her leading explanation "is that mental disorders and a weakened immune system may share underlying vulnerability factors such as early-life stress, and stress caused by mental disorders leads to a maladaptive immune system and a lower threshold for the development of colds."
More information about the connection between the mind and the immune system can be found in Psychiatric Newshere andhere.
Psychiatrists at Cincinnati Children’s Hospital Medical Center are in the midst of a study to better assess risk of violence on inpatient units. “Nationally, we need to increase safety for staff, patients, and fellow patients on child inpatient units and reduce use of seclusion and restraint as much as possible,” reported psychiatrist Douglas Mossman, M.D., at the American Academy of Psychiatry and the Law’s annual meeting Thursday in Montreal.
So Mossman and colleagues Thomas Blom, M.S., and Drew Barzman, M.D., developed an assessment tool—the Brief Rating of Aggression by Children and Adolescents (BRACHA). They streamlined 67 items that predicted violence to a more manageable 14-item list, with items ranging from previous psychiatric diagnoses to impulsivity to lack of remorse, among others. Their initial work led to the current validation study covering 2,552 patients with a mean age of 13.4 admitted to the hospital for at least two days. The BRACHA was administered in the Emergency Department prior to admission. Outcomes were measured by unit nurses using the Overt Aggression Scale.
Age mattered in the predictive power of the BRACHA, said Mossman. “In children under 7 years, only being a boy was predictive,” he said, “Among 7- to 13-year-olds, most items gained predictive power, and in 13- to 19-year-olds, all items were useful in predicting future violence.” The BRACHA, said Mossman, “differentiated between high-risk (35 percent aggressive) and low-risk (8 percent) subgroups.” Their next step is to undertake a prospective validation study and determine the optimum weightings of BRACHA’s items.
In 2005, the National Academy of Sciences (NAS) issued a report criticizing the status of forensic science in the United States. It called for better reliability, enforceable standards, and use of best practices. The NAS’s main conclusion: “Research is desperately needed.” The report barely mentioned forensic psychiatry, however, said Charles Scott, M.D., president of the American Academy of Psychiatry and the Law, in his presidential address at the organization’s annual meeting Thursday in Montreal. “We were in the book, but we were not well defined.”
To better define itself as a science, forensic psychiatry needs to continue its balance of clinical and actuarial methods of evaluating patients. However, more research is needed on the instruments forensic psychiatrists use to assess risk, especially now that statutes and regulations are beginning to require their use. Many such instruments were devised as research tools and work well with populations but are less predictive in assessing individuals, said Scott, a professor of psychiatry at the University of California, Davis, and a member of APA's Council on Psychiatry and Law. Research is needed to settle on a defined number of instruments that are appropriate, ethical, and administered by psychiatrists, he said. These tests can serve a number of purposes. They are a structured way to gather information and are important components of risk assessment in treatment settings. They also allow review of evidence and of other experts’ analyses. However, as questions about the validity and utility of these tools are refined, psychiatrists will need more training to keep up their skills, he stated.
When it comes to Internet usage and social media, the line of professionalism can become blurred between patients and physicians. Patients expect being able to e-mail their physicians about medical information, and relationships among physicians now have the ability to cross new boundaries via social media.
The AMA policy on Professionalism in the Use of Social Media suggests separating personal online content from professional online content. The policy states, “When using the Internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute and that once on the Internet, content is likely there permanently.” AMA’s policy on social media also suggests using the privacy features within social media platforms, but warns that the privacy features are not absolute and recommends that physicians manually monitor their online persona as well.
There are many concerns that can arise with Internet usage and online professionalism. Liability issues with e-mails, privacy and confidentiality problems with social media, and even academic pitfalls among psychiatric trainees can all impact psychiatrists. A task force report in the September Academic Psychiatry addresses these issues and gives recommendations for psychiatric educators on how to teach trainees about online professionalism. Read coverage of this issue in Psychiatric News hereand here.
The federal government has been dangling the carrot of financial incentives in front of physicians as a way to encourage them to implement electronic health records (EHR) systems in their practices. A plethora of EHR systems has been flooding the market over the last few years, but choosing among them involves a careful balancing act that weighs cost and functionality. Because so many psychiatrists are in solo or small-group practices, they do not have support staff to sift through the options and make recommendations, and different practices will have unique needs as they select an EHR system. To remedy this problem, APA, through its Committee on Electronic Health Records, is developing resources to help APA members negotiate the maze of competing systems.
In the latest issue of Psychiatric News, the committee's chair, Steven Daviss, M.D., notes that the committee is testing the ability for APA members who have used a particular EHR system to rate several characteristics and will make those reviews available to other APA members. Resources already available include minutes of the committee's discussions, information on federal incentives for physicians who adopt EHR systems, information on privacy and security issues, and a slide presentation by committee members on several aspects of using EHR systems. These resources are available at www.psychiatry.org/EHR. Read Daviss's column about choosing an EHR system in Psychiatric News.
Meng Chen, Ph.D., an epidemiologist at the University of Texas MD Anderson Cancer Center in Houston, reported these findings at the American Association for Cancer Research conference in Anaheim, Calif.
The study included 464 subjects with bladder cancer. Subjects with Center for Epidemiologic Studies Depression Scale (CES-D) scores of 16 or greater had an average survival time of 58 months, whereas subjects with CES-D scores below 16 had an average survival time longer than 200 months. When evaluating the combination of depression and telomere length, the researchers found that compared with subjects without depression symptoms (i.e., CES-D scores less than 16) and long telomeres, subjects with depression symptoms (i.e., CES-D scores of 16 or greater) and short telomeres showed more than a threefold increased danger of death from bladder cancer: 31 months versus 200 months.
More information about telomere length and mental health can be found in Psychiatric News.
Use of alcohol and other drugs among U.S. military service members remains “unacceptably high” and could harm force readiness and psychological fitness, according to an Institute of Medicine (IOM) report.
Binge drinking and other heavy use of alcohol have increased since the start of the wars in Iraq and Afghanistan, the IOM noted, and prescriptions by military doctors for pain medications quadrupled to 3.8 million from 2001 to 2009.
TRICARE, the DoD’s civilian health care contractor, relies too much on inpatient substance abuse rehabilitation treatment and underutilizes outpatient services, thanks to congressionally mandated regulations, said panel members.
“[T]he highest levels of military leadership must acknowledge these alarming facts and combat them using an arsenal of public-health strategies, including proactively attacking substance use problems before they begin by limiting access to certain medications and alcohol,” concluded the IOM panel, chaired by Charles O’Brien, M.D., a professor of psychiatry and director at the University of Pennsylvania.
For more in Psychiatric News about the IOM report, click here.
Cyberbullying—the use of the Internet, phones, or other technologies to repeatedly harass or mistreat peers—is often linked with teen suicide in media reports. However, new research presented earlier this week at the American Academy of Pediatrics National Conference in New Orleans, shows that the reality is more complex. Most teen suicide victims are bullied both online and in school, and many suicide victims also suffer from depression.
Researchers identified 41 suicide cases (24 female, 17 male, ages 13 to 18), 24 percent of whom were the victims of homophobic bullying, including the 12 percent of teens identified as homosexual and another 12 percent who were identified as heterosexual or of unknown sexual orientation. "Cyberbullying is a factor in some suicides, but almost always there are other factors such as mental illness or face-to-face bullying," said study author John LeBlanc, M.D., M.Sc., an associate professor in the Department of Pediatrics at Dalhousie University in Nova Scotia, Canada. "Cyberbullying usually occurs in the context of regular bullying." Leblanc said that certain social media, by allowing anonymity, may encourage cyberbullying, but he acknowledged that because of the complex issues involved, it's "difficult to prove a cause-and-effect relationship."
Teenage victims often find it difficult to escape cyberbullying, however.
Read more about this issue in Psychiatric Newshere.
A region of the genome involved in immune system function, called the major histocompatibility complex (MHC), is involved in genetic susceptibility to schizophrenia. So reported two international groups of scientists online on October 10 in Biological Psychiatry. Actually "we have replicated evidence for specific risk and protective alleles at the MHC locus—a critical step teasing apart the genetic risk mechanisms involved," commented Aiden Corvin, M.D., an associate professor of psychiatry at Trinity College in Dublin, Ireland, in an accompanying press release.
"Immunologic studies in schizophrenia that illuminate the nature of the contribution of variation in immune system genes to schizophrenia will be an important new direction in schizophrenia research," John Krystal, M.D., editor of Biological Psychiatry, stated in the same press release.
More information about the roles that the immune system plays in psychiatric illness can be found in Psychiatric News here and here.
Although many initiatives to conquer Alzheimer's disease focus on amyloid plaques in the brain, Andres Lozano, M.D., Ph.D., chair of neurosurgery at the University of Toronto, is concentrating on a different strategy—deep brain stimulation (DBS). He and his colleagues tested the hypothesis that DBS would increase cerebral glucose metabolism and lead to better clinical outcomes in five subjects with mild, probable Alzhemer's. And their results confirmed their hypothesis, they reported in the September Archives of Neurology. "We are conducting an NIH-funded phase 2 trial of DBS in Alzheimer's, and we plan on enrolling 50 patients," Lozano told Psychiatric News.
DBS is already approved for treating refractory Parkinson's disease and obsessive-compulsive disorder. Before long it may be approved for treating refractory depression as well. For more information on DBS research, see Psychiatric Newshere and here. Read about DBS in Tourette's syndrome in the American Journal of Psychiatry.
At least 48 states have established programs to monitor prescription and sale of opioid pain medications in an attempt to rein in the rapidly expanding abuse of these drugs. Among the states with such a program is Colorado. But a report in the Denver Post October 18 quotes a Drug Enforcement Administration official who said that the agency's data indicate that pharmacists filling the prescriptions and physicians writing them check the register only 10% to 15% of the time before issuing or filling opioid prescriptions, calling into question the effectiveness of these monitoring programs. Physicians and pharmacists in Colorado are encouraged to check the database for signs of unusual prescribing or buying patterns, but are not required to do so, and "there appears to be little support for making a cross-check of the database mandatory before writing or dispensing opioid prescriptions," the article noted.
One opioid prescription monitoring program that does appear to have achieved considerable success is PharmaNet in British Columbia, Canada, which has been operational since 1995. That program, which monitors benzodiazepine prescriptions as well as those for opioids, is credited with a 33% reduction in inappropriately filled opioid prescriptions and a 49% reduction in inappropriately filled benzodiazepine prescriptions. Read more about the study showing the success of the PharmaNet system in the new issue of Psychiatric News.
Teenagers whose parents have panic disorder and/or major depression are at risk for a range of mental disorders throughout their development, according to a report published October 3 in the American Journal of Psychiatry. Researchers at Massachusetts General Hospital and the State University of New York Upstate Medical Center examined rates of psychiatric disorders at 10-year-follow-up in four groups: adolescent offspring of parents with panic and depression, offspring of parents with panic but without depression, offspring of parents with depression alone, and offspring of parents with neither disorder.
They found that parental panic disorder, independently of parental depression, predicted lifetime rates in offspring of multiple anxiety disorders, panic disorder, agoraphobia, social phobia, and obsessive-compulsive disorder. Parental depression independently predicted bipolar disorder, drug use, and disruptive behavior disorders. They also found that together parental panic and depression interacted to predict specific phobias and major depressive disorder. Phobias were elevated in all at-risk groups, and depression was elevated in both offspring groups of parents with depression (with or without panic disorder).
With concern growing nationwide about a rapidly spreading epidemic of abuse of the psychoactive designer drug commonly known as "bath salts," findings from a study of a key ingredient of bath salts published online yesterday in Neuropsychopharmacology are particularly troubling. Led by Michael Baumann, Ph.D., of the National Institute on Drug Abuse (NIDA), the researchers found that in rats the ingredient MDPV—an amphetamine-like chemical—appears to be "at least 10 times more potent than cocaine at producing locomotor activation, tachycardia, and hypertension." They noted as well that "The robust stimulation of dopamine transmission by MDPV predicts serious potential for abuse and may provide a mechanism to explain the adverse effects observed in humans taking high doses of 'bath salts' preparations."
The increasing use of bath salts by teens and young adults, bought legally in the form of a synthetic powder under colorful names such as Purple Wave, Red Dove, Blue Silk, and Vanilla Sky, prompted an extensive message from NIDA Director Nora Volkow, M.D., last year. She stressed that bath salts have been associated with "an alarming number of ER visits across the country. Doctors and clinicians at U.S. poison centers have indicated that ingesting or snorting 'bath salts'...can cause chest pains, increased blood pressure, increased heart rate, agitation, hallucinations, extreme paranoia, and delusions."
Read more about the problem of bath-salts abuse in Psychiatric Newshere and here.
Alcoholism is deadly, and a new study shows that it may be more so for women. In fact, alcoholism may be twice as fatal for women as for men, according to an online report October 16 in Alcoholism: Clinical and Experimental Research. Researchers drew a random sample of the general population in one region of Germany, out of which they identified 153 alcohol-dependent individuals. For 149 of them, vital status information was provided 14 years later.
The researchers found that annualized death rates were 4.6-fold higher for women and 1.9-fold higher for men, compared with the age- and sex-matched general population of the region. Moreover, for both men and women, alcoholism appeared to contribute more to early death than other prominent factors, including smoking. Other findings were that having participated in inpatient alcohol dependence treatment was not related to longer survival and that poor self-rated health predicted mortality. An abstract of the study is posted here.
A 33-year prospective study of male children diagnosed with attention-deficit/hyperactivity disorder (ADHD) at age 8 has identified long-term repercussions of the diagnosis. Researchers at New York University Langone Medical Center found that children diagnosed with ADHD have worse educational, occupational, economic, social, and marital outcomes than their peers. Also found were higher rates of ongoing ADHD, antisocial personality disorder, substance use disorders, adult-onset psychiatric disorders, psychiatric hospitalizations, and incarcerations.
“The multiple disadvantages predicted by childhood ADHD well into adulthood began in adolescence, without increased onsets of new disorders after 20 years of age,” they wrote online in the October Archives of General Psychiatry. “Findings highlight the importance of extended monitoring and treatment of children with ADHD.”
For more information about the disorder, see ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults, available from American Psychiatric Publishing here. To read about the economic consequences of adult ADHD, see Psychiatric Newshere.
As part of National Substance Abuse Prevention Month, the National Institute on Drug Abuse (NIDA) has launched Family Checkup, an online resource that equips parents with research-based skills to help keep their children drug-free. NIDA-funded research has shown the critical role parents play in preventing their children from using drugs. Family Checkup poses questions for parents to consider as they interact with their children, highlighting parenting skills that are important in preventing the initiation or progression of drug use among youth. The resource incorporates videos and other information demonstrating positive and negative examples of parenting techniques. The tools were developed by the Child and Family Center at the University of Oregon. Research shows that positive parenting techniques can also alter a child's genetic susceptibility to psychiatric disorders. Read more in Psychiatric Newshere. See also the Concise Guide to Child and Adolescent Psychiatry, Fourth Edition, available from American Psychiatric Publishing here.
A four-year follow-up of more than 200 older people with mild cognitive impairment showed that those who had exhibited better recognition memory at the start of the study were less likely to progress to dementia than were those who had shown worse recognition memory. Specifically, 37 percent of the study cohort progressed to dementia. But while 52% of subjects with lower recognition memory scores eventually developed dementia, only 22% of subjects with higher recognition scores did. The study, led by Estrella Gomez-Tortosa, M.D., Ph.D., of the Department of Neurology at the Jimenez Diaz Foundation in Madrid, Spain, was published in the October American Journal of Geriatric Psychiatry.
A real-time opioid and benzodiazepine prescription monitoring program in British Columbia led to a 33% reduction in inappropriately filled prescriptions for opioids and an even greater reduction—49%—in inappropriately filled prescriptions for benzodiazepines. So reported Colin Dormuth, Sc.D., of the University of British Columbia online September 4 in the Canadian Medical Association Journal.
Commenting on the research findings, John Renner, M.D., associate chief of psychiatry for the VA Boston Healthcare System and chair of the APA Council on Addiction Psychiatry, said he thought the study was well done and that "the findings are consistent with other views and with the general opinions of the addiction psychiatry community." But for a prescription monitoring program to really achieve its goals of reducing abuse, it should not only be in real time, but national, Elinore McCance-Katz, M.D., Ph.D., a professor of psychiatry at the University of California, San Francisco, and an addiction psychiatrist, told Psychiatric News. She has urged the federal government to fully fund such a program, she said.
Currently, at least 48 states have implemented monitoring programs that track prescribing and sale of opioids, but unlike the Canadian program, none provides real-time information to pharmacists at the time that people try to fill opioid prescriptions.
More information about the Canadian prescription program will appear in the October 19 Psychiatric News.
An independent research consortium said this week that new information about the potential Alzheimer's drug solanezumab, being developed by Eli Lilly, is "encouraging." The Alzheimer's Disease Cooperative Study (ADCS) presented results from its analyses of the EXPEDITION study data at the annual meeting of the American Neurological Association. Lilly provided the data collected from the EXPEDITION studies to the ADCS.
On August 24, Lilly announced that its clinical trials in more than 2,000 people showed the drug was unable to halt the disease's progress on measures of cognition and functionality. Lilly's announcement followed by less than a month the failure of a similar drug being developed by Pfizer and Johnson and Johnson. But Lilly did note evidence of "statistically significant slowing of cogntive decline in subjects with mild to moderate Alzheimer's who were taking the drug."
Rachelle Doody, M.D., Ph.D., a professor of neurology at Baylor College of Medicine and a member of the ADCS steering committee, said "Alzheimer's disease research has been extremely challenging. The data results from the solanezumab phase 3 trials...represent an important step for the medical, academic, and scientific communities in understanding brain amyloid as a target of Alzheimer's disease therapies."
Could growth-hormone-releasing hormone (GHRH) injections keep seniors mentally sharp regardless of whether they have mild cognitive impairment? An intriguing new study headed by Michael Vitiello, Ph.D., a professor of psychiatry at the University of Washington, suggests that this is the case. The results were published recently in the Archives of Neurology.
The study included 137 adults aged 55 to 87 of whom 76 had normal cognitive status and 61 had mild cognitive impairment. The subjects received either a synthetic analog of human GHRH or a placebo for 20 weeks. The executive-function test results for the group that received GHRH were significantly better than for those who received a placebo. And even though the healthy adults outperformed those with mild cognitive impairment overall, the cognitive benefit of GHRH relative to placebo was comparable for both groups. And while not quite statistically significant, a similar pattern of results emerged for verbal memory.
"This is a well-conducted trial by an outstanding group of investigators with expertise in cognitive disorders of later life," Dilip Jeste, M.D., chair in aging at the University of California, San Diego, and president of APA, told Psychiatric News. "The results are highly promising."
Read more about this study in the latest issue of Psychiatric News.
Recently named as director of the federal government's Center for Mental Health Services (CMHS), Paolo del Vecchio, M.S.W., said that prominent on his agenda is strengthening the increasingly important connections between the primary care and mental health care sectors so that the high somatic comorbidity of mental and physical illness can be better addressed.In an interview with Psychiatric News soon after he took over the reins at CMHS, an agency of the Substance Abuse and Mental Health Services Administration, del Vecchio said that CMHS will give grants to programs that are trying various approaches to linking mental health care and general medical care. He emphasized as well his plans to expand CMHS's focus on developing programs in trauma-focused care, saying, "We want to look upstream to prevent trauma in the first place as a means to prevent behavioral health disorders from the start." Early intervention can lead to less disability and distress in the long run, he said.
Prior to his long career in mental health care in the private and public sectors, del Vecchio described another type of insider experience he had with mental health care. He told Psychiatric News that his background includes a long period as a youth and young adult when he clearly needed mental health care, including for alcohol and drug use, but spent decades avoiding it, fearful of the stigma that came with getting help for such problems.
Read more about del Vecchio's background and plans for CMHS in Psychiatric News.
The Food and Drug Administration (FDA) announced last week that it has withdrawn its approval for a generic version of the antidepressant bupropion manufactured by Impax Laboratories and distributed by Teva Pharmaceuticals USA. It asked the companies to remove it from the market, and they complied voluntarily.
The FDA action on the 300 mg—but not the 150 mg—strength of the product, which is marketed as Budeprion XL (extended relief) comes about five years after the FDA started receiving reports "that patients who were switched from Wellbutrin XL 300 to its generic counterparts were experiencing reduced efficacy." The FDA decided in 2010 to conduct tests on the product after dozens of complaints were received over several years about relapses and side effects after patients switched to a generic version. Its tests showed that "Budeprion XL 300 is not absorbed into the bloodstream at the same rate and to the same extent as Wellbutrin XL 300 mg." As for the multiyear delay in conducting tests on Budeprion, the FDA acknowledged that "A less-cautious approach in studying the bioequivalence of Budeprion XL 300 mg could have brought the data to light earlier."
The agency advised that "Patients taking Budeprion XL 300 mg as a substitute for Wellbutrin XL 300 mg should talk with their health care professionals if they have questions about taking this medication." The FDA pointed out that it has no data "showing that the other four generic [bupropion] products are not bioequivalent to Wellbutrin XL 300 mg."
To read about data on comparative efficacy of bupropion and other antidepressants, see Psychiatric News.
Psychiatrists treating depression in pregnant women face a difficult choice: use medications to reduce the mother’s symptoms or avoid them so as not to expose the fetus to the drugs. Neither are ideal options because maternal depression may negatively influence fetal development as much as medication exposure. Now researchers from the University of British Columbia and Harvard University tested the infants of three sets of mothers: those with depression but not treated with selective serotonin reuptake inhibitors (SSRIs); those with depression who were taking SSRIs; and those were not depressed and not taking an SSRI, who served as controls.
The control infants succeeded in discriminating vowel sounds at six months but not at 10 months, as expected. But babies exposed to SSRIs in the womb could not distinguish the sounds at either age. Those born to depressed but untreated mothers succeeded at 10 months instead of six months. "What is unknown at this time, and of key clinical importance, is whether these small perturbations in critical period timing of core perceptual components of language acquisition have a lasting impact,” wrote the authors online in Proceedings of the National Academy of Science Early Edition.
To read more about SSRIs and pregnancy, see Psychiatric Newshere and the American Journal of Psychiatryhere.
Lori Raney, M.D., of Dolores, Colo., advocates integrating psychiatry with primary care, just like many of her psychiatrist colleagues do. Working closely with a social worker and a psychologist, Raney offers support and consultation to the primary care clinicians at a federally qualified health center in southwest Colorado.
That's the traditional model of integrated care: moving the psychiatrist into the primary care clinic. However, at the same time, Raney approaches integration from the other direction. At the Cortez Integrated Health Center, she designed a facility for people with serious mental illness that also addresses their general medical needs. In addition to “consultation and education” rooms for psychiatric care, the facility has rooms for basic physical exams. “We’re open to everyone in the community for primary care,” Raney said at APA’s Institute on Psychiatric Services in New York. Every patient gets screened for factors such as cholesterol level, high blood pressure, diabetes, and smoking, as well as for psychiatric illnesses.
“It makes me feel like a more-well-rounded physician,” said Raney. “We psychiatrists are the only ones in the room trained in both worlds.”
To read more about integrated care, see Psychiatric Newshere.
Why don’t many psychiatrists do psychotherapy even though it works?
That’s a question Eric Plakun, M.D., and Joyce C. West, Ph.D., M.P.P., explored in a workshop at APA’s Institute on Psychiatric Services in New York. Plakun is a former chair of APA's Committee on Psychotherapy by Psychiatrists (now sunsetted) and director of admissions and professional relations at the Austen Riggs Center. West (pictured above) is policy research director for the American Psychiatric Institute for Research and Education (APIRE). Plakun and West presented data from an APIRE survey of 394 psychiatrists. For respondents' "last typical work week," 48 percent said they provided psychopharmacology alone, 41 percent said they provided both pharmacology and psychotherapy, and 7 percent said they provided psychotherapy alone. (Five percent said they provided "other services.")
More than two-thirds said financial issues were prominent barriers to providing psychotherapy. The survey also found that psychiatrists who were more likely to provide psychotherapy were over 65 and worked in solo practice settings with 50 percent or more of patients who were self-pay or 50 percent or more who were privately insured. Psychiatrists who provided a significant amount of psychotherapy were also less likely to report that medical debt affected their practice of psychotherapy.
"It is quite a powerful finding that it is older psychiatrists who are preserving psychotherapy as a provision by psychiatrists, and it speaks to a problem of a lost generation in training,” Plakun said. “There is a lost generation that was trained at the point of the deepest commitment to biological reductionism. That’s part of the reason why the Committee on Psychotherapy by Psychiatrists was originally formed. There was a recognition...that psychotherapy was in danger of being a skill lost in the practicing of psychiatrists and the training of residents."
For more information about psychotherapy by psychiatrists, see Psychiatric News here. To view a video of Plakun discussing the survey after the IPS session, go here.
Medications may help psychiatric patients get better, but “getting better” is a “profoundly value-laden term,” said Ronald Diamond, M.D., a professor of psychiatry in the School of Medicine and Public Health at the University of Wisconsin. “‘Better’ means different things to different people,” said Diamond at APA’s Institute on Psychiatric Services in New York. “It could be subjective improvement for the patient, better functioning, symptom improvement, reduced distress, or simply not getting worse.” What does the patient hope the medication will do? Try to agree on specific, concrete, detailed, outcomes based on observable behaviors, he said. “Our job is not to convince patients to take medications, but to structure the flow of information to help them to make good decisions about their conditions and treatments,” he said. Medications are a tool for recovery and can make nonpharmacological treatments more effective. “Medications are never a goal of treatment; rather, they can help patients reach their own goals,” said Diamond. “Ambivalence about medications is normal, but people will take them if they feel they will help them and won’t if they don’t.”
The recovery model--isn’t that something that takes lots of time to bring to reality for a patient? Not when it happens in the emergency department, Anthony Ng, M.D., told the audience at APA’s Institute on Psychiatric Services in New York. “The emergency department is the gateway to care,” said Ng, medical director of Arcadia Health System in Bangor, Maine. “This is where they’ll get their first impression of psychiatry, so even if they’re not ready to accept treatment, we can prepare them for that moment.”
Traditionally, emergency department psychiatry worked on a “triage-and-refer” model. Now an alternative approach (at least for some patients) can see the first stages of treatment there, although not without some major adjustments. For instance, the practical concerns of operating an emergency department creates a sense of urgency that is at odds with the usual paradigm of psychiatric care, said Ng.
“You have to do recovery work in minutes or hours versus days or months,” he said. But there can be a payoff if that effort reduces use of restraints or leads to fewer readmissions and trips back to the emergency department.
Engaging patients long enough to figure out what they really want when they approach the hospital may reveal that alternatives like day hospitals, crisis teams, or even phone calls may meet their real needs and cut unnecessary usage.
Thirty years after the HIV-AIDS epidemic made its appearance, the epidemic—and the stigma that surrounds it—are still with us.
So said Marjorie J. Hill, Ph.D., winner of APA’s John Fryer Award, at APA’s Institute on Psychiatric Services in New York. Hill is the chief executive officer of the Gay Men’s Health Crisis (GMHC), the oldest AIDS service and advocacy organization.
She told psychiatrists at the meeting that 1 in 5 people who are HIV positive are unaware of their HIV status. “HIV is fraught with enormous social, economic, and psychiatric challenges,” Hill said. “The nuances around HIV prevention, education, treatment, and care are linked to stigma....Stigma often impacts HIV testing as it may keep and does keep individuals from seeking an HIV test. Twenty percent of individuals living with HIV don’t know it. Why don’t they know it? Because they are not willing to take what is now a 20-minute rapid test. Stigma also impedes on treatment follow-up and HIV disclosure."
GMHC provides a continuum of services to 12,000 persons annually paired with a robust public policy advocacy. Previously, Hill was HIV/AIDS assistant Commissioner for the New York City Department of Public Health. The John Fryer Award is named in honor of psychiatrist John Fryer, a gay activist who made an appearance in disguise at APA's 1972 annual meeting to announce that he was gay.
That's the message Will Hall, M.A., brought to psychiatrists Saturday at APA's Institute on Psychiatric Services in New York. Hall is a therapist whose recovery from schizophrenia lends him a unique perspective on the experience of psychosis. He has become a leading advocate of alternative treatment options for people with mental illness, emphasizing psychosocial and interpersonal aspects of recovery. (Hall is pictured at left with Rishi Gautam, M.D., who chaired the session and introduced Hall.) He spoke on "13 Practical Innovations to Improve Recovery Outcomes for Schizophrenia and Bipolar."
"We need to tell people that recovery can happen," Hall told a packed room at the Institute. "I sometimes encounter the stereotype that I must not be someone who has a diagnosis with schi-zoaffective disorder, [that I] must have been misdiagnosed. But in fact the research is very consistent that people do recover, and when we tell people that these conditions are incurable, we are not representing the research accurately."
If psychiatrists want to be more effective and help a much larger population of people, they need to work in a model of integrated care where they can collaborate closely with primary care physicians, said psychiatrist Jurgen Unutzer, M.D., M.P.H., at APA’s Institute on Psychiatric Services in New York.
An internationally known health services researcher and director of the AIMS Center (Advancing Integrated Mental Health Solutions) at the University of Washington, Unutzer (pictured above) described innovative models of care that integrate mental health and general medical services. He presented evidence that psychiatrists working in a consultative way with primary care can significantly improve mental health care for large populations of people in primary care, while also lowering overall health care costs.
“In a collaborative care model, we as psychiatrists can help our colleagues in primary care make a big difference and improve the lives of the patients they are seeing,” Unutzer said.
To view a video of Unutzer discussing collaborative care, click here. Also, APA Medical Director James H. Scully Jr., M.D., spoke about the role of integrated care in health care reform. To view the video, click here.
"All contemporary studies of social and environmental factors affecting mental health and mental disorders—whether they know it or not—are standing on the shoulders of giants,” said psychiatrist Lewis Opler, M.D., M.P.H. And one of the tallest giants is the landmark “Manhattan Midtown Study."
At APA’s Institute on Psychiatric Services in New York, Opler and colleagues—Ernest Millman, Ph.D., M.P.H., Lawrence Yang, Ph.D., and Mark Opler, Ph.D., M.P.H. (Lewis' son)—outlined the origins, methodology, and findings of a pioneering epidemiologic study, the first volume of whose findings were published 50 years ago this year. Begun in the early 1950s in the wake of World War II and in response to the enormous numbers of men who were rejected for service because of psychiatric disorders, the Manhattan Midtown Study was a longitudinal, community-based survey of what was then the culturally and socioeconomically diverse neighborhood of midtown Manhattan. Undertaken during a period when psychoanalysis was the predominant school of psychiatry, the study was groundbreaking in demonstrating the prevalence of mental health problems in a community sample.
More importantly, its concepts—that social and environmental factors such as poverty, racial and ethnic segregation, and marital and socioeconomic status are crucial determinants of mental health and illness—laid the foundation for what is today a burgeoning field of social and cross-cultural psychiatry. Yang described new research on the social determinants of psychosis in rural China, and the younger Opler outlined emerging research on the association between paternal age (and the increasing social trend toward later and later parenting) and schizophrenia and autism.
“The lessons of the Midtown Manhattan Study, including its founding concepts and findings, are essential to the changes we face in an increasingly urban world where community psychiatry will play an ever greater role in the treatment and prevention of mental illness,” Mark Opler said.
To view a video of Lewis Opler’s comments about the study, click here.
Stigma remains a significant obstruction to care-seeking by troops but it may not even be the most significant one, according an international group of researchers who spoke yeseterday at APA’s Institute on Psychiatric Services in New York.
“Soldiers who are most in need of mental health care are also the ones who are less likely to ask for or receive care,” said Neil Greenberg, M.D., surgeon commander in the Royal Navy. Part of the reason is their concern about how seeking or accepting care might negatively affect their careers or result in denigration by their fellow soldiers or officers.
Greenberg appeared on a panel with other researchers from the Technical Cooperation Program, whose members include representatives from the U.S., Great Britain, Canada, Australia, and New Zealand.
However, other factors also kept service members from treatment, said Amy Adler, Ph.D., of the Walter Reed Army Institute of Research. “A positive view of mental health treatment predicts greater treatment-seeking, but higher scores on measures of self-reliance predict lower willingness,” she said.
A survey of 8,841 Canadian troops looking at time from onset to treatment found, among other things, that younger troops sought care sooner but that those in service for shorter time waited longer, said Canada’s Deniz Fikretoglu, Ph.D., a defence scientist at the Canadian Institute for Military and Veteran Health Research in Toronto.
“Also, the higher the rank, the less likely they were to seek care, because they thought it would affect their subordinates’ perception of their leadership abilities and result in deaths among their troops,” said Fikretoglu. “We have to look beyond the fear of stigma. Troops have many more concerns.”
“Mine is a story of wellness through recovery and integration,” said Elyn R. Saks, J.D., Ph.D., in a keynote address this afternoon at APA’s 64th Institute on Psychiatric Services in New York. Echoing the theme of this year’s conference—“Pursuing Wellness Though Recovery and Integration”—Saks recounted a remarkable story of academic and professional success in the face of schizophrenia. (She is pictured with APA President Dilip Jeste, M.D.)
Saks, the author of The Center Cannot Hold: My Journey Through Madness, is the Orrin B. Evans Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences at the University of Southern California Gould School of Law. She described her early ominous symptoms in childhood and adolescence, her first hospitalization while studying at Oxford University in England, her long resistance to and denial of mental illness, and her eventual acceptance of the efficacy of antipsychotic medication in combination with psychotherapy in her treatment and recovery. “I think that recovery is very important and that [psychiatrists] cannot think only about reduction of symptoms, but about quality of life. And we need to think about how to put that question to [psychiatric patients] themselves—How can we get them what they want out of life?”
In introducing Saks, Jeste said the future of psychiatry lies in embracing not just the treatment of acute symptoms but also a new focus on “positive” psychological traits of resilience, optimism, social integration, and wisdom embodied in Saks’ story. “Recovery is no longer a dream or a fantasy,” Jeste told psychiatrists at the meeting. “It is a reality.”
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