Teens Talking Drug Abuse With Experts Today

We are now in the middle of National Drug Facts Week, sponsored by the National Institute on Drug Abuse (NIDA), and events are being held in conjunction with the observance in all 50 states. And today features a highlight of those events—the fifth annual Drug Facts Chat Day during which high school students throughout the country can "chat" anonymously and in real time with NIDA scientists who will try to answer their questions about use of illicit drugs as well as the rapidly spreading problem of misuse of prescription drugs, which many teens believe are less risky than traditional drugs of abuse because a physician prescribed them. Schools have been encouraged to register to have their students participate in Drug Facts Chat Day and those that did received an access code to allow teachers and students to participate in the chat. More than 30 scientists and science writers are expected to be online to answer the students' questions today.

In a letter to teachers, NIDA Director Nora Volkow, M.D., called the event "an ideal project for students in science, health, language, computer use, or even gym classes," adding that she hopes that the project's anonymous nature "will encourage students to ask what is truly on their minds. What they get in return are scientific facts, not lectures." Soon after the day's chats are completed, NIDA will post a transcript of them.

Information about National Drug Facts Week and Drug Facts Chat Day is available here. A transcript of last year's chat is posted here.

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Oscar-Nominated Film Could Help Those With Mental Illness

"It has been a long time since a Hollywood movie actually seemed like it could help people suffering from mental illness, their families, and those who treat them," according to APA President-elect Jeffrey Lieberman, M.D. Writing online yesterday in "CNN Health," Lieberman praised the film "Silver Linings Playbook" for its "natural and poignant" depiction of people struggling with mental illness as they find ways to deal with their families and community. Nominated for eight Academy Awards, the film is an "antidote" to the stereotyped and stigmatizing portrayals of mental illness and its treatment that have long been staples of Hollywood films such as "One Flew Over the Cuckoo's Nest."

The timing of the film "is particularly welcome in light of the wanton killings in Newtown, Connecticut, and the president's initiative on gun control and violence," Lieberman emphasized. "The president is right to seek legislation, but what is also needed is helping people with mental disorders get treatment, the first step in which is to reduce stigma." In "Silver Linings Playbook," the characters' mental illnesses "don't define their identities—nor are they even the main point of the story.... This is a story in which everyday characters...experience mental disorders as part of their lives and manage to cope with them and ultimately prevail." Lieberman noted as well that this film, which has been a box-office hit, "shows us that treatment can work and that people can overcome their disorders. All are not doomed to suffer."

Read the full text of Lieberman's CNN article here. To read an analysis of how schizophrenia is portrayed in the media, see Psychiatric Services here.

Large Study Finds no Link Between SSRIs in Pregnancy and Stillbirth or Neonatal Death

A large population-based study looking at every birth in Denmark during a 13-year period found no association between use of SSRI antidepressants during pregnancy and either stillbirths or neonatal deaths. The study appears online today in AJP in Advance.

Researchers at the University of Copenhagen conducted a population-based study using the Danish Fertility Database to identify every birth in Denmark between 1995 and 2008. Time of exposure to SSRIs was calculated on the basis of standard treatment dosages and dispensed pack sizes according to the prescription register. Exposure was divided into first-, second-, and third-trimester exposure.

Researchers identified 920,620 births, of which 12,425 involved exposure to an SSRI during pregnancy. Neither stillbirth nor neonatal mortality was associated with SSRI use during any period in pregnancy. The researchers note that it is possible that women receiving SSRI antidepressants are more closely monitored during pregnancy, and the lack of an association with stillbirth or neonatal death could reflect more rigorous medical care. 

Click here to read more about this study, and for additional information on this subject, see Psychiatric News here.

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Cardiac Disease Linked to Mild Cognitive Impairment in Women

Cardiac disease appears to be an independent risk factor for nonamnestic mild cognitive impairment, and the risk appears to be greater for women, according to a report in the new JAMA-Neurology.

Researchers at the Mayo Clinic followed 2,719 participants for four years as part of a prospective, population-based study of the relationship between cardiac disease and mild cognitive impairment (MCI). Participants were evaluated at baseline and every 15 months using the Clinical Dementia Rating scale, a neurological evaluation, and neuropsychological testing. Cardiac disease at baseline was assessed from the participant's medical records. Of 1,450 participants without MCI or dementia at baseline, 366 developed MCI. Cardiac disease was associated with an increased risk of nonamnestic MCI. However, the association varied by gender, with an increased risk for women but not for men.

Appearance of mild cognitive impairment is an important stage for early detection and intervention in dementia, said lead author Rosebud Roberts, M.B., Ch.B., a health sciences researcher at Mayo Clinic. "Prevention and management of cardiac disease and vascular risk factors are likely to reduce the risk," he noted.

An abstract of the study is posted here. To read more about the relationship between cardiac disease and mental health problems, see Psychiatric News here.

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Erratum; New Telehealth Code Announced

A Psychiatric News Alert distributed on January 17 contained incorrect information. The item reported that APA had joined with the American Telemedicine Association in asking the Centers for Medicare and Medicaid Services (CMS) for a temporary accommodation to address problems created by the elimination of CPT code 90862. That code had been used for pharmacologic management by psychiatrists conducting telehealth rounds for hospitals that do not have a psychiatrist on staff. The report also stated that psychiatrists must use an evaluation and management (E/M) code to bill for this function and stated that E/M codes can be used for this purpose only once every three days.

In fact, at the time the Alert was published, CMS had already made a correction to eliminate this problem.  CMS created a G-code, G0459, effective January 1, that allows for  all medically necessary inpatient telehealth psychiatric pharmacologic management, including prescription, use, and review of medication with minimal medical psychotherapy. There are no restrictions on the frequency with which this code can be used; also, there are no restrictions on the frequency with which medically necessary E/M codes can be used outside of telemedicine. We apologize for the errors.

For more information, click here.

Coming Out of the Closet Often Leads to Better Health

Lesbian, gay, and bisexual individuals who make known their sexual orientation to others had lower levels of cortisol and fewer symptoms of anxiety and depression, according to findings by Canadian researchers led by Sonia Lupien, Ph.D., director of the Centre for Studies on Human Stress at Louis H. Lafontaine Hospital, a part of the Université de Montréal.

They tested 87 people with an average age of 25. They took cortisol samples, administered psychological examinations, and measured insulin, sugar, cholesterol, blood pressure, adrenalin, and inflammatory and other markers. With that data, they calculated the allostatic load on each subject, a measure of general “wear and tear” on the body. “Lesbians, gay men, and bisexuals who were out to family and friends had lower levels of psychiatric symptoms and lower morning cortisol levels than those who were still in the closet,” said lead author Robert-Paul Juster, M.S.C., writing online today in Psychosomatic Medicine.

The research suggests that self-acceptance and disclosure can have positive effects on the health and well-being of lesbian, gay, and bisexual individuals and is thus a serious public-health matter, concluded Juster.

For more in Psychiatric News about gay and lesbian mental health issues, click here and here. See also The LGBT Casebook, new from American Psychiatric Publishing.

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Brain Changes May Affect Sleep in Older Adults

The reasons why older adults are not as adept at remembering new information as young people are may be due to several factors, a new study suggests. As they age, adults lose tissue in the prefrontal cortex of the brain, which then disturbs sleep, and the sleep disturbance then interferes with memory. The study was headed by Matthew Walker of the University of California, Berkeley, and findings were published online yesterday in Nature Neuroscience.

The study included 15 older adults and 18 younger adults. Walker and his colleagues found that in the older adults age-related medial prefrontal cortex atrophy was linked with reduced slow-wave sleep, which then mediated the impairment of overnight sleep-dependent memory retention. Moreover, this memory impairment was linked with reduced task-related hippocampal-prefrontal cortex functional connectivity.

"This important study demonstrates that disrupted slow-wave sleep, potentially mediated by structural brain atrophy, contributes to impaired consolidation of episodic memory," Brent Forester, M.D., a Harvard Medical School psychiatrist and chair of the APA Council on Geriatric Psychiatry, said during an interview with Psychiatric News.

More information about sleep disorders in older adults and how to treat them can be found in the American Psychiatric Publishing book Clinical Manual for Evaluation and Treatment of Sleep Disorders. Also see a review in Psychiatric News.

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Sex Hormones Linked With Risk of Committing Sexual Crimes, Study Finds

Elevated levels of the two sex hormones—luteinizing hormone (LH) and follicle-stimulating hormone (FSH)—predict recidivism among male sex offenders better than do elevated levels of the sex hormone testosterone, report John Bradford, M.D., one of Canada's leading sex-offender experts, and colleagues in the latest issue of the Journal of the American Academy of Psychiatry and the Law. LH and FSH, which are also referred to as gonadotrophic hormones, are made by the pituitary gland. LH stimulates the testes to produce testosterone. FSH stimulates the testes to make sperm.

"This study is an important one, with a surprising finding that gonadotrophic hormones were better predictors of recidivism for sexual crimes than testosterone," Richard Krueger, M.D., an associate clinicial professor of psychiatry at Columbia University College of Physicians and Surgeons who has studied sexual offenders, said in an interview with Psychiatric News. 

However, it is doubtful that elevated levels of LH and FSH are alone responsible for sexual crimes, Bradford and colleagues pointed out in their report. So what other factors might contribute to such behavior? Perhaps hostility, the researchers suggested, since they found that hostility was associated with the impact of LH and FSH on recidivism.

For information about research on sexual offenses including pedophilia, see Psychiatric News. Psychological insights into sex offenders can be found in the American Psychiatric Publishing book Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior and Dangerous Sex Offenders: A Task Force Report of the American Psychiatric Association.

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APA Submits Testimony to Congress on the State of America's Health System

APA Medical Director and CEO James H. Scully Jr., M.D., submitted testimony yesterday on behalf of APA to the Senate Committee on Health, Education, Labor, and Pensions (HELP Committee) in conjunction with its hearing on the state of the U.S. mental health system. “This hearing comes at a critical time when our leaders in government are faced with difficult choices about where to allocate limited resources,” said Scully. “The current state of our nation’s mental health system is weak and demands immediate and significant attention by Congress and the administration.”

In his testimony, Scully urged issuance of a final rule on the Mental Health Parity and Addiction Equity Act of 2008 and reintroduction of the Medicare Mental Health Inpatient Equity Act, which would increase access to care for people with serious mental illness. APA also supports formation of a new Commission on Mental Health, either presidential or congressional, to conceptualize how the nation’s mental health system can better meet the needs of all Americans. APA, he said, supports investment in biomedical research, ongoing initiatives to develop and implement new treatments for addiction, and state block grants for mental health and substance use services, suicide prevention, and jail-diversion programs for people with mental illness.

He stressed as well that APA strongly backs the preservation of both direct and indirect graduate medical education payments from the government, which fund 16,000 residencies each year. And finally, APA strongly supports efforts to train school personnel to identify early warning signs of violent behavior in children and adolescents.

To read more about the parity law implementation, see Psychiatric News.

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American Psychiatric Foundation Teams with Miami-Dade School System to Address Teen Mental Health

The American Psychiatric Foundation (APF) and Miami-Dade County Public Schools will be implementing APF's Typical or Troubled? School Mental Health Education Program for all public junior high and high schools in the Miami-Dade system. The program will train more than 500 teachers, school psychologists, social workers, and guidance counselors on early identification of potential mental health problems, will educate and engage parents, and will ultimately link students with mental health services when needed.

Typical or Troubled? is an educational program that helps school personnel distinguish between typical teenage behavior and evidence of mental health warning signs that could warrant intervention. The program includes culturally sensitive technical assistance for school personnel on best practices and educational materials in English, Spanish, and soon in Haitian Creole.  To date, the program has been used in more than 500 schools and school districts and educated more than 40,000 teachers, coaches, administrators, and other school personnel across the country.

Miami-Dade County Judge Steven Leifman, who is a member of the APF board of directors, said, “The school is the perfect place to bring students, parents, teachers, and other school personnel together to ultimately connect those students who need help with support and treatment. This program is a model program for every school community in our nation.”

The partnership of APF and Miami-Dade County Public Schools will take a "proactive" approach to tackle the issue through partnerships and targeted training that hone in on the identification and effective treatment of mental health problems before those problems before they are manifest through  truancy, substance abuse, violence, or tragedy.

A recent NIMH study addressed the question of whether teens with psychiatric disorders are overmedicated. Read about it in Psychiatric News, here.

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APA Generally Pleased With HIPAA Final Privacy Rule

APA says it is encouraged by additional patient privacy protections that the Department of Health and Human Services (HHS) has included in a final HIPAA rule released this week. The HIPAA Final Rule enables patients who pay with cash to instruct their health care providers to not make information about their treatment available to insurers, while also requiring health care providers who are HIPAA covered entities to include within their Notice of Privacy Practices (NPPs) a statement of the right of patients to be notified following a breach of their protected health information. It also allows patients to ask for a copy of their electronic medical records.

Also, the HIPAA Final Rule revises the definition of privacy “breach” and modifies elements contained within the risk-assessment test used to determine whether a breach of protected health information has occurred. HHS has removed the harm standard and altered its risk assessment to focus more objectively on the risk that a patient’s protected health information has been compromised. Notification of a breach is no longer necessary if a HIPAA covered entity or business associate demonstrates through a risk assessment that there is a low probability that the protected health information has been comproised. In addition, HHS has broadened the list of those who may be liable for HIPAA Privacy Rule violations to include subcontractors employed by a covered entity's business associates, while also setting a four-tier financial penalty structure for breaches deemed serious enough to warrant a federally imposed penalty. Fines will range from $100 to $50,000 per violation, with a $1.5 million annual cap. 

To access a short or long summary of the HIPAA Final Privacy Rule prepared by APA’s regulatory staff, click here. The text of the rule is to be published in tomorrow's Federal Register.

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Are Patient Notes by Residents Ready for Release to Patients?

Among the arguments made by supporters of the shift from paper to electronic medical records (EMRs) is that the latter will make it much easier for patients to access and review their records and then discuss their care with their physician. But with concerns raised in particular about how patients' may respond to the often sensitive information included in psychiatrists' notes, Simon Kung, M.D., of the Department of Psychiatry and Psychology at the Mayo Clinic, and colleagues investigated whether notes written by PGY-3 to PGY-5 psychiatry residents were in fact ready for release to patients. As they report in the new issue of Academic Psychiatry, in general these notes did not raise concerns about readiness for release to patients.

In this study, 128 outpatient treatment notes by the residents that were not marked as "highly confidential" were reviewed by a psychiatrist and a nonpsychiatrist (a third-year medical student who had completed a psychiatry rotation or an experienced psychiatry recreation therapist). The primary outcome was the question, "Overall, if a patient read this note, do you think they would be offended, confused, alarmed, injured, upset? Is the note written in a respectful tone, with sensitivity to culture, age, gender, sexual orientation, disability?" The researchers found that 70% of the notes were assessed as "no concern" by both reviewers, 23% were of "some concern," and 7% were of "major concern." There was a difference, however, between how the psychiatrists and the nonpsychiatrists perceived the notes, with 94% of nonpsychiatrists rating them as of "no concern" but only 72% of psychiatrists doing so.

Read more about this study in Academic Psychiatry.

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Cognitive Decline in Teens Might Signal Risk of Psychosis, Study Suggests

Early indicators that might predict later onset of psychiatric disorders could help guide interventions and prevention efforts. Research has shown that people who develop psychosis as adults often displayed cognitive deficits as children or teenagers. A new population-based Swedish study of 10,717 people indicates that the progression of these cognitive deficits over the teen years was associated with an increased risk for schizophrenia and other psychoses.

The researchers looked at groups of boys born in 1953, 1967, 1972, and 1977. All the boys were given tests of verbal, spatial, and inductive ability at age 13 and again at age 18, when drafted into the army. Compared with unaffected young men, those who later developed psychoses had a relative decline in verbal ability over the testing period, said James McCabe, Ph.D., of King’s College, London and colleagues, writing online in JAMA Psychiatry.

“Decline between ages 13 and 18 years was a much stronger predictor of psychosis than the verbal ability score at age 18 years alone,” they said. “This suggests an impairment of late neurodevelopment affecting the acquisition of verbal skills in adolescent boys and young men who later develop psychosis."

To read more about prevention of psychosis, see Psychiatric News here and here.

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Members of Congress Push for More Mental Health Funding for Schools

U.S. Rep. Grace Napolitano (D-Calif.) and Sen. Al Franken (D-Minn.) said yesterday that they will introduce the Mental Health in the Schools Act in the House and Senate, respectively. The two spoke at a briefing on Capitol Hill for congressional staffers co-chaired by Napolitano and Rep. Mike Thompson (D-Calif.) on mental health aspects of gun-violence prevention.

The proposed act would provide resources for schools to work with mental health care providers and offer comprehensive training to parents and teachers about warning signs of mental illness, said Franken. “It’s not just about preventing violence,” he said. “It’s about making sure kids have access to mental health services.”

Napolitano has introduced similar legislation in previous sessions of Congress, but the program has only received pilot-stage funding. She is concerned that fiscal obstacles lie in the way of final passage. “Unless we find the money, the likelihood of passage is quite low,” she said in an interview with Psychiatric News after the briefing. Nevertheless, she and other speakers said the tragic shooting at Sandy Hook Elementary School in Newtown, Conn., might spur action to reduce gun violence and increase access to mental health services for young people.

For more in Psychiatric News about the Mental Health in the Schools act, click here.

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New DSM-5 Series Includes Supplementary Information; Order Your Manual Now!

In addition to information about important changes to diagnostic criteria for neurodevelopmental disorders and an overview of broad conceptual and organizational changes to DSM-5, a new series in Psychiatric News—launched last Friday—also has links to fact sheets and video interviews of experts discussing changes to the manual. These include Susan Swedo, M.D., chair of the Work Group on Neurodevelopmental Disorders, who discusses autism spectrum disorder and specific learning disorder, and APA President Dilip Jeste, M.D., and DSM-5 Task Force Chair David Kupfer, M.D., who discusses the overall development of DSM-5.

The first articles in the Psychiatric News series are posted here and here. The supplementary materials and videos can be accessed at www.psychiatry.org/dsm5.

DSM-5, which will be published in May and available for purchase at APA’s 2013 annual meeting in San Francisco, can be preordered now along with a suite of complementary publications. The latter include the DSM-5 Desk Reference and the Pocket Guide to DSM-5 Diagnostic Exam, both available in May; the DSM-5 Guidebook and DSM-5 Test Questions, available in August this year; and DSM-5 Clinical Cases, DSM-5 Study Guide, and the Handbook of Differential Diagnoses, which will be available in September.

The print version of the book, as well as the suite of complementary publications, may be ordered online or by calling (800) 368-5777.

ADHD Diagnoses in California Health Plan Jump 24 Percent in 10 Years

Rates of diagnosis of ADHD among children in a large California health plan jumped 24 percent from 2001 to 2010, according to a report this week in JAMA-Pediatrics. In the study, researchers at Kaiser Permanente Southern California (KPSC) examined medical records for all children who received care at KPSC from January 2, 2001, through December 31, 2010. Records for 842,830 children were studied. The main outcome measure was incidence of physician-diagnosed ADHD in children aged 5 to 11.

The researchers found that rates of ADHD diagnosis were 2.5% in 2001 and 3.1% in 2010. They also found that the rate increased most among whites, followed by blacks and Hispanics, and that children living in high-income households were at increased risk of diagnosis compared with peers in lower-income households. The increase in ADHD diagnosis among blacks was largely driven by an increase in diagnoses among girls.

“The findings of this study suggest increasing trends in the clinical diagnosis of ADHD among children in the health plan,” the researchers said. “We also observed disproportionately high ADHD diagnosis rates among white children and notable increases in rates among black girls over time.”

The study can be accessed here. For more information about trends in ADHD diagnosis, see Psychiatric News here. Also see the new issue of Psychiatric Services in Advance for a study of trends in medication treatment of ADHD.

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APA Applauds White House Gun-Control Proposals

Speaking on behalf of the APA yesterday, President Dilip Jeste, M.D., said the organization applauds the proposals set forth by President Obama to reduce gun violence. “I am strongly encouraged by the President’s recommendations because they include a focus on improving mental health care," Jeste told Psychiatric News, "I am also glad that the President’s statement mentioned that people with mental illnesses are more often victims of violence than perpetrators of the same.”

A new initiative outlined by Obama would provide training for school personnel and help ensure that young people who need help are referred to treatment. This is in line with an effective school outreach program developed by the American Psychiatric Foundation aimed at improving early identification of young people with mental health problems. The program, called Typical or Troubled?, works with school systems throughout the country to help identify warning signs of mental health problems in teens and teach educators how to respond to them. The Obama administration has also proposed funding for state efforts to support young adults with mental health concerns, to support school-based violence prevention efforts, and to train 5,000 additional mental health professionals to serve students and young adults.

Jeste also expressed the organization's appreciation for Obama's clarification that doctors are not prohibited from asking their patients about guns in their homes. APA has actively opposed a Florida law to bar physicians from discussing gun ownership with their patients. Read more about the Florida law in Psychiatric News, here.

Series on DSM-5 Launched Today; Preorder Your Manual Now

The issue of Psychiatric News posted today launches a series of articles on the major differences between DSM-IV and DSM-5; the series will conclude in May, coinciding with the publication of the manual. Today’s installment consists of two articles that outline the broad concepts that have guided the organization of the text and information on changes impacting the diagnosis of neurodevelopmental disorders. The articles can be accessed here:

"Continuity and Changes Mark New Text"
"DSM-5 Provides New Take on Developmental Disorders"

Also, beginning today, DSM-5 may be preordered from American Psychiatric Publishing; preorders will be fulfilled beginning on the manual’s publication date of May 22. Those attending APA’s 2013 annual meeting, which is being held in San Francisco May 18 to 22, have another purchase option: they will have an exclusive opportunity to buy the manual before it goes on sale to the public. Click here to register for the meeting; early-bird rates are in effect until January 24.

In an interview with Psychiatric News, DSM-5 Task Force Chair David Kupfer, M.D., explained that those overarching conceptual ideas include incorporation of a developmental approach to psychiatric disorders, recognition of the influence of culture and gender on how psychiatric illness presents in individual patients, a move toward the use of dimensional measures to rate severity and disaggregate symptoms that tend to occur across multiple disorders, harmonization of the text with ICD, and integration of genetic and neurobiological findings by grouping clusters of disorders that share genetic or neurobiological substrates.

With regard to the chapter on neurodevelopmental disorders, a major change to the description and organization of criteria for autism and related disorders tops the major revisions clinicians can expect to see. The chapter also includes the addition of a new “social communication disorder,” reorganization of criteria for learning disorders, and changes to the criteria for intellectual disability (known in DSM-IV as mental retardation).

Small Study Suggests Some Patients With Autism Can Recover

Can some children diagnosed with autism recover? A new study suggests that a subset of children diagnosed early in life with autism are later free of symptoms to the point that they lose the diagnosis. The study, “Optimal Outcome in Individuals With a History of Autism” appears online in the Journal of Child Psychology and Psychiatry.

In the study, a team led by Deborah Fein of the University of Connecticut recruited 34 people aged 8 to 21 who had been diagnosed before age 5 and no longer had symptoms. This “optimal outcome” (OO) group was compared with an age- and sex-matched group of high functioning autism (HFA) patients and a “typical development” (TD) group without autism. They found that the OO group and TD groups did not differ on mean scores of socialization, communication, face recognition, or most language subscales.

"This is an interesting and helpful report.," child and adolescent psychiatrist David Fassler, M.D., told Psychiatric News. "The authors describe a small subset of people initially diagnosed with autism who appear to `recover', over time, at least with respect to cognitive and social functioning. As the study involved a relatively small number of subjects from a limited geographic area, it should be interpreted with caution. It should also be stressed that while such significant improvement can and does occur, it's a relatively rare event. Hopefully, future studies will replicate the current findings and help us better understand this intriguing phenomenon."

The study is posted here. For more information about autism, see Psychiatric News here.

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APA Urges Fix for Problem Arising From Elimination of a CPT Code

APA has joined with the American Telemedicine Association in asking the Centers for Medicare and Medicaid Services (CMS) for a temporary accommodation to address problems created by the elimination of CPT code 90862. That code covered pharmacologic management by psychiatrists conducting telehealth rounds for hospitals that do not have a psychiatrist on staff. Under new rules that went effect at the beginning of the year, psychiatrists will have to use an evaluation and management (E/M) code to bill for this function. However, E/M codes can only be used once every three days, and hospitals using telepsychiatry often require that acutely ill psychiatric patients be seen at least five times a week by a psychiatrist.

“It is essential that psychiatrists be able to do rounds on these patients more frequently than every three days,” wrote APA Medical Director James Scully, M.D., and Jonathan Linkous, chief executive officer of the American Telemedicine Association, in a letter to CMS Administrator Marilyn Tavenner. “We are concerned that under the new coding format, seriously ill patients will not be able to receive the care they require.”

The two organizations have asked CMS for delay of several months to permit a re-evaluation of the rule and “a thoughtful long-term adjustment.”

To read more about recent changes to CPT codes, see Psychiatric News.

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Two Brain Areas Appear to Rule Borderline Emotions

Heightened brain activity in circuits involving negative emotions coupled with reduced activation of circuits that normally suppress negative emotion appear to underlie the emotional dysregulation seen in borderline personality disorder (BPD), according to an analysis of 11 published neuroimaging studies by Anthony Ruocco, Ph.D., an assistant professor of psychology at the University of Toronto Scarborough. He and his colleagues found evidence that two interconnected neural systems may affect emotion dysregulation in BPD. One triggered “a heightened subjective perception of the intensity of negative emotions,” while the other, mainly in the frontal brain regions, poorly regulated the emotions.

“Importantly, reduced activity in a frontal area of the brain, called the subgenual anterior cingulate, may be unique to borderline personality disorder and could serve to differentiate it from other related conditions, such as recurrent major depression,” said Ruocco in the January 15 Biological Psychiatry. “[T]hese findings could suggest that dysfunctions in critical frontal ‘control’ centers might be normalized after successful treatment,” he concluded.

To read more in Psychiatric News about treating borderline personality disorder, click here. And see also American Psychiatric Publishing's book, Psychodynamic Psychotherapy for Personality Disorders: Clinical Handbook.

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Better Preventive Care Urged for Schizophrenia Patients

People with schizophrenia die 12 to 15 years earlier than their counterparts in the general population, a difference driven largely by ischemic heart disease and cancer, according to a large study of Swedish patients. “Despite having more than twice as many contacts with the health care system than other people, schizophrenia patients had no increased risk of having a diagnosis of nonfatal ischemic heart disease or cancer but had a far greater mortality from these conditions, suggesting substantial underdiagnosis and/or undertreatment,” said Casey Crump, M.D., Ph.D., of the Department of Medicine and the Stanford Prevention Research Center at Stanford University, and colleagues online yesterday in AJP in Advance.

For instance, ischemic heart disease was diagnosed prior to death in only 26% of schizophrenia patients, compared with 44% of others who died of heart disease. “Preventive interventions should prioritize primary health care tailored to this population, including more effective risk modification and screening for cardiovascular disease and cancer,” the researchers said.

For an in-depth review of this topic, see the book Medical Illness and Schizophrenia, Second Edition, from American Psychiatric Publishing. For an analysis showing higher standardized mortality ratios for cardiovascular and other diseases in people with mental illness, see the new online issue of the  APA journal PS in Advance. 

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N.Y. Gun Bill Has Mental Illness Component

New York's lawmakers and governor have not waited to see what, if any, changes to gun access will come out of Congress and the White House. Instead, they acted yesterday to pass a bill designed to limit the ability of some people with mental illness to obtain guns and expand the state's tough assault-weapons ban. The state Senate and Gov. Andrew Cuomo agreed on a bill that makes New York the first state to act on this issue since the massacre in Newtown, Conn., last month brought the issue to the fore. Passed by a 43-18 vote by the state Senate late Monday night, and being debated today by the state Assembly, which is expected to pass it, New York's Secure Ammunition and Firearms Enforcement (SAFE) Act would include a mandate that mental health care providers notify law-enforcement officials if they are aware of anyone who appears to be a danger to themselves or other individuals. Law-enforcement personnel would then check this name against gun-registration databases and have the authority to confiscate guns that such individuals may possess. Mental health care providers would not face penalties if they fail to report the identities of potentially dangerous patients as long as they are determined to have acted "in good faith." The bill would also require gun owners to ensure that guns in their home are inaccessible to anyone who has been involuntarily committed, convicted of a crime, or the subject of a protective order.

Former APA President Paul Appelbaum, M.D., chair of APA's Committee on Judicial Action and director of the Division of Law, Ethics, and Psychiatry at Columbia University, raised the issue of unintended consequences arising from the mental illness provision, telling Psychiatric News that "even if there is no reason to believe that the person has a weapon, it represents a major change in the rules of confidentiality that have always governed mental health treatment." He added that the prospect of having their name reported to police officials "may be enough to discourage patients with suicidal or homicidal ideation from seeking treatment or from talking about their disturbing thoughts. It may discourage the very people we most want to have in treatment from seeking help." Appelbaum emphasized that, "At the very least, it would seem prudent to hold hearing on the possible consequences of this sweeping legislation rather than adopting it in haste."

To read Psychiatric News coverage of the mental health aftermath of the shootings in Newtown, click here and here.

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Dietary Supplement During Pregnancy Could Reduce Risk of Schizophrenia

A dietary supplement known as choline, when given to pregnant women, could help diminish the risk of brain abnormalities associated with schizophrenia in offspring, according to a report released online today in AJP in Advance.

If the findings are replicated, it is possible that choline supplementation during pregnancy might serve as a broad public health measure to prevent schizophrenia, in the same way that folic acid today is used to help prevent birth defects. Choline has been shown to activate receptors in the brain that facilitate development of “cerebral inhibition,” a term for faculties—such as sensory gaiting and attention—that help the brain manage and organize incoming sensory stimuli and that are deficient in schizophrenia.

In the study, 46 pregnant women were randomized in the second trimester of pregnancy to receive a dietary supplement of phosphatidylcholine and 47 women to receive placebo. Seventy-six percent of the infants whose mothers received choline supplementation were found to have intact cerebral inhibition according to a electrophysiological test, compared with just 43 percent of the infants whose mothers got placebo. Moreover, a genotype associated with schizophrenia was correlated with diminished cerebral inhibition in the placebo-group, but not in the choline group.

AJP Editor and senior author of the study Robert Freedman, M.D., told Psychiatric News, “The hypothesis that improving prenatal brain development might decrease the risk of developing schizophrenia later in life merges decades of clinical observation of infants who later developed schizophrenia with recent findings that many genes that increase risk for schizophrenia have roles in fetal brain development."

The study, “Perinatal Choline Effects on Neonatal Pathophysiology Related to Later Schizophrenia Risk,” can be accessed here.

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Aggressive Behavior Can Cost People Their Jobs

If additional reasons are needed for people to find strategies for controlling their aggressive behavior, they can be found in a new study reported in the January Comprehensive Psychiatry showing how potentially damaging such behavior can be in the workplace. Randy Sansone of Wright State University and colleagues evaluated 325 individuals visiting an outpatient internal medicine clinic on factors related to self-reported aggressive behaviors and employment histories. Their data showed that a higher number of aggressive behaviors correlated with a greater number of different jobs held and a greater number of firings.

One form of aggressive behavior with which psychiatrists are familiar is intermittent explosive disorder. It is characterized by recurrent episodes of aggression involving violence or destruction of property out of proportion to a provocation. Information about intermittent explosive disorder can be found in Psychiatric News.

Other recent research on aggression has found that a small protein called neuropeptide Y, which can be found in the hypothalamus and other brain regions, appears to play a key role in aggressive behavior. An antagonist of neuropeptide Y might be able to temper aggression in some individuals. Read more about this topic in Psychiatric News as well.

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Great Recession Contributed to Rise in Heart Attacks, Study Suggests

Has the Great Recession of the past few years, which as taken a toll on so many phases of life in the U.S., contributed to heart attacks among Americans? Quite possibly, a study headed by Matthew Dupre, Ph.D., of Duke University and reported in JAMA Internal Medicine suggests. Dupre and his colleagues followed more than 13,000 Americans aged 51 to 75 from 1992 to 2010. (The recession started in 2008). The researchers found that heart attacks occurred significantly more often among unemployed subjects than among employed ones and that the risk increased incrementally from experiencing one job loss to experiencing four job losses, even when socioeconomic factors, behavioral risk factors, and various clinical factors were considered.

The psychological stress of carrying debt can also adversely impact Americans' health, a study reported in the Journal of Aging and Health suggests. People who were carrying high levels of debt had more anxiety, depression, and anger than nondebtors did, even when potentially confounding variables such as age, gender, education, and occupational status were included in the analysis. For more information about this study, see Psychiatric News. In addition, for a review of the complex clinical interaction of mental health and medical illness, see The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition.

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Dose-Dependent Relationship Found Between Meth Use and Psychosis Symptoms

There appears to be a large dose-dependent increase in the occurrence of psychotic symptoms during periods of methamphetamine use, according to a study published online in JAMA Psychiatry. Australian researchers found a 5-fold increase in the likelihood of psychotic symptoms during periods of methamphetamine use compared with periods of no use. The increase was strongly dose-dependent: individuals who had used methamphetamine 16 or more days in the prior month were significantly more likely to experience psychotic symptoms than those who had used the drug 15 days or less.

The researchers looked at 278 participants aged 16 or older who met DSM-IV criteria for methamphetamine dependence but did not meet DSM-IV criteria for lifetime schizophrenia or mania. The main outcome measures were clinically significant psychotic symptoms in the prior month, defined as a score of 4 or more on any of the Brief Psychiatric Rating Scale items of suspiciousness, hallucinations, or unusual thought content.

“Although psychotic symptoms appeared to be largely circumscribed to periods of methamphetamine use, the long-term effect of methamphetamine use on a person’s vulnerability to psychosis needs to be better understood,” the researchers said.

For more information about the mental health effects of methamphetamine see Psychiatric News here.

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FDA Wants Lower Dosage Recommendations for Zolpidem

The Food and Drug Administration (FDA) announced that it is requiring manufacturers of widely used sleep medications that contain zolpidem to lower current recommended dosages. The ruling will affect manufacturers of Ambien, Ambien CR, Edluar, and Zolpimist. New data show that zolpidem blood levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving.

The FDA informed the manufacturers that the recommended dosage of zolpidem for women should be lowered from 10 mg to 5 mg for immediate-release products (Ambien, Edluar, and Zolpimist) and from 12.5 mg to 6.25 mg for extended-release products (Ambien CR). For men, the FDA said that the labeling should recommend that health care professionals consider prescribing these lower dosages (5 mg for immediate-release products and 6.25 mg for extended-release products). These products are available in both the higher and lower dosages.

Data show the risk for next-morning impairment is highest for patients taking the extended-release forms of these drugs. “To decrease the potential risk of impairment with all insomnia drugs, health care professionals should prescribe, and patients should take, the lowest dose capable of treating the patient’s insomnia,” said Ellis Unger, M.D., director, Office of Drug Evaluation I in the FDA's Center for Drug Evaluation and Research. “Patients who must drive in the morning or perform some other activity requiring full alertness should talk to their health care professional about whether their sleep medicine is appropriate.”

Ruth Benca, M.D., a professor of psychiatry and director of the sleep center at the University of Wisconsin School of Medicine, said the ruling is appropriate. “We have always known that zolpidem is a bit more potent in women than in men,” she told Psychiatric News. “It doesn’t mean that everyone should automatically cut their dose if they are doing okay with what they are taking, but clinically it is always good practice to start low and prescribe the lowest dose that is effective.”

For more information on treating sleep problems, see American Psychiatric Publishing's Clinical Manual for Evaluation and Treatment of Sleep Disorders. For purchasing information click here.

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APA Participates in White House Gun-Violence Meeting

Vice President Joseph Biden's Task Force on Gun Violence, formed after the Newtown, Conn., school shootings, heard input from an APA representative at its meeting yesterday at the White House. Former APA President Paul Appelbaum, M.D., now chair of APA's Committee on Judicial Action, emphasized that “Substantial research shows that the vast majority of people with serious mental illnesses never act violently, and the vast majority of violent crimes—96% by the best available estimate—are not perpetrated by persons with mental disorders.” A far greater danger associated with firearms is suicide deaths, he noted, which account for nearly two-thirds of firearm deaths.

He pointed out as well that research shows that "individuals with mental illness who engage in regular treatment are considerably less likely to commit violent acts than those in need of, but not engaged in, appropriate mental health treatment." Yet despite evidence of the effectiveness of mental health treatment, funding for mental health services has plunged in the last few years, particularly in the public sector.

Appelbaum described four strategies to address serious problems in the U.S. mental health system—1) appointing a presidential commission to develop a vision for a system of mental health care; 2) creating a mechanism for facilitating responses to key mental health issues, such as designating a White House point person; 3) improving early identification of youth with mental health problems; 4) and developing "sensible, nondiscriminatory approaches" to ensuring that dangerous individuals cannot gain access to guns.

He stressed as well APA's willingness to work with the administration and Congress in efforts to improve access to and the quality of mental health services and public safety.

Read Appelbaum's full comments on APA's Web site at www.psychiatry.org.

Brain Benefits of Exercise May Fade When Exercise Period Ends

Studies presented at the annual meeting of the Society for Neuroscience suggest the "brain benefits" of exercise don't last long once the exercise ends. According to a story in yesterday's New York Times, researchers in Sao Paulo, Brazil, have shown that rats who exercise are much better at tests of memory than their sedentary counterparts, but those advantages fade quickly once they stop exercising. After three to six weeks of inactivity, the mental advantages had disappeared, perhaps indicating that exercise-induced benefits are at best transient.

Another group of researchers, this one from McMaster University in Hamilton, Ontario, reported at the same meeting that rats who ran regularly for 10 weeks but were then inactive for three weeks had brains that were almost indistinguishable from those of rats that had never exercised. "This is analogous to what happens to muscle bulk or heart rate following exercise withdrawal," Michael Mazurek, M.D., a professor in the Division of Neurology at McMaster University who oversaw the study, told the Times.

Recent research has also shown that exercise can reduce the number of amyloid plaques in the brain, which might help ward off Alzheimer's disease. Read more about that study in Psychiatric News here.

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Only Subset of ADHD Boys Develop Risky Behaviors

In general, boys with attention-deficit hyperactivity disorder (ADHD) exhibit no more risky behavior than other adults.

However, that is not true among boys with ADHD who also go on to develop conduct disorder and antisocial personality disorder (CP/APD), according to Rachel Klein, Ph.D., of the New York University Medical Center, and colleagues, writing in the Journal of the American Academy of Child and Adolescent Psychiatry, online January 5.

The researchers assessed 135 boys at average age 8 years and again at average age 41, and compared them to 136 control subjects without ADHD.
As adults, the ADHD group displayed significantly more risky driving, sexually transmitted disease, head injuries, and emergency department admissions—all markers of risky behavior. However, it was subjects with CP/APD accounted for all the difference, wrote Klein.

“Over their lifetime, those who did not develop CD/APD did not differ from comparison subjects in risk-taking behaviors,” she said.

For another take in Psychiatric News on Klein et al’s long-term research, click here. And for more about treatment of children and adolescents, see American Psychiatric Publishing's Clinical Manual of Child and Adolescent Psychopharmacology.

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Sharing Medical Records Cuts Readmissions

Can sharing electronic medical records within a hospital make a difference in patient outcomes?

A survey of 13 of the top 18 U.S. hospitals found that only 22 percent both maintained patient records electronically and allowed access to those records by non-psychiatric physicians.

That combination was associated with modestly reduced 14- and 30-day readmission rates of psychiatric patients compared to hospitals that did not share electronic psychiatric records, reported Adam Kaplin, M.D., Ph.D., an assistant professor of psychiatry at the Johns Hopkins University School of Medicine, and colleagues, in a study published online in the International Journal of Medical Informatics. “The big elephant in the room is the stigma," said Kaplin, in a statement.

Hospitals may keep psychiatric records hidden to “protect” patients’ confidentiality, but that may not help patients, especially when drugs prescribed for psychiatric disorders interact with other medications, he said. “We're hurting our patients by not giving their medical doctors the full picture of their health."

For more in Psychiatric News about how APA is joining with other physician groups to learn more about how doctors use electronic health records, click here. APA's official position statement on electronic health records can be found here.

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