New Year's Message From APA President Jeffrey Lieberman, M.D.

Dear APA Friends and Colleagues,

As 2013 draws to a close, I want to wish you a happy, healthy, and productive new year. The past year has been eventful with the successful launch of DSM-5, the transition in APA's CEO leadership, and the arrival of the Affordable Care Act and the final rule for the Mental Health Parity and Addiction Equity Act, among other significant events. I would like to express my gratitude to all of the staff at the American Psychiatric Association for their hard work and support during my year as President and what they do every day for our profession and to make this organization a success.

We enter 2014 with bright prospects and great challenges. I am confident that we will rise to the occasion and find a way to overcome every challenge and as we endeavor to provide the best quality care to persons with mental illness and in need of psychiatric treatment. It is a privilege to be part of, much less serve as President of APA, and I want to thank you for this opportunity and for all that you do for our profession and for APA.

In closing, I would like to quote one of our great leaders who we lost in the past year but I know will continue to be an inspiration to us all.

“There is no passion to be found playing small―in settling for a life that is less than the one you are capable of living.” ― Nelson Mandela

Yours truly,
Jeffrey Lieberman

Studies of Pharmacologic Delirium Treatments Show Promising Results

Encouraging data for the effectiveness of medications for delirium—especially for prevention of the disorder—were found in a systematic review of literature on the subject. "Pharmacological Treatments of Non-Substance-Withdrawal Delirium: A Systematic Review of Prospective Trials" was published online in AJP in Advance.

Delirium can accompany a number of medical conditions and hospital-based treatments. Researchers at Icahn School of Medicine at Mount Sinai and the Clinical Neuroscience Center at Pilgrim Psychiatric Center in New York reviewed published prospective trials of potential pharmacological interventions for preventing and treating delirium. The pharmacological strategies reviewed showed greater success in preventing delirium than in treating it. Significant delirium prevention effects were associated with haloperidol, second-generation antipsychotics, iliac fascia block, gabapentin, melatonin, lower levels of intraoperative propofol sedation, and a single dose of ketamine during anesthetic induction and with dexmedetomidine, compared with other sedation strategies for mechanically ventilated patients.

“Given the association between delirium and increased hospital-based complications, including mortality, and long-term complications such as cognitive decline and need for custodial care, there is an imperative to prevent the appearance of delirium and, once present, to treat it with the intention of both improving the immediate clinical picture and potentially improving long-term outcome," the researchers said. "The preponderance of evidence suggests greater success at preventing delirium with the pharmacological strategies reviewed here than treating delirium once it develops."

“These promising results warrant further study with consideration of the methodological weaknesses and inconsistencies of studies to date,” they acknowledged.

For more information on recent research on delirium, see the Psychiatric News article, “Researchers Explore Relationship Between Dementia, Delirium.”

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Retinal Blood Vessels May Be Abnormal in Schizophrenia, Study Finds

The blood vessels in the retina of the eye are abnormal in individuals with schizophrenia, according to the study "Microvascular Abnormality in Schizophrenia as Shown by Retinal Imaging" in the American Journal of Psychiatry. The senior researcher was Richie Poulton, Ph.D., codirector of the National Centre for Lifecourse Research at the University of Otago in Dunedin, New Zealand. The cohort included more than 1,000 individuals who were followed from birth to adulthood. At age 38, the subjects underwent retinal imaging. The researchers compared the retinal imaging results of 27 individuals who had developed schizophrenia with those of individuals who had not and found that the former had microvascular abnormalities reflective of insufficient brain oxygen supply.

These findings have both research and clinical implications, the researchers said. For example, "Longitudinal and high-risk studies can determine whether retinal vessel caliber in juveniles predicts risk of developing psychosis or accompanies the progression of schizophrenia...." And if that is indeed the case, then retinal imaging might eventually be used to track youth at high risk of developing psychosis, since it is noninvasive and available in many primary care, optometry, and ophthalmology centers, and could foster intervention earlier than is now the case.

For an in-depth review of the latest knowledge on the causes of and treatments for schizophrenia, see Essentials of Schizophrenia from American Psychiatric Publishing.

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Study Finds Genetic Overlap in Schizophrenia and Cognitive Ability

Subtle cognitive impairment has been found in several research studies in relatives of individuals with schizophrenia, suggesting the possibility of genetic overlap between schizophrenia and cognitive aptitude. To further evaluate this apparent association, researchers from New York's Zucker Hillside Hospital and Feinstein Institute for Medical Research conducted the first study investigate whether genetic markers of cognitive impairment intersect those linked to schizophrenia. The findings were published in last week's Molecular Psychiatry.

The researchers compared single-nucleotide polymorphisms (SNPs) from more than 5,000 subjects who had a diagnosis of cognitive impairment or schizophrenia with those from individuals without a mental illness diagnosis. Levels of genetic overlap were measured by polygenic scores, a sum of trait-associated alleles between two or more chronically ill populations as well as a predictor of an individual's genetic risk for certain diseases. The researchers reported that polygenic scores indicated that schizophrenia was associated with lower cognitive ability than was the case for controls with neither cognitive impairment nor schizophrenia. In addition, multiple SNPs from cognitively impaired subjects significantly overlapped in trait-associated alleles that were found in subjects with schizophrenia.

“Schizophrenia has long been recognized to have a cognitive component,” Anil Malhotra, M.D., senior author and director of psychiatry research at the Zucker Hillside Hospital, told Psychiatric News. “We have demonstrated that the genes that influence cognitive ability also influence schizophrenia, and, as before, clinicians should be attentive to the very real problem of cognitive impairment in schizophrenia.”

To read more about studies involving genetic markers of psychiatric disorders, see the Psychiatric News article, "Genome Analysis Quantifies Risk Across Psychiatric Disorders."

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Liver Injury Associated With Antidepressant Use Requires Quick Action

Although uncommon, drug-induced liver injury (DILI) from antidepressant drugs does rarely occur and may be irreversible, and clinicians should promptly discontinue antidepressant drug use when liver abnormalities appear, according to the study “Antidepressant-Induced Liver Injury: A Review for Clinicians,” which appears online in AJP in Advance.

French researchers conducted a PubMed literature search for publications from 1965 onward related to antidepressant-induced liver injury. The search terms were “liver injury,” “liver failure,” “DILI,” “hepatitis,” “hepatotoxicity,” “cholestasis,” and “aminotransferase,” cross-referenced with “antidepressant.”

They found that 0.5% to 3% of patients treated with antidepressants may develop asymptomatic mild elevation of serum aminotransferase levels. Liver damage is in most cases idiosyncratic and unpredictable, and it is generally unrelated to drug dosage. The antidepressants associated with greater risks of hepatotoxicity are iproniazid, nefazodone, phenelzine, imipramine, amitriptyline, duloxetine, bupropion, trazodone, tianeptine, and agomelatine. The antidepressants that seem to have the least potential for hepatotoxicity are citalopram, escitalopram, paroxetine, and fluvoxamine.

Aminotransferase surveillance is the most useful tool for detecting DILI, Moreover, early detection and prompt drug discontinuation are critical, the researchers stated. “Surveillance of liver function in clinical trials and careful evaluation of reported abnormalities could make a major contribution to the early detection of antidepressants associated with a high risk of causing DILI. Finally, further research is required before rigorously founded recommendations can be established for clinical practice.”

For further information about antidepressant effectiveness and side effects, see the Psychiatric News article “New Data Rebut Claims About Antidepressants.”

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New Study Links Inflammatory Cytokines With Anger Problems

It appears that people who have difficulty controlling their anger may have inflammatory markers in their bloodstream, according to research published in JAMA Psychiatry and led by Emil Coccaro, M.D., chair of psychiatry at the University of Chicago and an expert on intermittent explosive disorder (IED).

The study included 69 individuals with IED, 61 nonaggressive individuals with other psychiatric disorders, and 67 individuals with neither IED nor other psychiatric disorders. The researchers measured the levels of two inflammatory cytokines—interleukin 6 and C-reactive protein—in subjects' blood. Levels of the two cytokines were significantly higher in IED subjects than in the other two groups, even when potentially confounding factors such as a history of stressful life events or depression were considered. "These data suggest a direct relationship between plasma inflammatory processes and aggression in humans," Coccaro and colleagues concluded.

It's also possible that inflammatory cytokines actually contribute to anger and aggression, the researchers noted. In one study they cited, for example, infusion of inflammatory cytokines into the brains of experimental animals made the animals aggressive. In another study, individuals treated with inflammatory cytokines reported feeling increasingly angry and aggressive.

More information about IED and possible treatments for it are reported in the Psychiatric News articles "A Small Protein May Play a Big Role in Controlling Aggression" and "IED Quite Common, but Treatments Elusive."

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High Anxiety Levels May Increase Risk of Stroke, Study Finds

Prolonged elevated anxiety levels may increase one’s risk for stroke, according to a study published in yesterday’s edition of the journal Stroke. Researchers from the University of Pittsburgh and Harvard School of Public Health evaluated more than 6,000 Americans aged 25 to 74 who had not experienced a stroke prior to study initiation. Participants were required to complete questionnaires that measured anxiety and depression levels, and they were then followed for up to 22 years. Stroke occurrences in the subjects were determined through death certificates and medical records. The results showed that highly anxious individuals were 33 percent more likely to experience a stroke when compared with their less-anxious counterparts. This risk persisted after controlling for depression symptoms.

“Most of the focus [on mental health and stroke] up until this point has been on depression. These findings underscore the importance of also considering anxiety when considering cardiovascular diseases,” said Rebecca Thurston, Ph.D., senior author of the study and an associate professor of psychiatry at the University of Pittsburgh. “These findings encourage practitioners to assess and treat anxiety, as well as to reconsider popular notions such as ‘worried well’—this worrying may not make us so well.”

Because even a modest increase in anxiety was associated with an increase in stroke risk, the researchers noted that more education and awareness on managing anxiety is of great importance.

To read more about anxiety and therapies to manage anxiety, see the Psychiatric News articles, "Music Can Reduce Anxiety in ICU Patients" and "Imaging Helps Predict Anxiety Patients Who May Benefit From CBT."


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Jay Scully Deserves Our Thanks for a Job Well Done

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. Please send your comments to pnupdate@psych.org.

Leading the national association for psychiatrists isn’t for the faint of heart. We can be a contentious group, not because we aren’t collegial, but because we have strong opinions about our chosen field of medicine. These opinions become particularly impassioned when psychiatry is faced with challenges and must adapt to change.

For more than a decade, Jay Scully has led APA as its chief executive officer and medical director (CEO/MD) through an extraordinary period of change. His calm manner, keen mind, consummate professionalism, and willingness to engage openly with members have helped the Association set a course to overcome challenges and maintain its focus on what is most important.

While his most notable contributions are from his time as CEO/MD, it’s important to note that his involvement with the Association has spanned his career. Prior to his term as CEO/MD, Jay served as a deputy medical director of APA and director of its Office of Education from 1992 to 1996.

Since he rejoined the APA staff in 2002, Jay has had to address head-on some of the most difficult issues that APA has ever encountered—APA’s finances, membership, and transparency of industry relationships. He strengthened the Association’s financial posture through a critical reorganization and creatively crafted policies to increase revenues and optimize resource allocation.

To read more, click here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman. To do so, go to https://twitter.com/DrJlieberman, log in or register, and click on “Follow.”

Final Budget Bill Contains 3-Month Delay in Drastic Cut to Physician Medicare Fees

In a rare burst of congressional bipartisanship, the Senate has approved a federal budget compromise that includes a three-month postponement of the 24.4% cut in physician Medicare reimbursement that was scheduled to take effect January 1. The House passed a similar three-month patch as part of its budget bill, and President Obama is expected to sign the legislation.

The huge payment cut stemmed from the sustainable growth rate (SGR) formula, which each year is used as a key part of the calculation to determine Medicare reimbursements. The size of the cut is in large measure a result of actions by Congress annually for at least a decade to postpone—not cancel—the fee cut mandated by the SGR, thus allowing its size to keep growing. Discussions have been underway in committees in both houses of Congress to find a permanent solution to the problems caused by the SGR formula. "Proposals have called for replacing the current scheme with one in which payment would reflect physicians' use of quality-based patient care measures, participation in integrated care, and use electronic health records, among other factors," said Sam Muszynski, director of APA's Office of Healthcare Systems and Financing. "Until a payment method to replace the SGR is enacted, psychiatrists will benefit not only from the three-month delay in reimbursement cuts, but from increased reimbursements approved as part of the 2014 Medicare fee schedule," he noted, now that the government has approved updates to values for the CPT codes many psychiatrists routinely use. "APA is constantly monitoring Medicare reform proposals under discussion on Capitol Hill," he said.

To read more about proposals to replace the SGR, see the Psychiatric News articles, "Law to Repeal SGR Clears Key Congressional Committee" and "AMA Acts on Medicare Payment as Congress Considers Legislation." For more on increases in values for psychiatry CPT codes, click here.

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Children's Mental Health Needs Following Disaster Said to Require Special Attention

Children are frequently caught up in natural or man-made disasters, but the specific postdisaster mental health needs of this vulnerable population are too often overlooked in disaster-preparedness planning, according to a report of a recent workshop by the Institute of Medicine. About 1 in 3 individuals (including children) who survive a disaster are at risk for developing a new psychiatric disorder afterward; however, parents may discount symptoms in their children as understandable reactions to the disaster, or children may suppress their complaints out of fear of being considered “abnormal” or because they don’t want to further burden their parents at a difficult time.

Thus, school personnel, primary care clinicians, and mental health professionals should know about mental health screening and triage protocols, such as the PsySTART Rapid Mental Health Triage and Incident Management System, available to identify and refer children who need help. “Adults who work with children should understand the likely reactions to disaster and know techniques to help them cope,” said the report, quoting pediatrician David Schonfeld, M.D., director of the National Center for School Crisis and Bereavement at St. Christopher’s Hospital for Children in Philadelphia.

"Triaging high-risk children, while also taking into account important trauma histories and exposure to other incidents can be instrumental in ensuring that children progress through a recovery of timeline along with their peers, and return to their normal baseline after an event or reach further growth potential," the report concluded.
 

For more in Psychiatric News about helping children after disasters, see the article, "Preparedness Key to Effectively Helping Children After Disasters." And see also the American Psychiatric Publishing book, Disaster Psychiatry: Readiness, Evaluation, and Treatment.

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SAMHSA Gives High Marks to Evidence for Effectiveness of Child Behavioral Management Services

Behavioral management services for children—services designed to help develop or maintain pro-social behaviors in the home, school, or community—should be considered for inclusion in health plans, according to “Behavioral Management for Children and Adolescents: Assessing the Evidence,” a review of evidence commissioned by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) and just published in Psychiatric Services in Advance.

Researchers reviewed literature on behavioral management for children and adolescents published from 1995 through 2012. They chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. An example of a behavioral management service is Parent-Child Interaction Therapy, which uses in-person coaching of parents during parent-child interactions to help parents establish nurturing relationships with their children, clear parent-child communication and limit setting, and consistent contingencies for child behavior.

The level of evidence for behavioral management was rated as high because of the number of well-designed randomized controlled trials across settings, particularly for family-centered and integrated family- and school-based interventions. Results for the effectiveness of behavioral management interventions were strong, depending on the type of intervention and mode of implementation.

“Further research addressing the mechanisms of effect and specific populations, particularly at the school level, will assist in bolstering the evidence base for this important category of clinical intervention,” the SAMHSA researchers said.

The review is part of the Assessing the Evidence Base series, commissioned by SAMHSA to review the evidence for commonly used, recovery-focused mental health and substance use services. For more information on mental health aspects of child behavior, see “Normal Child and Adolescent Development: A Psychodynamic Primer,” new from American Psychiatric Publishing.

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Schema Therapy Appears Superior in Treatment of Personality Disorders, Study Finds

Schema therapy—a form of psychotherapy combining cognitive-behavior therapy and psychodynamic concepts—was found to be superior to other approaches in treatment of personality disorders, according to a report of the study "Results of a Multicenter Randomized Controlled Trial of the Clinical Effectiveness of Schema Therapy for Personality Disorders" in AJP in Advance.

Dutch researchers conducted a multicenter randomized controlled trial from 2006 to 2011 at 12 mental health institutes. A total of 323 patients with personality disorders were randomly assigned to different forms of therapy—147 received schema therapy, 135 received “treatment as usual,” and 41 received “clarification-oriented psychotherapy.” (In treatment-as-usual, clinicians were free to use whatever approach seemed to fit the patient's needs.) The primary outcome was recovery from personality disorder three years after treatment started (assessed by blinded interviewers). Secondary outcomes were dropout rates and measures of personality disorder traits, depressive and anxiety disorders, general psychological complaints, general and social functioning, self-ideal discrepancy, and quality of life.

Researchers found that a significantly greater proportion of patients recovered in schema therapy than in treatment as usual or clarification-oriented psychotherapy. Findings did not vary with specific personality disorder diagnosis. Schema therapy patients had less depressive disorder and higher general and social functioning at follow-up.

For more information about schema therapy and other forms of therapy for personality disorders see the Psychiatric News article, “Psychotherapy for BPD Gets Growing Evidence Base." To read more about personality disorders, see The American Psychiatric Publishing Textbook of Personality Disorders.

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APA Issues Document Showing Maintenance of Certification Requirements and Useful Products

APA today issued a summary of the American Board of Psychiatry and Neurology's (ABPN) requirements regarding maintenance of certification (MOC). Also included is a list of the many products APA has prepared to help its members meet MOC requirements. The new document outlines a schedule that the ABPN will use to phase in various components of the MOC requirement based on the year in which a psychiatrist was originally certified. It shows the total number of CME credits required by year of original certification and the program units that psychiatrists will need to complete. In addition, the document describes components and requirements of the Continuous Pathway to Lifelong Learning Program (CP-MOC) for diplomates certified or recertified in 2012 or later.

To help members who are engaged in the MOC process, APA has developed self-assessment tools, performance-in-practice modules, and examination-preparation products. A list of these is also part of the new document.

Click here to access the APA MOC document, which is accessible on the APA website to members only. To read more about MOC, see the Psychiatric News article "ABPN Leaders Explain Goals, Background of MOC Program."

 

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Young Suicide Attempters Said to Need Long-Term Care to Reduce Future Impairment

The outlook for young people who attempt suicide is unfavorable over the long run, a prospective study of more than 1,000 subjects who were followed from age 3 to age 38 has found. The study results are published in JAMA Psychiatry.

For example, while the young suicide attempters made up only 9% of the cohort, by the end of the follow-up study they accounted for 15% of those with metabolic syndrome, 22% of those with persistent psychiatric disorders, and 35% of those convicted of violent crimes. Moreover, they needed extensive unemployment or welfare benefits and tended to be lonely and dissatisfied with their lives, the researchers found.

"The surprising part of the study is the degree of impairment in multiple areas outside of purely mental health outcomes and their extent," Timothy Lineberry, M.D., an associate professor of psychiatry at the Mayo Clinic and a suicide expert who was not associated with the new study, told Psychiatric News. "For clinicians, the study results emphasize, even more than previous research has, that suicide attempts are a marker in young people of illness severity and potential future impairment."

Long-term monitoring and health services are needed for young suicide attempters, the researchers said. Yet when Psychiatric News asked lead researcher Sidra Goldman-Mellor, Ph.D., a postdoctoral fellow in psychiatry at Duke University, whether anyone was providing such monitoring and services, she said, "The few programs for which there is evidence of a reduction in subsequent suicidal behavior (and other negative outcomes) emphasize immediate post-attempt care, integrated mental and [general] health care provision systems, and continuity of care. The U.S. Air Force's Integrated Delivery System Program is one such example. Another is the suicide prevention program instituted by a municipality in Norway in the 1980s.... These programs show that it can be done, but it takes a great deal of dedication and resource commitment at all levels of an organization."

More information about the societal burden of suicide as well as suicide prevention can be found in the Psychiatric News article "Kennedy Makes Suicide Concerns Focus of National Media Tour."  Information about caring for suicidal patients can be found in The American Psychiatric Publishing Textbook of Suicide Assessment and Management, Second Edition.

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APA CEO Reflects on Homosexuality’s Removal From DSM on 40th Anniversary

On December 15, 1973, APA courageously decided to remove homosexuality as a mental disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM). In this video, APA CEO and Medical Director Saul Levin, M.D., M.P.A., recognizes the 40th anniversary of this historic move by thanking APA for its foresight at that time by recognizing homosexuality as a normal variant of human sexuality and putting this country on the path to giving gays, lesbians, bisexuals, and transgender individuals the marital and employment protections they deserve.

Click here to watch the video.

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APA Hosts Congressional Briefing on Schizophrenia Research

Yesterday on Capitol Hill, APA, along with the Congressional Neuroscience Caucus and the American Brain Coalition, hosted a briefing titled, “Update on Schizophrenia: Applying Science, Stopping the Stigma, Improving Lives,” which highlighted the latest research on treatments for schizophrenia.

“As we struggle to adequately address mental health in this country, it’s essential that Congress have better understanding of the causes and consequences of schizophrenia and address the associated stigma," said Rep. Earl Blumenauer (D-Ore.), co-chair of the Congressional Neuroscience Caucus. "Only through research and collaboration by groups like the National Institute of Mental Health and the many members of the American Psychiatric Association can we find the proper ways to improve the lives of those who suffer from this disease through early action."

Schizophrenia experts at the briefing included APA President Jeffrey Lieberman, M.D., who discussed the link between psychiatry and neuroscience and how it may lead to the development of diagnostic tests to help predict the likelihood of schizophrenia episodes in those at greatest risk. Lisa Dixon, M.D., M.P.H., director of the Center for Practice Innovations at Columbia University, discussed her research in the National Institute of Mental Health-funded study, Recovery After an Initial Schizophrenia Episode (RAISE), a project trying to reduce the long-term disability that can result from schizophrenia so that people with the disease may lead productive and independent lives. Laurie Flynn, former executive director of the National Alliance on Mental Illness and parent of an adult child with schizophrenia, addressed the challenges of securing services for a loved one from the family’s perspective, including the limits of current treatment options and financial burdens.

APA CEO and Medical Director Saul Levin, M.D., M.P.A., who moderated the briefing, emphasized that “the cost of mental illness in the U.S. is some $99 billion each year, and scientific advances such as those presented today have the potential to greatly enhance patient care as well as reduce future health care expenditures.”

To read more about the briefing click here. For more information on schizophrenia and recent research, see the Psychiatric News article "‘60 Minutes’ Interviews APA President on Schizophrenia."

APA President Addresses Sandy Hook Shooting Anniversary

Saturday will mark one year since the massacre at Sandy Hook Elementary School in Newtown, Conn., that resulted in the deaths of 26 students and educators. In conjunction with that tragic anniversary, APA President Jeffrey Lieberman, M.D., issued a statement today saying "our thoughts and prayers remain with the loved ones still struggling to come to terms with the loss of innocent lives." With issues of mental illness and access to treatment in an intense public spotlight after the Newtown shootings, Lieberman also addressed recent developments that will impact mental health care for the better.

He stated that APA appreciates the Obama administration's actions to increase access to mental health care, including to preventive services such as screenings and behavioral assessments, emphasizing that "Early detection and intervention for mental disorders in adults and children will limit and ultimately prevent the consequences of mental disorders in our society." He added that the Affordable Care Act, as well as the issuance last month of the final rule to implement the federal parity law, "send a strong message on the part of the White House that access to quality mental health and substance abuse disorder treatment must be one of our nation's highest priorities." He also applauded the just-announced appropriation of $100 million for community-based mental health and substance abuse services as another sign that the Obama administration understands the urgency of improving access to mental health treatment.

To read Lieberman's full statement, click here. To read about how residents of Newtown are responding to the upcoming anniversary, see the Psychiatric News article, "Newtown Shuns Spotlight as It Tries to Heal."

Government Proposes New Timeline for Implementing 'Meaningful Use' Criteria

The Centers for Medicare and Medicaid Services (CMS) has proposed a modification of its timeline for physician adoption and meaningful use of electronic health records (EHRs). This program, designed to encourage physicians and hospitals to use EHR programs, pays an incentive that is added to Medicare reimbursements for physicians who adopt EHRs, but will impose deductions on the reimbursements of those who fail to do so. Under the revised timeline, Stage 2 of EHR adoption will be extended through 2016, and Stage 3 will begin in 2017 for providers who have completed at least two years in Stage 2. The program is currently in Stage 1. Among the goals of the proposal to shift the timeline is to give CMS more time to use data from Stage 2 participation to inform policy decisions for Stage 2, the agency explained in a press release. According to CMS, "The proposed timeline for meaningful use would have a number of benefits, such as:

• More analysis of feedback from stakeholders on Stage 2 progress and outcomes;

• More available data on Stage 2 adoption and measure calculations—especially on new patient engagement measures and health information exchange objectives;

• More consideration of potential Stage 3 requirements;

• Additional time for preparation for enhanced Stage 3 requirements;

• Ample time for developers to create and distribute certified EHR technology before Stage 3 begins, and incorporate lessons learned about usability and customization."

In 2015, Medicare providers who have not started using a certified EHR will begin seeing a claims penalty. However, as the meaningful use program is voluntary for Medicaid providers, they will not be subject to penalties if they do not participate.

To read more about the meaningful use EHR program, see the Psychiatric News article, "Is 'Meaningful Use' for Me?"

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Biden Announces $100 Million in New Mental Health Funding

Vice President Joseph Biden yesterday announced the federal government will make $100 million available to increase access to mental health services and improve mental health facilities.

“The fact that less than half of children and adults with diagnosable mental health problems receive the treatment they need is unacceptable,” Biden said. “The President and I have made it a priority to do everything we can to make it easier to access mental health services, and today’s announcements by the U.S. Departments of Health and Human Services and Agriculture build on that commitment.” The announcement was made just a few days short of the one year anniversary of the shootings at Sandy Hook Elementary School that took 26 lives.

Biden said the $100 million in new funds will include $50 million for community health centers to establish or expand services for people with mental illness or addiction.  The centers can use these funds, made available through the Affordable Care Act, for efforts such as hiring new mental health care professionals and adding mental health and substance abuse services.

Another $50 million will help finance construction, expansion, or improvement of mental health facilities in rural areas over the next three years. These funds, made available through the Department’s Community Facilities direct loan program, can be used to improve or construct mental health service facilities or put in place innovative tools such as telemedicine to expand access to mental health services at rural schools, community centers, hospitals, and other community-based settings.

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ADHD Diagnoses Show Sharp Upward Trend, CDC Reports

The Centers for Disease and Control and Prevention (CDC) reports that there has been a 42% increase in attention-deficit/hyperactivity disorder (ADHD) diagnoses in children aged 4 to 17 from 2003 to 2011. Data were published in the Journal of the American Academy of Child and Adolescent Psychiatry. The study included 2011 data from a randomized, cross-sectional national survey of more than 95,000 U.S. households known as the National Survey of Children's Health. Information was gathered on the prevalence of parent-reported ADHD diagnoses, current ADHD diagnosis, and current medication prescriptions to treat the condition. Information was compared with data from previous surveys conducted in 2003 and 2007.

The results showed by 2011, 11% of children—or 6.4 million children nationwide—had received a diagnosis of ADHD. Among those with a diagnosis for ADHD, approximately 70% were currently taking medication for the disorder—increasing by 28% from 2007 to 2011. Nearly 1 in 5 high school boys was diagnosed with ADHD, compared with 1 in 11 high school girls. ADHD-diagnosis frequency was most prevalent in Kentucky, at 15 percent, and least prevalent in Nevada, at 4.2 percent.

“The number of U.S. households impacted by childhood diagnoses of ADHD is growing. Early treatment can be a tremendous help to children whose behavior, performance, and relationships are being negatively impacted by ADHD,” said Susanna Visser, M.S., a CDC epidemiologist and lead author of the study. The authors speculate that “better detection of underlying ADHD, due to increased health education and awareness efforts,” may be the reason for the increase of ADHD diagnoses among American children.

To read more about the prevalence and treatment of ADHD, see the Psychiatric News article "ADHD Outcome Data in Adults Show Value of Early Treatment."

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Head Injury May Increase Risk for Psychiatric Illness, Study Finds

Head injuries appear to increase risk for mental illness, according to a report online today in AJP in Advance. Danish researchers used linkable Danish nationwide population-based registers to investigate the incidence of schizophrenia spectrum disorders, unipolar depression, bipolar disorder, and organic mental disorders in 113,906 persons who had suffered head injuries. Data were analyzed by survival analysis and adjusted for gender, age, calendar year, presence of a psychiatric family history, epilepsy, infections, autoimmune diseases, and fractures not involving the skull or spine.

They found that head injury was associated with a higher risk of schizophrenia, bipolar disorder, and organic mental disorders. This effect was larger than that of fractures not involving the skull or spine for schizophrenia, depression, and organic mental disorders, which suggests that the results were not merely due to accident proneness. Head injury between ages 11 and 15 years was the strongest predictor for subsequent development of schizophrenia, depression, and bipolar disorder. The added risk of mental illness following head injury did not differ between individuals with and without a psychiatric family history.

“[I]t has been suggested that after injury, brain tissue can be released into the peripheral blood with a possible synthesis of CNS-reactive antibodies,” the researchers state. “Such antibodies might reach the brain during subsequent periods of increased permeability of the blood-brain barrier, in line with the mechanisms by which autoimmune diseases and infections have previously been suggested to increase the risk of schizophrenia and depression.”

For more on this subject, see the Psychiatric News article "Researchers Look for Link Between Brain Injury, Psychiatric Illness."

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Experts Say More Work Still Needs to Be Done After Issuance of Final Parity Rule

At a unique “stakeholders” meeting convened by APA in Washington, D.C., in the wake of the government’s release of the final rule for implementing the Mental Health Parity and Addiction Equity Act (MHPAEA), former member of Congress Patrick Kennedy told participants that the fight for parity is not over. “So many people have worked so many years to get us this far, but we are starting all over again," he said. “The new mission is oversight and implementation and enforcement of the MHPAEA. The last thing we need to do is let up on the momentum now because we have lulled ourselves into a false sense of security that somehow we have done it. Until this is written into the hearts and minds of practitioners across the whole spectrum of mental health and substance use, and until it is written into the hearts and minds of the American people that this is something they should expect when they seek care, then we still have work to do... We are here to discuss the mechanics of a law and its regulations, but I hope you are all aware that this is a civil-rights issue.”

The meeting brought together more than 35 groups representing psychiatry, addiction medicine, other medical fields, social work, psychology, and patient-advocacy groups to discuss the final rule and develop an action plan around three core issues related to implementation of the MHAPEA: education, compliance/disclosure/enforcement, and issues related to Medicaid and the SCHIP program. (The final rule does not extend to Medicaid and SCHIP.)

APA CEO and Medical Director Saul Levin, M.D., M.P.A., emphasized the need for unity across all disciplines in helping to ensure enforcement of the parity law; he also especially emphasized that substance abuse and addictions are to be included in parity coverage. And the South African-born Levin also used the occasion—the day after the death of Nelson Mandela—to commemorate the antiapartheid leader and said Mandela served as a model for how to stand up against discrimination. 

APA President Jeffrey Lieberman, M.D., told representatives that the present time marks a pivotal moment in history for the equitable treatment of patients with mental illness and substance abuse. “We are at the best time ever in terms of being able to provide care…and at this point, we are really uniquely advantaged in terms of possibilities…. We have a tremendous research capacity we have never had before, and it is progressing at an accelerated rate. We have tremendous prospects…. It’s up to all of us to make the most of [this moment].”

To watch a video of Lieberman discussing the meeting, click here.

(photo: David Hathcox)

BDNF May Protect Against Alzheimer's, Study Suggests

Higher blood levels of brain-derived neurotrophic factor (BDNF) appear to protect against Alzheimer's disease (AD)and other types of dementia, a prospective  study of more than 2,000 older adults suggests. The study is published in JAMA Neurology and was led by Sudha Seshadri, M.D., a professor of neurology at Boston University.

Each standard-deviation increment of BDNF was associated with a 33% lower risk for AD or dementia. Compared with the bottom quintile, BDNF levels in the top quintile were associated with less than half the risk for AD or dementia. However, these links were restricted to men and women over age 80, women under age 80, and to individuals with a college education or higher.

"This is a potentially important study from the perspective of reducing the risk of dementia," Dilip Jeste, M.D., chair in aging at the University of California, San Diego, and immediate past previous APA president, told Psychiatric News. "BDNF has been previously shown to be related to lifestyle factors and interventions. One study even reported an increase in BDNF in individuals with schizophrenia who received cognitive-enhancement therapy. Continued research on BDNF and related neurotrophic factors in people at risk of dementia is necessary to help develop interventions to treat and prevent cognitive deficits in older adults."

These results have clinical implications, Seshadri told Psychiatric News. For example, blood levels of BDNF might be used to help predict risk for AD in older adults. Or giving BDNF to older people might prevent or counter AD symptoms. "We need to study the benefits and potential side effects of giving BDNF to people. Ways of doing this"—for example, using agonists that would cross the blood-brain barrier into the brain—are being studied, she noted. And interestingly, lithium, long used to treat bipolar disorder, has been found to increase BDNF levels in individuals with Huntington's disease, she pointed out. So it might also possess some effectiveness against AD. Indeed, preliminary evidence reported in the May 2012 Drugs and Aging bolsters this possibility.

More information about Alzheimer's and BDNF can be found in the Psychiatric News article, "For Now, Preventive Efforts Are Best Alzheimer's Weapon," and in the American Psychiatric Publishing book, Clinical Manual of Alzheimer Disease and Other Dementias. 

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Nelson Mandela Honored by APA CEO and Medical Director Saul Levin

In a video interview today, APA CEO and Medical Director Saul Levin, M.D., M.P.A., pays tribute to Nelson Mandela, who died last night in his home in Johannesburg, South Africa. Levin, who was born in South Africa and was a staunch opponent of apartheid, is a former president and chief executive officer of Medical Education for South African Blacks, the largest private sponsor of medical education for blacks in South Africa. Levin discusses how Mandela's battle against apartheid serves as an inspiration to APA as it continues to fight against discrimination toward mentally ill people and for their right to have access to the care they need.

To watch the video, click here.

(Video: Aaron Levin. Image: David Hathcox)

Study Finds CBT More Effective Than Psychoanalysis in Treating Bulimia

A randomized controlled trial of therapies for treating bulimia nervosa finds that cognitive-behavioral therapy (CBT) is more likely than psychoanalytic psychotherapy to produce marked symptom improvement.

In a study reported online in AJP in Advance, researchers in the Oxford University Department of Psychiatry and University of Copenhagen Department of Psychology randomized bulimia patients to either two years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over five months. Both therapies used versions designed specifically for bulimia treatment. The researchers found that while both treatments produced results, "a marked difference was observed" between the two. At the five-month evaluation, 42% of CBT patients and 6% of psychoanalytic psychotherapy patients had stopped binging and purging. At the two-year follow-up, 44% of CBT patients and 15% of psychoanalytic psychotherapy patients were no longer binging and purging. When improvement occurred, it was usually faster in patients receiving CBT. Study patients had eating-disorder symptoms for a mean of 12.3 years.

The researchers concluded that in light of the fact that substantial numbers of patients in each group still had bulimia symptoms after the therapy, "further treatment developments are needed. One could be the continued development and extension of CBT. Another could be the development of a more structured and symptom-focused version of psychoanalytic psychotherapy, possibly augmented with cognitive and behavioral strategies."

Read more in AJP in Advance about the report "A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa."

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Optimism Linked to Brain Function in Older People, Study Finds

Optimism is known to benefit physical health, emotional health, and longevity. And one way in which it does so may be by reducing the brain's reactions to negative information. This is a key finding of a study of the neural correlates of emotion processing related to optimism conducted by Dilip Jeste, M.D., chair in aging and a distinguished professor of psychiatry at the University of California, San Diego, and colleagues. Their results are published in the Journal of Neuropsychiatry and Clinical Sciences. Jeste is also APA's immediate past president.

Jeste and colleagues had older individuals without a history of psychiatric disorders complete multiple standardized self-report measures to assess how optimistic they were. The researchers then used fMRI imaging to examine the brains of the individuals while they viewed faces whose expression indicated fear—that is, processed negative information. They found that greater optimism was associated with reduced activation in the fusiform gyrus and frontal regions, even after taking potential confounding variables, such as cortical thickness and amygdala volume, into consideration.

These "findings have potential implications for the promotion of successful aging," Jeste and his colleagues stated in their study report. In brief, "Optimists may be relatively less fearful, particularly about the likelihood of negative events."

Strategies for remaining optimistic and engaged as one ages and the neuroscience of healthy aging are detailed in the American Psychiatric Publishing book Successful Cognitive and Emotional Aging, which was coauthored by Jeste.

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Danger, Risk of Violence—Not a Mental Illness Diagnosis—Should Rule Gun Restrictions, New Report Says

Dangerousness and an increased risk of violence, rather that mental illness per se, should guide development of evidence-based policies regarding access to firearms, said a report issued Monday at the University of Virginia. The Consortium for Risk-Based Firearm Policy offered three recommendations to guide state policymakers.

First, strengthen state laws to temporarily prohibit individuals from buying or possessing guns after a short-term involuntary psychiatric hospitalization, when there is a higher risk of violence.

Second, similar limits should be placed on people likely to be dangerous, such as those convicted of a violent misdemeanor, those under a temporary domestic-violence restraining order, and anyone convicted at least twice in five years of either misdemeanors involving a controlled substance or of driving while intoxicated.

Third, permit law-enforcement officers to remove firearms when identifying someone who poses an immediate or credible threat to self or others, with appropriate due-process protections.

“Importantly, successful implementation of our recommendations depends on all firearms transfers requiring a background check under federal law,” concluded the report.

“This is an important effort to refocus the discussion about gun violence on groups that represent high risks for violence, rather than continuing with a misdirected focus on people with mental illness,” said forensic psychiatrist and past APA President Paul Appelbaum, M.D., a member of the consortium and a professor of psychiatry, medicine, and law at Columbia University College of Physicians and Surgeons, in an interview with Psychiatric News.

To read more about gun violence and mental illness, see the Psychiatric News articles "Gun-Policy Advocates Cite Mental Illness, But Lack Supporting Evidence," and "Study Finds Psychiatric Factors Not Linked To Multiple Homicide Victims."

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Study Identifies Four Recovery Patterns in Patients With Serious Mental Illness

A two-year study of patients with schizophrenia, schizoaffective disorder, bipolar disorder, or affective psychosis reveals four recovery trajectories and the factors that affect those outcomes. All too often, serious mental illness is seen as incurable, permanent, and progressively deteriorating, but 60% to 70% of patients can achieve some level of recovery, said Carla Green Ph.D., M.P.H., of the Center for Health Research at Kaiser Permanente Northwest, in Portland, Ore.

Green and colleagues used extended interviews with 92 women and 85 men, asking about psychiatric symptoms, quality of life, general health, and the mental health care they were receiving, they explained in their report, "Recovery From Serious Mental Illness: Trajectories, Characteristics, and the Role of Mental Health Care" in the December Psychiatric Services. They also used self-reports and health-plan data in their analysis. The scores on the various measures pointed to four patterns of recovery: high and stable levels of recovery; moderately high but fluctuating; moderately low but fluctuating; and consistently low and stable.

“Few demographic or diagnostic factors differentiated clusters at baseline,” the researchers said. “Consistent predictors of trajectories included psychiatric symptoms, physical health, resources and strains, and use of psychiatric medications.” The most consistent predictors of recovery were psychiatric symptoms and changes in those symptoms, they said. Those in turn are dependent on good-quality care, which includes satisfaction with their clinicians and with the medications they are taking. "Providing such care has the potential to change recovery trajectories over time,” they concluded. 

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Common Screening Tool May Help Identify Patients at Risk of Suicide

While there is no screening tool proven to identify people at risk of suicide, a new study examining medical records of more than 84,000 patients who completed the Patient Health Questionnaire (PHQ-9) at every depression-care visit over several years suggests that the commonly used depression-assessment instrument may be a useful screening tool for detecting suicide risk.

Among outpatients completing PHQ-9 depression questionnaires, a response to item 9 predicted increased risk of suicide attempt or completed suicide over the following several months. That item reads: "Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way.” Response options are "not at all," "several days," more than half the days," or "nearly every day." How patients answered was a strong predictor of suicide attempt and suicide death over the following year.

Researchers at the Group Health Cooperative in Seattle found that the cumulative risk of suicide attempt over one year was 0.4% among outpatients reporting thoughts of death or self-harm “not at all,” while it was 4% among those reporting thoughts of death or self-harm “nearly every day.” Even after accounting for treatment history and demographic factors, "item 9 remained a strong predictor of any suicide attempt," the researchers said. In their report "Does Response on the PHQ-9 Questionnaire Predict Subsequent Suicide Attempt or Suicide Death?" in the December Psychiatric Services, Gregory Simon, M.D., M.P.H., and colleagues explained that the immediate risk of suicide attempt was low but increased over several days and continued to grow for several months, indicating a need for follow-up care to address ongoing risk. “Suicidal ideation should be viewed as an enduring vulnerability rather than simply a short-term crisis,” they said.

To read more about recent research on suicide risk, see the Psychiatric News article "Psychotic Symptoms Found to Be Strong Suicide Risk Factor in Teens."

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Study Finds Low Zinc Levels Associated With Depression

A meta-analysis of studies measuring blood concentrations of zinc in some 1,600 depressed subjects and 800 control subjects has found that zinc concentrations were significantly lower in the patients with depression. And in the studies that measured depressive symptoms, greater depression severity was associated with a greater relative zinc deficiency. The senior researcher was Krista Lanctot, Ph.D., of the University of Toronto, and results are published in Biological Psychiatry.

What the results mean from a clinical viewpoint, however, remains to be determined, the researchers point out. Since the literature on zinc and depression is largely limited to case-control and cross-sectional studies, it is not known whether depression creates a zinc deficiency or a zinc deficiency helps set the stage for depression. Zinc is an essential nutrient with multiple biological functions.

It is possible that depression creates a zinc deficiency, the researchers suggest, since appetite changes are a common component of major depression. One study of subjects with the disorder identified trends between lower zinc concentrations and weight loss and anorexia symptoms. On the other hand, a zinc deficiency can induce depressive-like behaviors in animals, which in turn can be reversed by zinc supplements, the researchers point out. Thus "the potential benefits of zinc supplementation in depressed patients warrant further investigation," they note.

A comprehensive overview of depression and how to offer optimal care to depressed patients can be found in the new American Psychiatric Publishing book, Clinical Guide to Depression and Bipolar Disorder: Findings From the Collaborative Depression Study. For more on treating depression, see Treatment-Resistant Depression: A Roadmap for Effective Care.

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