Friday, February 28, 2014

APA Sets Record Straight on HIPAA Compliance of DSM Code Sets

In response to misinformation circulating on the Internet indicating that DSM-IV and DSM-5 do not provide HIPAA-compliant code sets and may not be used in HIPAA standard transactions, APA has issued a statement correcting those claims.

As DSM-5 was being developed, the authors were aware that ICD-10-CM would be implemented as the standard medical coding system for use in the United States beginning October 1, 2014. Because DSM-5 was released in May 2013, APA included both the valid and HIPAA-compliant ICD-9-CM and ICD-10-CM codes associated with each disorder so that the diagnostic criteria and the HIPAA-complaint ICD codes could be found in one place.

Accordingly, ICD-9 and ICD-10 codes are the only codes in DSM-5 and both are HIPAA compliant.

For information concerning DSM-5 and ICD codes, see "Understanding ICD-10-CM and DSM-5: A Quick Guide for Psychiatrists and Other Mental Health Clinicians" on APA's website.

Study Examines HIV Infection Rates in Certain Mental Health Care Settings

Individuals receiving treatment for mental disorders are up to four times more likely to be infected with HIV than is the general population, according to a study published in the American Journal of Public Health. Michael Blank, Ph.D., and colleagues from Perelman School of Medicine at the University of Pennsylvania and the University of Maryland, administered HIV tests to more than 1,000 patients who were being treated for symptoms of depression, psychosis, or substance abuse at university-based inpatients psychiatry units and community mental health centers throughout Baltimore and Philadelphia over a 20-month period.

The researchers found that 51 of the patients (4.8%) receiving treatment for mental illness were infected with HIV, approximately 4 times the base rate for the general public in each city and 16 times the base rate for the general U.S. population. In addition, 13 of the 51 individuals reported they were unaware of their HIV status.

“These findings expose the lack of the HIV testing being provided to individuals in mental health care settings, despite recommendations to do so from the Centers for Disease Control and Prevention," Francine Cournos, M.D., a professor of clinical psychiatry at Columbia University, told Psychiatric News. "The numbers from this study definitely send a message to psychiatrists that all patients with mental illness should be offered routine testing for HIV."

To read more the about the association of HIV infection and psychiatric disorders, see the Psychiatric News article "HIV/AIDS Care Ahead of the Curve in Integrating Treatment."

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Thursday, February 27, 2014

Suicide Attempts Early in Life Signal Long-Term Social, Health Problems, Study Finds

Young people who attempt suicide are not only more likely to have persistent psychiatric problems as they approach midlife than nonattempters, but they are also more likely to have physical health problems, engage in violence, and need more social supports as they age. These are key findings from a study by led by Sidra Goldman-Mellor, Ph.D., and colleagues at Duke University and several other institutions and reported in JAMA Psychiatry.

The researchers followed a birth cohort that comprised 91 young suicide attempters and 946 nonattempters, 95% of whom were followed to age 38. Study members were all individuals born from April 1972 to March 1973 in Dunedin, New Zealand, participants in a longitudinal study of health and behavior in a complete birth cohort. They were assessed at ages 18, 21, 26, 32, and 38 with structured interviews to determine incidents of self-harm and suicidal behavior, as well as physical health and social factors. Young attempters were classified as those who made an attempt prior to age 25.

Researchers found that young suicide attempters were twice as likely to have persistent episodes of major depression and substance dependence than nonattempters, and 20% made additional suicide attempts from ages 26 to 38. They were also significantly more likely to commit violence against others, including in intimate relationships. The young attempters were "in significantly worse physical health as they approached midlife." In particular, they were more likely to meet criteria for the metabolic syndrome, have higher levels of biomarkers of systemic inflammation, and to sustain more unintentional injuries. They did caution, however, that they "did not assume that suicide attempts are a cause of these outcomes" but rather are an "early warning signal for persistent vulnerability to poor outcomes." They point out that with suicidal behavior on the increase in the U.S. and other developed nations since the global recession began in 2007, their data highlight the need for "additional suicide prevention efforts and long-term monitoring and aftercare services."

To read about efforts to prevent suicides, see the Psychiatric News articles, "Kennedy Makes Suicide Concerns Focus of National Tour," and "Advocates, Federal Officials Vow Enhanced Suicide-Prevention Efforts."

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Cognitive Training May Benefit Older People Over the Long Term

Cognitive training can benefit seniors up to a decade after they've received the training, a study reported in the Journal of the American Geriatrics Society has found. The study was headed by George Rebok, Ph.D., a professor at the Johns Hopkins University Bloomberg School of Public Health.

The study cohort included approximately 2,800 individuals with an average age of 74 at the start of the study. Half of the subjects were randomized to a training group and the other half to a control group. All subjects were community-dwelling adults who did not show signs of significant cognitive decline. The training group received training sessions in reasoning, information-processing speed, and memory—domains that show declines with aging. The training produced significant improvements in all three cognitive areas. Ten years later, most of the cognitively trained subjects were still at or above their baseline level in reasoning and speed processing; this was not the case for the controls, in whom deterioration of these cognitive functions was seen at the 10-year follow-up. However, the memory improvements that the training group had initially made were not sustained a decade later.

"One of the most common questions asked by our older patients is, 'What can I do to prevent memory loss?' " Art Walaszek, M.D., an associate professor of psychiatry at the University of Wisconsin and a geriatric psychiatrist, noted in an interview with Psychiatric News. "This study, impressive for its large sample size and long-term follow-up, helps answer this question.... It appears that cognitive training may help older adults with their reasoning skills, processing speed, and activities of daily living, but not with memory. This raises the intriguing possibility that, though memory decline may be difficult to avoid, older adults may be able to develop other cognitive skills in order to maintain their functioning."

More information about ways in which older individuals can retain or even improve their cognition can be found in the book "Successful Cognitive and Emotional Aging" from American Psychiatric Publishing.

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Wednesday, February 26, 2014

Study Finds Gene Methylation a Marker of PTSD Vulnerability

Researchers have long sought biological factors to help them understand the development of psychiatric illnesses, information that often depends on patient self-reports. Now a team of scientists has studied 122 combat veterans and found different epigenetic patterns in those who developed posttraumatic stress disorder (PTSD) and those who did not.

Cytosine methylation of the NR3C1-F promoter was lower in in peripheral blood mononuclear cells among combat veterans with PTSD and was “inversely correlated with clinical markers and symptoms associated with PTSD,” said Rachel Yehuda, Ph.D. (shown above), a professor of psychiatry and neuroscience at Icahn School of Medicine at Mt. Sinai in New York, and colleagues.“NR3C1-1F promoter methylation was also associated with three functional measures of glucocorticoid activity that have been associated with PTSD in combat veterans,” they explained in their report published online February 19 in Biological Psychiatry.

These epigenetic changes may represent one mechanism by which environmental exposures, such as combat, lead to changes in neuroendocrine function and thus help differentiate combat-exposed veterans who are likely to develop PTSD from those who are not, concluded the researchers.

To read more about recent research on the biology of PTSD, see the Psychiatric News articles, “Fear Extinction Requires Multipronged Intervention" and "9/11 Tragedy Spurs Advances in PTSD Research."

(Image: Aaron Levin/Psychiatric News)

Tuesday, February 25, 2014

Acetaminophen Use During Pregnancy Linked to ADHD in Offspring, Study Suggests

Use by mothers of acetaminophen during pregnancy may increase the risk of ADHD and hyperkinetic disorders (HKDs), according to a report in JAMA Pediatrics.

Researchers at the University of California and other institutions prospectively assessed acetaminophen use during pregnancy via three computer-assisted telephone interviews during pregnancy and 6 months after child birth. They studied 64 322 live-born children and mothers enrolled in the Danish National Birth Cohort during 1996-2002.

They used parental reports of behavioral problems in children 7 years of age using the Strengths and Difficulties Questionnaire; retrieved HKD diagnoses from the Danish National Hospital Registry or the Danish Psychiatric Central Registry prior to 2011; and identified ADHD prescriptions for children from the Danish Prescription Registry. They then estimated hazard ratios for receiving an HKD diagnosis or using ADHD medications and risk ratios for behavioral problems in children after prenatal exposure to acetaminophen.

Children whose mothers used acetaminophen during pregnancy were at higher risk for receiving a hospital diagnosis of HKD, use of ADHD medications, or having ADHD-like behaviors at age 7 years. Stronger associations were observed with use in more than 1 trimester during pregnancy, and exposure response trends were found with increasing frequency of acetaminophen use during gestation for all outcomes.

Child psychiatrist David Fassler, M.D., called the report intriguing. "The findings demonstrate an increased incidence of ADHD by age 7 in children whose mothers took acetaminophen during pregnancy," he told Psychiatric News. "The association persists after controlling for factors such as maternal fevers, infections and inflammation. The authors speculate that acetaminophen may have an impact on hormone levels during critical periods of fetal brain development. Although an intriguing hypothesis, further research will clearly be needed both to replicate the current findings and to establish a definitive causal relationship between prenatal exposure to acetaminophen and ADHD. However, the current results underscore the importance of avoiding unnecessary exposure to all medications, including acetaminophen, during pregnancy."

For more information on ADHD see the Psychiatric News article, "Addressing Comorbid ADHD, Substance Abuse Disorder in Adolescents."

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CBT More Efficacious Than Other Psychological Interventions for Positive Symptoms of Psychosis

Small but important differences in effectiveness of various psychological interventions for symptoms of psychosis emerged in a metanalysis, “Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies,” in AJP in Advance (February 18, 2014).

Dutch researchers analyzed forty-eight outcome trials comparing psychological interventions for psychosis. The comparisons included 3,295 participants. Categorization of interventions resulted in six interventions being compared against other interventions pooled: Cognitive behavior therapy (CBT), supportive counselling, social skills training, psychoeducation, cognitive remediation and befriending. Separate sub-meta-analyses for positive, negative, or general symptoms were undertaken when there were sufficient studies assessing these outcomes.

CBT was significantly more efficacious than other interventions pooled in reducing positive symptoms, and significantly more efficacious when compared directly with befriending for overall symptoms and supportive counseling for positive symptoms. Social skills training was significantly more efficacious in reducing negative symptoms.

“Although the differences observed between interventions for psychosis were small in this meta-analysis, the relatively robust nature of the differences and the pattern by which differences occur have implications for the continued clinical implementation, design, and improvement of psychosocial therapies for psychosis," the researchers state.

For more on how CBT has been used in a city-wide system to treat symptoms of psychosis see the Psychiatric News article, “CBT Addresses Most Debilitating Symptoms in Chronic Schizophrenia.”


Monday, February 24, 2014

Cognitive Function May Predict Development of Chronic Pain, New Study Finds

Patients with deficits in attention, memory, or executive function might be at high risk of developing chronic pain after surgery or some other pain-inducing event. This is a major finding from a study published in Brain and headed by Nadine Attal, M.D., Ph.D., of the Ambroise Pare Hospital in Boulogne-Billancourt, France.

The study cohort included 189 subjects aged 18 to 85 who were about to undergo one of two operations—either knee replacement because of osteoarthritis or breast cancer surgery. The researchers measured attention, memory, and executive function in the subjects before surgery, then followed them for a year. Impairment in attention, memory, or executive function before surgery significantly predicted clinically meaningful pain six or 12 months after surgery in both groups of patients, even when the presence of anxiety, depression, or pain before surgery were considered.

"This is an interesting study," Michael Clark, M.D., an associate professor of psychiatry and director of the Pain Treatment Program at Johns Hopkins Medical Institutions, said in an interview with Psychiatric News. "I think that the determination of risk factors that predict the development of chronic pain is an important area.... [The results] highlight the need to take extra care in the management of acute pain for individuals with existing neurological disorders to decrease the risk of persistent pain after surgery. In addition, given that chronic pain management often focuses on improving coping skills, these results support the use of cognitive training to facilitate the development of more effective therapies for reaching functional goals in rehabilitation programs."

More information about the interface between psychiatry and chronic pain can be found in the Psychiatric News articles "Psychiatrists Have Multiple Roles in Treating Chronic Pain" and "Psychiatrists' Expertise Useful in Managing Chronic Pain" as well as in the American Psychiatric Publishing book "Clinical Manual of Pain Management in Psychiatry."

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Case Examples of Harmful Reparative Therapy Sought for Legal Case

The organization Lambda Legal wishes to hear from psychiatrists and other licensed therapists who can relate real-life stories of the negative impact on and damage done to individuals who were subjected to reparative therapies as youth. According to APA member Jack Drescher, M.D. (photo at left), Lambda Legal will use the information anonymously in the preparation of an amicus brief to file in the case King v. Christie.

The case stems from a challenge to a law signed in August 2013 by New Jersey Gov. Chris Christie prohibiting state-licensed therapists from trying to change the sexual orientation or gender identity of patients under age 18. An anti-LGBT legal group immediately filed a federal lawsuit challenging the law on behalf of two New Jersey therapists and two organizations that support the use of these therapies to change sexual orientation. In November 2013, the United States District Court for the District of New Jersey dismissed the suit, ruling that the law does not violate freedom of speech or religion. The case is now on appeal to the United States Court of Appeals for the Third Circuit.

Jack Drescher, M.D., who, at the request of the New Jersey Attorney General's office, has filed a declaration in support of this law, told Psychiatric News: "I think it important for mental health practitioners who know the harm done by sexual orientation conversion efforts speak up and participate in providing further clinical material to support this law.

Drescher is a past president of the Group for the Advancement of Psychiatry and a member of APA’s DSM-5 Workgroup on Sexual and Gender Identity Disorders.

The amicus brief is due March 6. Those who would like to share case information should contact Amy Shapiro of Lambda Legal at (917) 446-7116 or

Friday, February 21, 2014

Decriminalizing Marijuana Increases Risk Children Will End Up in ER, Study Finds

States that legalized marijuana for medicinal purposes witnessed a significant increase in children requiring medical intervention for unintentional cannabis exposure, according to a study published in the Annals of Emergency Medicine.

“We believe that high-dose edible products—such as candies, cookies and chocolates—may have played a significant role in the increased rate of reported exposure chiefly because kids can't distinguish between products that contain marijuana and those that don't," commented George Wang, M.D., the study's lead author and a pediatrician and toxicologist at the Rocky Mountain Poison and Drug Center in Denver.

Wang and colleagues analyzed call rates to U.S. poison-control centers for unintentional pediatric cannabis exposure from 2005 to 2011 among states with decriminalizing marijuana laws and states where the substance remained illegal. Data showed that call volume for pediatric cannabis exposure increased by more than 30% annually in states with marijuana-legalization laws, while rates in states without such laws did not change. In addition, more pediatric marijuana exposure cases in decriminalizing states required medical evaluation and critical care admission, mainly for neurological effects, than those in other states. The median age for children exposed ranged from 18 months to 2 years.

“Pediatricians, toxicologists, and emergency physicians need to be willing to advocate for the safety of children to lawmakers as this burgeoning industry expands across the U.S.," said Wang. "As more states decriminalize marijuana, lawmakers should consider requirements—such as child-resistant packaging, warning labels, and public education—to reduce the likelihood of ingestion by young children.”

To read more about marijuana and illicit drug exposure in children and adolescents, see the Psychiatric News articles, “AMA Urges Public Health Approach to Cannabis and Other Illicit Drug Use” and "Medication Coupled With Rewards Found to Reduce Cannabis Use."

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Switching Schools Associated with Increased Risk for Psychotic-Like Symptoms for Youth

Researchers report in the Journal of the American Academy of Child and Adolescent Psychiatry that multiple school transfers may put young children at risk for developing psychotic-like symptoms during adolescence. Nearly 14,000 children were followed from age 2 to 9 to assess the mental impact of school and residential mobility. At age 12, the subjects were evaluated for psychosis-like symptoms, such as hallucinations and delusions, in addition to being interviewed about peer engagement complications, such as friendship difficulties and bullying involvement.

The analysis showed that relocating schools during childhood more than three times heightened the risk for developing psychotic-like symptoms in early adolescence by 60%. Being the victim of bullying was also found to be associated with school switching. “Changing schools can be very stressful for students. Our study found that the process of moving schools may itself increase the risk of psychotic symptoms—independent of other factors [such as race and family adversity], said Swaran Singh, M.D., coauthor and head of the Division of Mental Health and Wellbeing at Warwick Medical School in England.

The authors said that switching schools may lead to feelings of low self-esteem and a sense of social defeat. Because the impact of school mobility can be both serious and potentially long lasting, they suggested that psychiatrists should be aware of frequent school shifts when assessing youngsters who have psychotic disorders.

To read more about factors and symptoms of psychosis in children and adolescents, see the Psychiatric News article, "Diagnosing Psychosis in Children and Adolescents." For an in-depth review of mental illness in youth, see Concise Guide to Child and Adolescent Psychiatry, Fourth Edition, from American Psychiatric Publishing.

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Thursday, February 20, 2014

APA 2014: Changing the Practice and Perception of Psychiatry

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. This column was written by Dr. Lieberman and Philip Muskin, M.D., chair of the APA Scientific Program Committee. Please send your comments to

Annually, thousands of mental health professionals descend on a major American city to participate in a three-ring circus of pedagogic activities that comprise the annual meeting of the American Psychiatric Association. This event is an academic smorgasbord of all information relevant to psychiatric medicine and mental health care. It provides one-stop shopping for clinicians who wish to avail themselves of the latest scientific developments and all the education needed to practice their craft. The annual meeting is the highlight of the year for U.S. psychiatry.

APA’s 167th Annual Meeting will take place May 3 to 7 in New York City and will be the epicenter for those who wish to learn of emerging knowledge and connect to leaders in the field of psychiatry. New York is a perfect place to host this year’s meeting, given the extraordinary and historic events of the past year, including the launch of DSM-5, the release of the final rule for the Mental Health Parity and Addiction Equity Act, further implementation of the Affordable Care Act, and the emotionally wrenching discussion of mental illness and violence in the media.

The theme of the 2014 annual meeting is aptly titled “Changing the Practice and Perception of Psychiatry,” reflecting the historic transformation in how our profession will be practiced, as well as perceived by our medical colleagues and the public at large. The Scientific Program Committee, chaired by Phil Muskin with Co-Chair Cam Carter, has produced an amazing program with a who’s who of luminaries scheduled to speak. The Opening Session will feature a “Dialogue on Science and the Media” that I will moderate between Nobel Laureate Eric Kandel and the acclaimed actor Alan Alda. The Convocation Lecture will be delivered by a major political figure who is leading major legislative initiatives in mental illness. Look for more information in a future issue.

To read more, click here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman.

Antidepressant Shows Mixed Results in Treating Alzheimer's Patients, Study Finds

While citalopram has been used to reduce agitation and aggression in individuals with Alzheimer’s disease (AD), a new study published in the Journal of the America Medical Association suggests that use of the drug in these patients may be increasing their health risks.

Researchers from Johns Hopkins Bayview Medical Center and the University of Rochester Medical Center randomized 186 nondepressed patients with AD to received nine weeks of psychosocial therapy plus either citalopram or placebo to evaluate the efficacy of 30mg per day of citalopram for AD-associated agitation—which affects 90% of patients with AD, according to study. Results showed that 40% of the patients receiving citalopram had improvements in agitation from baseline, compared with 26% of placebo recipients. However, the patients taking citalopram had longer QT intervals—a measure of abnormal heart functions that greatly increases the risk for heart attacks—than did the placebo group.

Constantine Lyketsos, M.D., M.H.S, coauthor and director of psychiatry at Johns Hopkins Bayview, commented in statement that he and his colleagues plan to investigate the effectiveness of lower doses of citalopram in treating AD-related agitation, a strategy that may pose less cardiovascular risk. In the meantime, Lyketsos said, the drug offers an alternative to treating agitation in individuals with AD who may be nonresponsive to nonmedication treatments.

To read more about citalopram and adverse cardiovascular health risks, see the Psychiatric News article, "FDA Responds to AJP Manuscript on Citalopram Safety." For more information on treating AD, see Clinical Manual of Alzheimer Disease and Other Dementias from American Psychiatric Publishing.

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Wednesday, February 19, 2014

Equal Benefit for Minorities From Psychotherapy, Study Finds

Members of racial or ethnic minority groups benefit just as much from psychotherapy as do members of the white majority in Western countries, according to a report in Psychiatric Services in Advance.

Researchers from Vrije Universiteit (VU), University Amsterdam, and the EMGO Institute for Health and Care Research looked at 56 randomized, controlled trials among adults that compared psychotherapies with usual care or a waiting list. The most common treatments were cognitive-behavioral therapy (in 32 trials) or interpersonal psychotherapy (11 trials).

The meta-analysis could not determine patient-level differences in outcomes, but did measure the relationship between the effect size of the studies and the proportion of minority participants, wrote Pim Cuijpers, Ph.D., a professor and chair of the Department of Clinical Psychology at the Vrije Universiteit, and colleagues. The mean effect size was “moderate,” after multivariate metaregression analysis, they wrote.

“Our overall results suggest there is little reason to assume that psychotherapy is less effective for racial-ethnic minority populations compared with nonminority populations,” concluded the authors. “Because our meta-analysis did not give strong indications that psychological treatments work differently between specific racial-ethnic minority groups, more attention should be paid to the gap between effective mental health care and the delivery of these services.”

For information about ethnic-minority subjects in research, see the Psychiatric News article "Ethnic Diversity in MH Clinicians, Clinical Trials Improves."

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Effectiveness of Peer Specialists Found to Vary By Type

More and more individuals who are well along the road to recovery from serious mental illness are assisting others who are not so far along this path. They are called peer specialists. Peer services are now available in many states and are delivered through numerous program types, service structures, and funding streams.

But how effective are peer specialists? Matthew Chinman, Ph.D., of the U.S. Department of Veterans Affairs Pittsburgh Medical Center, and colleagues decided to evaluate the evidence currently available to answer this question. They reported today in Psychiatric Services that the effectiveness of peer specialists varies by service type. Peer specialists who are added to traditional services or who deliver structured curricula to patients are more effective than peers who assume regular provider positions--say, work as case managers.

These findings have implications for psychiatrists, Chinman said in an interview. "The biggest implication is that peers can play a valuable role in the range of mental health services offered at facilities. However, care needs to be taken in how the position is set up and managed to make sure that peers are getting incorporated into the teams well (resistance among clinicians is an ongoing implementation issue) and are using their peer skills. Psychiatrists, who are usually in positions of authority in mental health facilities, could use that authority to make sure that peers are hired, supported, trained, and receive ongoing clinical supervision. Given that peer specialists are a relatively new field compared with the other professions, sites will not automatically want to hire peers. There is usually someone who must champion the idea. Psychiatrists could be those champions."

The report is part of a series of literature reviews in Psychiatric Services commissioned by the Substance Abuse and Mental Health Services Administration.

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Tuesday, February 18, 2014

One-Third of Patients With First-Episode Psychosis May Disengage From Treatment

Approximately a third of individuals with first-episode psychosis (FEP) disengage from treatment services, according to “First-Episode Psychosis and Disengagement From Treatment: A Systematic Review,” which appears online in Psychiatric Services in Advance.

Irish researchers conducted a comprehensive search for and review of published studies that reported rates and predictors of disengagement within first-episode psychosis services using the databases PubMed (1966–2012) and PsycINFO (1882–2012). Relevant terms were used to search the Internet and the reference sections of papers for other pertinent studies. Independent searches for recent publications by leading researchers in the field were also conducted.

Ten articles were included in the review. The review revealed a lack of consensus on a clear definition of engagement and disengagement, but evidence from the review indicates that approximately 30 percent of individuals with FEP disengage from services. Some of the variables that were consistently found to exert an influence on disengagement were duration of untreated psychosis, symptom severity at baseline, insight, substance abuse and dependence, and involvement of a family member.

“Given the importance of continuity of care for FEP, there is a need for a clearly defined and agreed measurement of service engagement and disengagement across FEP services,” the researchers stated. “In particular, those who enter an FEP program without family involvement and support as well as those who maintain persistent substance abuse are at higher risk of disengagement. Early identification of such individuals and the development of approaches to reduce risk of service disengagement are likely to increase the effectiveness of these services.”

For more on first-episode psychosis, see the Psychiatric News article "Threat Delusions Linked to Violence in First-Episode Psychosis."

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Seizure Drugs Shows Promise for Alcohol Dependence in Subjects With Genetic Polymorphism

Treatment with the drug topiramate, used to treat seizures, appears to significantly reduce heavy drinking days and increase abstinent days in alcohol-dependent individuals relative to placebo, according to the report titled "Topiramate Treatment for Heavy Drinkers: Moderation by a GRIK1 Polymorphism" in AJP in Advance. But notably, the drug’s effects were only significantly better than placebo in individuals carrying a particular single nucleotide polymorphism known as rs2832407, which is believed to be associated with alcohol dependence.

Henry R. Kranzler, M.D, of the Department of Psychiatry at the University of Pennsylvania Perelman School of Medicine, and colleagues at several other institutions randomly assigned a total of 138 individuals to receive 12 weeks of treatment with topiramate (n=67), at a maximal daily dose of 200 mg, or placebo (n=71). Both groups received brief counseling to reduce drinking and increase abstinent days. DNA was extracted from whole blood, and subjects were genotyped for the presence of rs2832407.

There was a significant main effect seen in the medication group, with topiramate patients reducing heavy drinking more than placebo patients. By the last week of treatment, the odds of experiencing a heavy drinking day in the placebo group was 5.33 times that of the topiramate treatment group, and the number of patients with no heavy drinking days during the last four weeks of treatment in the topiramate group was more than double that of the placebo group. Topiramate patients also reported more abstinent days than placebo patients.

The effect on heavy drinking days was seen only in patients with the rs2832407 polymorphism. (The effect on days of abstinence was not significant.)

“The moderator effect of rs2832407, if validated, would facilitate the identification of heavy drinkers who are likely to respond well to topiramate treatment and provide an important personalized treatment option,” the researchers stated.

For more information on topiramate’s potential effects on addiction, see the Psychiatric News article, “Seizure Drug Shows Promise as Cocaine Addiction Treatment.”

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Thursday, February 13, 2014

Results of APA's 2014 Election Announced

APA's Committee of Tellers met today and approved the following results for APA's 2014 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting on March 8 and 9 in Arlington, Va.

Renee L. Binder, M.D.

Frank W. Brown, M.D.

Anita S. Everett, M.D.

Area 2 Trustee
Vivian B. Pender, M.D.

Area 5 Trustee
R. Scott Benson, M.D.

Resident-Fellow Member Trustee-Elect
Ravi N. Shah, M.D.

Complete results of the election will be reported in a future issue of Psychiatric News.

Treating Depression May Help Improve Memory, Executive Function in Parkinson's

Successful treatment of depression associated with Parkinson’s Disease may be associated with cognitive improvements, according to a report in The Journal of Neuropsychiatry and Clinical Neurosciences.

Researchers in the departments of psychiatry and neurology at Robert Wood Johnson Medical School conducted a randomized, controlled trial of cognitive-behavioral therapy (CBT) plus clinical monitoring versus clinical monitoring-only for the treatment of depression associated with Parkinson’s (dPD) from April 2007 until July 2010. Treatment was provided for 10 weeks. The CBT protocol incorporated behavioral activation, cognitive restructuring, sleep hygiene, anxiety management, and caregiver psychoeducation.

The researchers found that improvements in depression and anxiety were associated with modest gains in verbal memory and executive functioning over the 10-week treatment period and accounted for greater variance in neuropsychological outcomes at the end of treatment than other known correlates of cognitive functioning in Parkinson's, such as disease severity, age, and education. Baseline working memory and executive skills were also associated with depression improvement over time.

“This study provides preliminary evidence to suggest that memory and executive functioning may improve after the successful psychosocial treatment of dPD,” the researchers stated. “Anxiety, a common correlate of depression, may also influence cognitive changes in PD and may be most relevant to the assessment of delayed recall…. [I]t may be beneficial for depression treatment to be initiated before cognitive remediation attempts, so that lesser cognitive deficits need to be addressed in cognitive remediation.”

For more information, see the Psychiatric News article "Depression May Be Linked to Onset of Parkinson's." 

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Wednesday, February 12, 2014

SAMHSA Phone App Helps Responders After Disasters

The Substance Abuse and Mental Health Services Administration (SAMHSA) today released a smartphone app with behavioral health information and resources for responders providing support to survivors of disasters.

“It has simple but effective tips to help address problem-solving with survivors, as well as key reminders for supervisors,” said tech expert John Luo, M.D., a clinical professor of psychiatry and senior physician informaticist at the David Geffen School of Medicine at UCLA.

The SAMHSA Disaster App is available in iPhone/iPad, Google Android, and Blackberry versions. Content includes brief refreshers on psychological first aid, suicide prevention, disaster mental health, and self-care. One section discusses the special aspects of working as part of emergency operations following terrorist events. A search function allows users to locate behavioral health services (so far, mostly substance abuse services) based on ZIP code, city and state, or address. There are also postdeployment guides for responders, their families, and supervisors. All sections contain links to more extensive information on SAMHSA and other websites.

“The app also downloads content when started in order to provide regular updates, which is a great feature,” said Luo in an interview. “I highly recommend that all behavioral health providers download it now to be better prepared in the event of a disaster.”

For more in Psychiatric News about how being prepared can help psychiatrists when disaster strikes, see: “Psychiatrists Act Quickly After Bombings In Boston.” Additional information can be found in the book Disaster Psychiatry Readiness, Evaluation, and Treatment by American Psychiatric Publishing.

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Review Backs Use of Prazosin for PTSD-Related Nightmares

Off-label use of prazosin to manage nightmares in veterans with combat-related posttraumatic stress disorder received a boost with publication of a critical review in the Journal of Neuropsychiatry and Clinical Neuroscience. Use of antidepressants to alleviate PTSD-related nightmares has shown little benefit.

The examination of seven published studies on prazosin, an alpha adrinergic antagonist long used to treat high blood pressure, included 210 patients, 95 percent male, and veterans of conflicts from World War II to Iraq and Afghanistan.

Two randomized, controlled trials reported positive effects on reducing nightmares. One other showed a negative effect, but “nightmare intensity was not properly measured” in that study, wrote Brian Writer, D.O., Eric Meyer, M.D., and Jason Schillerstrom, M.D., of the Department of Psychiatry at Wilford Hall Ambulatory Surgical Center in San Antonio, Texas. In addition, one retrospective chart review and three open-label trials yielded positive results across a range of ages, said the authors. When prazosin was discontinued, the nightmares returned but resolved again when the drug was restarted.

“[G]iven the sobering morbidity and frequency of combat-related PTSD nightmares in conjunction with the available positive evidence-base signal, this review highlights an indication for further randomized, controlled examination of prazosin, specifically in the combat-PTSD cohort,” concluded the authors.

For more in Psychiatric News about prazosin and nightmares, see “Conquering Vets' Nightmares Diminishes PTSD Symptoms.” For a recent report in the American Journal of Psychiatry, see: "A Trial of Prazosin for Combat Trauma PTSD With Nightmares inActive-Duty Soldiers Returned From Iraq and Afghanistan."

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Tuesday, February 11, 2014

TAC Report Gives Poor Grade to States on Laws Requiring Treatment

The majority of U.S. states are in need of significant improvements to their mental illness treatment laws to protect and provide for individuals in psychiatric crisis, according to a new report by the Treatment Advocacy Center (TAC).

TAC advocates for civil commitment laws and court-ordered outpatient treatment, often called “assisted outpatient treatment.”

The TAC report, “Mental Health Commitment Laws: A Survey of the States,” analyzes the quality and use of laws each state has enacted to meet the needs of people with severe mental illness who cannot recognize their own need for treatment. The report grades each state on the quality of the civil commitment laws that determine who receives court-ordered treatment for mental illness, under what conditions, and for how long. States also received grades on their use of treatment laws based on a survey of mental health officials.

No state earned a grade of “A” on the use of its civil commitment laws. Seventeen states earned a cumulative grade of “D” or “F” for the quality of their laws, and only 14 states earned a grade of “B” or better for the quality of their civil commitment laws. Twenty-seven states provide court-ordered hospital treatment only to people at risk of violence or suicide even though most of these states have laws that allow treatment under additional circumstances.

“The cost of not treating severe mental illness--to the individuals suffering from it, their families, communities and taxpayers-- is incalculable,” said Doris A. Fuller, executive director of the TAC, in a statement. “The failure of most states to enact and or use common-sense laws that would reduce these impacts should be recognized as the national disgrace it is.”

For more on court-ordered treatment, see the Psychiatric News article, "Treatment Law Evaluation Shows That investment Pays Off."

(Image: Shutterstock/Monika Wisniewska)

Intensive CBT for PTSD Found Effective With Faster Time to Recovery

Cognitive therapy for PTSD delivered intensively over little more than a week was as effective as cognitive therapy delivered over three months, and both were superior to supportive therapy, according to a study published in the American Journal of Psychiatry, "A Randomized Controlled Trial of 7-Day Intensive and Standard Weekly Cognitive Therapy for PTSD and Emotion-Focused Supportive Therapy."

British researchers randomly allocated patients with chronic PTSD (N=121) to seven-day intensive cognitive therapy for PTSD, three months of standard weekly cognitive therapy, three months of weekly emotion-focused supportive therapy, or a 14-week waiting-list condition. The primary outcomes were change in PTSD symptoms and diagnosis as measured by independent assessor ratings and self-report. Evaluations were conducted at the baseline assessment and at six and 14 weeks (the posttreatment/wait assessment).

At the posttreatment/wait assessment, 73 percent of the intensive cognitive therapy group, 77 percent of the standard cognitive therapy group, 43 percent of the supportive therapy group, and 7 percent of the waiting list group had recovered from PTSD. All treatments were well tolerated and were superior to waiting list on nearly all outcome measures; no difference was observed between supportive therapy and waiting list on quality of life. For primary outcomes, disability, and general anxiety, intensive and standard cognitive therapy were superior to supportive therapy. Intensive cognitive therapy achieved faster symptom reduction and comparable overall outcomes to standard cognitive therapy.

“The feasibility of intensive cognitive therapy is of interest for therapeutic settings where treatment needs to be conducted over a short period of time, such as in residential therapy units or occupational groups exposed to trauma, or where patients have to get better quickly to avoid secondary complications such as job loss or marital problems," the researchers stated. "The feasibility of intensive treatment is also of interest for patient choice, as some patients may find a shorter condensed treatment preferable.”

For more on treatment of PTSD see the Psychiatric News article, "Neurotransmitters Studied as Way to Enhance PTSD Treatment." Also, see Care of Military Service Members, Veterans, and Their Families by American Psychiatric Publishing.

(Image: Shutterstock/Tashatuvango)

Monday, February 10, 2014

Neurocognitive Growth Lag Appears to Accompany Psychotic Symptoms in Children

In a large population study, researchers found that children experiencing psychotic symptoms lagged behind their typically developing peers of the same age in neurocognition. Moreover, this lag was found to be present as early as at 8 years of age.

The senior researcher was Rachel Gur, M.D., Ph.D., a professor of psychiatry at the University of Pennsylvania. The results appear in JAMA Psychiatry.

The study included 2,321 youth aged 8 to 21 who reported having psychotic symptoms. They were compared with 1,963 typically developing children with no psychiatric disorders and also with 981 children with psychiatric symptoms other than psychosis. As for the latter, they did not show a neurocognitive delay, indicating that the delay was limited to an association with psychosis.

The results have clinical implications, Gur and her team wrote in their paper. "Combined clinical and neurocognitive assessment can facilitate early detection and targeted intervention to delay or ameliorate disease progression." For instance, "Although as a group psychotic-symptom individuals show greater lag in complex cognition than other domains, including executive function, the lag pattern may differ for individuals and can form the basis for designing tailored intervention approaches."

Early identification of psychosis is critical, Gur believes. For her views on this subject, see the Psychiatric News article "Expert Says Early Identification of Psychosis Should Be Priority."

Peripheral blood biomarkers of inflammation and other processes appear to help indicate which individuals with a high risk for psychosis will actually convert to psychosis. For information on this subject, see the Psychiatric News article "Blood Biomarkers Could Aid Prediction of Psychosis Risk."

Collaborative Care Cuts Risk of Cardiovascular Events in Depressed Patients

An impressive new benefit of collaborative care for depression has been identified. It can slash the risk of fatal and nonfatal heart attacks and strokes in older individuals without preexisting heart disease.

The study was headed by Jesse Stewart, Ph.D., of Indiana University-Purdue University Indianapolis. The results appear in Psychosomatic Medicine.

Back in 2002, Jürgen Unützer, M.D., a professor and vice chair of psychiatry at the University of Washington, and colleagues found that collaborative care for depression in individuals aged 60 or older was superior to usual primary care for it. Stewart and his group followed up, for eight years, 235 Indiana residents who had participated in the IMPACT trial to see whether collaborative care for depression could reduce the subsequent risk of heart attacks and strokes. Stewart and his team found that it did not reduce risk in individuals who had preexisting cardiovascular disease, but that it did reduce risk--by 48%--in individuals without preexisting cardiovascular disease.

"We have known for a long time that depression is associated with an increased risk of heart disease," Unützer said in an interview. "This eight-year follow-up of participants in the IMPACT study suggests that effective collaborative care for depression cut in half the risk of fatal and nonfatal cardiovascular events in those without preexisting heart disease. It further strengthens the argument for evidence-based collaborative care programs like IMPACT that have been shown to improve patient and provider satisfaction and mental and physical health outcomes."

More information about collaborative care and its benefits can be found in the Psychiatric News articles "Collaborative Care: an Integral Part of Psychiatry's Future" and "Three Decades of Working in Integrated Care."

(Image: stam_photo/

Friday, February 7, 2014

Childhood Infection May Increase Risk for Psychosis In Adulthood, Study Suggests

Findings from a study published in Schizophrenia Bulletin suggest that hospital admission for infections during childhood may put individuals at risk for the onset of a nonaffective mental disorder, such as schizophrenia. The study is featured in today's Psychiatric News.

Researchers from the Karolinksa Institutet in Sweden analyzed medical records of more than 1 million individuals from birth to adulthood to assess the link between childhood infections and nonaffective psychosis. The results showed that those who were hospitalized for an infection between birth and age 13 were 10 times more likely to be diagnosed with nonaffective psychosis than those who were not hospitalized for an infection, regardless of gender, socioeconomic status, and familial psychiatric history.

Researchers also found that bacterial infection and infection of the central nervous system during the preadolescent years (ages 10 to 13) further increased the risk for developing nonaffective psychosis in adulthood.

The authors suggested that individuals who later develop nonaffective psychosis might have subtle immune deficiencies that render them more susceptible to early-life infections, but whether these infections reflect a vulnerability that may be associated with social or genetic risk factors remains to be determined.

For more information on the current study, see the Psychiatric News article, "Link Found Between Childhood Infections, Later Psychosis. To read about other studies linking infections to serious mental disorders, see the article, "Psychiatrist Hunts for Evidence Of Infection Theory of Schizophrenia." Also see "A Nationwide Study on the Risk of Autoimmune Diseases in Individuals With a Personal or a Family History of Schizophrenia and Related Psychosis" in the February American Journal of Psychiatry.

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Infants Who Disengage From Speaking Faces May Be at Increased Autism Risk, Study Finds

A study published in this week's Biological Psychiatry suggests that infants who divert their gaze from a speaking face may be at increased risk for being diagnosed with autism spectrum disorder (ASD) later in childhood.

Researchers from Yale University School of Medicine and University of Texas Southwestern Medical Center used an eye-tracking technology to analyze the gaze of 100 six-month olds who looked at videos of still, smiling, and speaking faces. Three years later, the infants were divided into groups based on typical development, developmental delays, or a diagnosis of ASD. The analysis showed that infants who later developed ASD not only looked at faces less than other infants, but also looked away from key facial features such as eyes and mouth when being shown a face that was speaking. According to the authors, this is the first study to isolate an atypical response to speech as a specific characteristic in the first half year after birth that is associated with later emerging ASD.

"It seems clear that brain changes related to autism appear much earlier than we traditionally diagnose this disorder," commented John Krystal, M.D., editor of Biological Psychiatry and chair of the Department of Psychiatry at Yale, who was not involved in the study. "This study elegantly illustrates that autism-related disturbances in social relatedness are present very early in life, shaping one's most fundamental social contacts."

To read more about a relationship between infant eye-gaze and ASD, see the Psychiatric News article, “Infants’ Eyes May Reveal Clue to Autism Risk. Also see the American Psychiatric Publishing book, “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.”

(Image: Sokolova Maryna/

Thursday, February 6, 2014

Psychiatry Embraces Patient-Centered Care

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. This column was written by Dr. Lieberman and Lisa Dixon, M.D. Please send your comments to

Psychiatry has long been considered the medical specialty most attuned to listening to the patient. With few diagnostic laboratory or imaging tests available or other physical indicators of illness, psychiatrists have been trained to attend carefully to their patients’ histories and subjective reports of symptoms to make a diagnosis and determine the course of treatment. But the nature of the doctor-patient relationship was traditionally one-sided. Patients talked and their physicians listened, and then the doctor prescribed the treatment and the patient followed.

But now psychiatry is changing as the field of medicine adopts patient-centered care. This model of care places greater emphasis on patients' involvement in determining the goals of treatment that are meaningful to them and the nature of their care. Meaningful goals for patients generally go beyond symptoms to include quality of life, functioning, and a sense of hope and self-efficacy. Patient-centered care isn’t just about putting the patient at the center of the care equation. Rather, it shifts the balance of authority and responsibility of the doctor-patient relationship and incorporates shared decision making (SDM) between the clinician and the patient, particularly when it comes to treatment.

SDM is defined as “a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.” Practicing SDM requires that psychiatrists assess the patient’s interest in participating in decisions, providing information on the risks and benefits of specific treatments or approaches in an understandable format, and dialogue with patients about their choices. SDM does not mean that psychiatrists don’t make strong recommendations; rather, it means that those recommendations need to be reconciled with patients’ views and choices.

To read more, click here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman.

Wednesday, February 5, 2014

New Agenda Aims to Guide Future Direction of Suicide Research

Despite efforts at prevention, suicide rates in the U.S. have remained the same for the last half century. About 38,000 Americans die by suicide every year, and 650,000 hospital visits are attributed to suicide attempts. The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force today issued a prioritized research agenda based on three years of work by the public-private consortium, led by Phillip Satow, chair of the board at the Jed Foundation, and Thomas Insel, M.D., director of the National Institute of Mental Health.

“To reduce suicide, we need to know how to target our efforts: to be able to reliably identify who is at risk, how to reach them, and how to deter them from acting on suicidal thoughts,” wrote Insel, in a blog post today. The agenda poses the following six key questions that its authors hope will guide research over the next five to 10 years, with the goal of reducing suicides by 20%:

  • Why do people become suicidal?
  • How can we better or more optimally detect/predict risk?
  • What interventions prevent individuals from engaging in suicidal behavior?
  • What services are most effective for treating the suicidal person and preventing suicidal behavior?
  • What other types of interventions (outside of health care settings) reduce suicide risk?
  • What new and existing research infrastructure is needed to reduce suicidal behavior?
The task force hopes to draw attention to measures already known to be effective, to test whether commonly used antisuicide programs are indeed effective, and to identify new research needed in less-studied areas. “We believe the Research Agenda gives us a roadmap to save lives,” said Insel.

To read more about other recent initiatives to prevent suicides, see the Psychiatric News article, "Kennedy Makes Suicide Concerns Focus of National Media Tour." Also see The American Psychiatric Publishing Textbook of Suicide Assessment and Management, Second Edition.

(Image: WaveBreakMedia/

Strong Evidence Said to Support Opioid-Addiction Treatment With Methadone, Buprenorphine

Strong evidence confirms that two forms of medication maintenance therapy show benefits in treating opioid use disorders, according to literature reviews published in the new issue of Psychiatric Services. Buprenorphine treatment or a combination of buprenorphine and naloxone “indicated a high level of evidence for its positive impact on treatment retention and illicit opioid use," said Cindy Thomas, Ph.D. (pictured), an associate research professor at the Heller School for Social Policy and Management at Brandeis University, and colleagues. Buprenorphine may be safer than methadone for pregnant women and their newborns, they noted. The treatment may also work as well for patients with prescription opioid dependence as for those dependent on heroin, said the authors. Access may be better, too, since buprenorphine can be prescribed in doctors’ offices rather than only in specialized treatment centers, as is the case withmethadone.

Methadone treatment also had significant value in reducing illicit opioid use and in retaining patients in treatment, said Catherine Fullerton, M.D., M.P.H., of Truven Health Analytics in Cambridge, Mass., and colleagues. Evidence for methadone treatment's effects on mortality, drug-related HIV risk behaviors, and criminal activity were less robust but still positive. However, methadone may also present risks for adverse events, including respiratory depression and cardiac arrhythmias.

Neither form of treatment appeared to be improved by the incorporation of psychosocial therapies, the authors noted. After reviewing the data, the authors of the studies, which are part of the journal's SAMHSA-sponsored "Assessing the Evidence Base" series, concluded that health officials and policymakers should expand insurance coverage of methadone and buprenorphine maintenance treatments.

To read more about buprenorphine treatment, see the Psychiatric News article, "Rule on Dispensing Buprenorphine Eased." For a comprehensive review of the use of medication in addiction treatment, see American Psychiatric Publishing's, Clinical Manual of Addiction Psychopharmacology, Second Edition and APA's website.

(Image: Brandeis University)

Tuesday, February 4, 2014

Treatment Beliefs, Support of Family Key to Vets Seeking Needed PTSD Care

Veterans’ perceptions about their need for treatment of posttraumatic stress disorder (PTSD) is a motivating factor in seeking treatment, but friends and family can also have a substantial impact on influencing their loved one to seek care. That’s the finding from the study, “Impact of Treatment Beliefs and Social Network Encouragement on Initiation of Care by VA Service Users With PTSD,” which is published online in Psychiatric Services in Advance.

Researchers at the Center for Chronic Disease Outcomes Research at the Minneapolis Veterans Affairs (VA) Medical Center conducted a prospective, national cohort study of mental health care use among by 7,645 veterans recently diagnosed with PTSD. Data from self-administered surveys and administrative databases were analyzed to assess contributions of treatment-related beliefs and social-network encouragement to seek subsequent mental health care use, after facility, demographic, need, and access factors were controlled.

VA service users who perceived a need for PTSD treatment were more likely to initiate care and to hold positive beliefs about psychotherapy or antidepressants. These veterans also showed increased odds of taking steps to receive the respective treatment. In addition, when veterans received social-network encouragement from friends or family to get mental health care, it increased the odds the vet would follow through and begin treatment.

“VA service users’ social networks, veterans’ perceptions of their need for mental health care, and their beliefs about PTSD treatment effectiveness may be fruitful targets for future treatment engagement interventions,” the researchers emphasized.

For more on this subject, see the Psychiatric News article, "What Factors Affect Chances That Vets Will Get PTSD Care?" Also see the book, Care of Military Service Members, Veterans, and Their Families, new from American Psychiatric Publishing.

(image: Tashatuvango/

One-Third of Female Inmates Appear to Meet Criteria for Serious Mental Illness, Study Shows

Almost 1 in 3 incarcerated women meet criteria for past-year serious mental illness, and almost half of this group have severe functional impairment, according to the new study, “A Multisite Study of the Prevalence of Serious Mental Illness, PTSD, and Substance Use Disorders of Women in Jail,” published online in Psychiatric Services in Advance.

Shannon Lynch, Ph.D., of Idaho State University and colleagues at four other institutions interviewed 491 randomly sampled women in jails in Colorado, Idaho, South Carolina, and the metropolitan area of Washington, D.C. Structured interviews assessed lifetime and 12-month prevalence of disorders and level of impairment. The researchers found that 43% of participants met lifetime criteria for a serious mental illness, and 32% met 12-month criteria; among the latter, 45% ;showed severe functional impairment. In addition, about 53% of subjects showed PTSD symptoms. They also assessed psychiatric comorbidity, finding that about 33% met criteria for a serious mental illness and PTSD, 38% for a serious mental illness and a co-occurring substance use disorder, and about 25% for all three in their lifetime.

“The prevalence of serious mental illness and its co-occurrence with substance use disorders and PTSD in this multisite sample suggest the critical need for comprehensive assessment of mental health at the point of women’s entry into the criminal justice system and the necessity for more programs that offer alternatives to incarceration and that can address the complexity of female offenders’ treatment need,” the researchers said.

Commenting on the study for Psychiatric News, Debra Pinals, M.D., an associate professor of psychiatry and director of forensic education at the University of Massachusetts Medical School, said "the growing rate of female offenders makes it imperative that we more thoroughly understand their challenges and behavioral health care needs. Attention to trauma histories, risk levels, and psychosocial variables related to recidivism, along with a focus on barriers to success and the impact of incarceration and offending on families and children warrant specific attention. Where serious functional impairments are identified, programs that attend to rehabilitation and support can be developed that can help these women achieve additional improvements."

For more on issues concerning mental illness in jails and prisons, see the Psychiatric News articles, "Untreated Schizophrenia Increases Risk for Violence By Inmates" and “Judges, Psychiatrists Confer on Handling Mental Illness in Justice System.”

(image: Africa Studio/


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