Friday, October 18, 2019

Risk of Heart Disease Quadruples in Women Hospitalized for Bulimia

The risk of cardiovascular disease skyrockets for women who have been hospitalized for bulimia nervosa, a study in JAMA Psychiatry reports. The risk is greatest in the first two years after hospitalization and remains high for another three years before disappearing at the 10-year mark.

“Our findings suggest that women with a history of bulimia nervosa should be informed of an increased risk of cardiovascular disease and death in the first decade after the index admission for bulimia,” wrote Rasmi M. Tith, R.D., M.P.H., of the University of Waterloo in Ontario and colleagues. “These women may benefit from screening for prevention and treatment of cardiovascular risk factors.”

The study followed more than 416,000 women for up to 12 years from 2006 to 2018. Of the patients, 818 were hospitalized for bulimia, and the rest were hospitalized for pregnancy-related events such as delivery of a live or stillborn infant, abortion, or pregnancy outside the uterus (ectopic pregnancy). The average age of the women at hospitalization was 28 years.

“The comparison group was representative of most women in the province … because 99% of deliveries and a significant proportion of other pregnancy events occur in hospitals,” the researchers wrote.

Compared with women who had been hospitalized for pregnancy-related events, women who had been hospitalized for bulimia had nearly 22 times the risk of heart attack within two years of hospitalization and more than 14 times the risk at five years. Over the entire follow-up, they had more than four times the risk of any cardiovascular disease, including six times the risk of heart attack, seven times the risk of ischemic heart disease (heart problems caused by narrowed heart arteries), and seven times the risk of atherosclerosis. They also had five times the risk of death. Those who had multiple hospitalizations for bulimia had a higher risk of cardiovascular disease and death than those who had been hospitalized only once.

The researchers noted that bulimia has been associated with metabolic changes such as changes in lipids that may affect the risk of cardiovascular disease. They added that bulimia may cause endocrine abnormalities such as low estrogen levels, which may also increase cardiovascular risk.

“Although more studies are needed, the findings from the present study suggest that bulimia nervosa, especially bulimia that requires multiple hospitalizations for treatment, may be associated with a range of cardiovascular disorders,” the researchers concluded. “Bulimia nervosa may be an important contributor to premature cardiovascular disease in women.”

For related information, see the Psychiatric News article “Brief Update and Review on Treating Eating Disorders.”

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Thursday, October 17, 2019

Transcranial Direct Current Stimulation May Effectively Treat Negative Schizophrenia Symptoms

Transcranial direct current stimulation (tDCS) appears to be an effective and safe add-on treatment for ameliorating negative symptoms in schizophrenia, such as loss of interest in everyday activities and emotional withdrawal, according to a study published yesterday in JAMA Psychiatry. This noninvasive therapy delivers weak, direct currents into the brain via electrodes placed on the scalp.

“There is an unmet clinical need for the treatment of negative symptoms in schizophrenia,” wrote Leandro da Costa Lane Valiengo, M.D., Ph.D., of the Instituto Nacional de Biomarcadores em Neuropsiquiatria Faculdade de Medicina in São Paulo, Brazil, and colleagues. “[G]iven its acceptability, tolerability, and short treatment protocol, tDCS could be evaluated as an add-on intervention for patients with schizophrenia with negative symptoms in outpatient settings.”

The double-blind, placebo-controlled, randomized trial took place from September 2014 to March 2018 in two São Paulo outpatient clinics. The 100 participants aged 18 to 55 were all diagnosed with schizophrenia using the Portuguese version of DSM-IV, had Positive and Negative Syndrome Scale (PANSS) negative symptom scores of 20 or more, and had stable positive and negative symptoms for four weeks or more. Participants received tDCS in twice-daily, 20-minute sessions over five consecutive days. A sham group went through the same procedure without receiving tDCS. A total of 95 patients completed the trial.

The participants’ symptoms were assessed at baseline, five days, two weeks, four weeks, six weeks, and 12 weeks after the treatment began. After 12 weeks, there was a 4.5-point improvement in the mean PANSS negative symptoms subscale score for patients who received tDCS, compared with a 1.8-point improvement in the sham group. Forty percent of those in the tDCS group achieved treatment response (a 20% or greater improvement in negative symptoms), compared with only 4% in the sham group. The participants had no serious adverse effects, such as acute psychosis or hospitalization, though those who received tDCS reported a burning sensation over the scalp.

“Our findings encourage the use and optimization of this technique in patients with psychotic disorders,” the authors concluded.

For related information, see the American Journal of Psychiatry article “Low-Intensity Transcranial Current Stimulation in Psychiatry.”

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Wednesday, October 16, 2019

APA Celebrates 175th Anniversary Today

APA is 175 years old today.

On October 16, 1844, 13 superintendents of U.S. institutions for people with mental illness came together in Philadelphia for a four-day meeting that led to the creation of the Association of Medical Superintendents of American Institutions for the Insane. In 1892, the Association’s name was changed to the American Medico-Psychological Association, and in 1921 it became the American Psychiatric Association.

“APA’s founders were determined to provide their patients with psychosocial care in a humane environment,” said APA President Bruce Schwartz, M.D. “They gathered to talk about the common challenges they faced and to advance treatments to improve the lives of their patients. In the 175 years since, APA and its members have worked to promote the highest quality of care for individuals with mental illness and substance use disorders.”

Over the past 175 years, APA has advanced the field of psychiatry by promoting research, advocating at the federal and state levels for equitable treatment of people with mental illness and substance use disorders, standing up for the rights of people with mental illness in the courts, and educating the public about mental illness and the effectiveness of treatment. Documents and other resources related to APA’s rich history are preserved in the Melvin Sabshin, M.D. Library & Archives at APA headquarters in Washington, D.C.

Highlights of APA’s history include the following:
  • In 1917 the American Medico-Psychological Association, working with the National Committee for Mental Hygiene, created a formal system for classifying mental illnesses. This would later become the Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952. Further revisions, most recently in 2013 with DSM-5, reflect significant scientific advances in understanding and diagnosing mental illness.
  • Throughout the 1970s and 1980s APA was instrumental in confronting the former Soviet Union over its use of psychiatric hospitals to detain political dissidents; APA has also advocated for civil rights of people with mental illness in Chile, Cuba, South Africa, and China.
  • In 1981 American Psychiatric Publishing Inc., APA’s publishing company, was created to produce books, journals, and multimedia to provide cutting-edge information to medical students, residents, and practicing psychiatrists. (APA members may access the American Journal of Psychiatry from its beginnings as the American Journal of Insanity in 1844.)
  • In 1992 APA created the American Psychiatric Association Foundation to advance mental health through educational programs in schools, workplaces, correctional institutions, and the broader community.
  • In 2008 Congress passed the Mental Health Parity and Addiction Equity Act, requiring insurers to provide coverage for treatment of mental illness and substance use disorders on the same par as that provided for general medical and surgical treatments. APA was a leading advocate for this legislation and has continued to work on ensuring the law’s enforcement.
APA kicked off celebrating its 175th anniversary during its Annual Meeting earlier this year in San Francisco. The year of commemoration concludes at the organization’s next Annual Meeting in Philadelphia in April 2020.

“We are proud to recognize our rich and deep history,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “By exploring our past, we can see how far we have come as a medical organization and the great potential we have moving forward.”

For information on APA’s founding, see the Psychiatric News article “APA’s Origins Reflected Enlightened Thinking About Care for People With Mental Illness.”

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Tuesday, October 15, 2019

Suicide Attempts by Black Adolescents Rising, Report Suggests

Between 1991 and 2017, the rate of black adolescents who reported attempting suicide rose, according to a report published Monday in Pediatrics. This trend was not seen in adolescents who identified as white, Hispanic, Asian American or Pacific Islander, or being of multiple races.

“Examining trends in suicidal ideation and behaviors over time by sex and race and ethnicity allows us to determine where to focus prevention and intervention efforts,” wrote Michael A. Lindsey, Ph.D., M.S.W., M.P.H., of New York University and colleagues.

Lindsey and colleagues analyzed data from the Youth Risk Behavior Survey (YRBS)—a national survey administered to high schoolers across the United States—from 1991 through 2017. As part of this survey, youth were asked to report suicidal thoughts and behaviors; such questions included the following: “During the past 12 months, did you make a plan about how you would attempt suicide?”; “During the past 12 months, how many times did you actually attempt suicide?”; and “Did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?”

The sample included 198,540 high school students. During the study period, the weighted overall prevalence rates of suicidal ideation, plan, attempt, and injury by attempt were 18.8%, 14.7%, 7.9%, and 2.5%, respectively, Lindsey and colleagues reported. While the analysis revealed that the rates of suicidal ideation and suicide plans by the adolescents trended downward over time across all sex and racial and ethnic groups, black adolescents experienced an increase in rates of suicide attempts.

Additional analysis revealed that self-reported suicide attempts increased at an accelerating rate in black girls (even as suicide attempts among adolescent girls overall declined), and there was a significant increase in injuries from self-reported suicide attempts in black boys.

“[O]ver time, black youth have experienced an increase in suicide attempts, which is the most prominent risk factor associated with suicide deaths,” Lindsey and colleagues wrote. They suggested that this finding may be related to disparities in access to mental health treatment and social factors disproportionately experienced by black youth, such as racial discrimination.

“Despite the recent increases in rates of suicide, black adolescents continue to have a lower suicide rate than white adolescents,” noted Benjamin N. Shain, M.D., Ph.D., of the University of Chicago in an accompanying commentary. Nonetheless, he wrote, “the increases in rates of suicide and suicide attempts by black adolescents are concerning and should influence prevention and intervention efforts. Future research should be aimed at delineating the reasons for the increases and suggesting approaches useful for clinicians, schools, and leaders in charge of health care and social policy.”

For related information, see the Psychiatric News article “Mental Health Needs of Blacks Not Being Met, Says APA President.”

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Friday, October 11, 2019

Candidates for APA's 2020 Election Announced

The APA Nominating Committee, chaired by immediate past President Altha Stewart, M.D., reports the following slate of candidates for APA’s 2020 election. This slate is considered public, but not official, until the Board of Trustees approves it at its December 2019 meeting.

David C. Henderson, M.D.
Henry A. Nasrallah, M.D.
Vivian B. Pender, M.D.

Ann Marie T. Sullivan, M.D.
Richard F. Summers, M.D.

Frank Clark, M.D.
Mark Komrad, M.D.
Michele Reid, M.D.

Area 2 Trustee
James P. Kelleher, M.D., M.B.A.
Glenn A. Martin, M.D.

Area 5 Trustee
Jenny Boyer, M.D., Ph.D., J.D.
Philip L. Scurria, M.D.

Resident-Fellow Member Trustee-Elect
Mariam Aboukar, D.O.
Aatif Mansoor, M.D.
Sanya Virani, M.D., M.P.H.

The deadline for candidates who wish to run by petition is November 15. All candidates and their supporters are encouraged to review APA’s Election Guidelines. Candidates’ photos and the addresses of their personal websites will be published in the December 20 issue of Psychiatric News.

APA voting members may cast their ballots from January 2 to January 31, 2020. For more election information, please visit the Election section of APA’s website or email

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Thursday, October 10, 2019

Changes in Depressive Symptoms at Two-Week Treatment Mark May Predict 12-Week Remission Outcomes

Whether patients with major depressive disorder show improvement (or lack thereof) at the end of their second week on an antidepressant medication may predict whether they will ultimately achieve remission at the end of 12 weeks, a study published in Psychiatric Research & Clinical Practice found.

“For any antidepressant medication trial, it is important to identify as early as possible whether the patient is likely to achieve remission …,” wrote Paul B. Hicks, M.D., Ph.D., of Texas A&M College of Medicine and colleagues. “The present study bolsters the proposed use of the lack of early improvement as a predictor of failure to achieve remission with the current medication.”

The researchers conducted a secondary analysis of data from the Veterans Affairs Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D) study, which involved 1,552 veterans aged 18 and older whose major depressive disorder was unresponsive to at least one course of antidepressant treatment. The study participants were randomly assigned to one of three medication treatment groups: augmentation with bupropion sustained release, augmentation with aripiprazole, or switch to a different antidepressant. The dosage remained relatively constant throughout the trial, though the researchers allowed adjustments to doses as early as the end of the first week. The researchers evaluated participants at baseline and at the end of weeks 1, 2, 4, 6, 8, 10, and 12.

Early improvement was defined as a drop from the baseline depression severity score of 20% or more, as measured by the Quick Inventory of Depressive Symptomatology-Clinician Rated (QIDS-C), within the first two weeks of the treatment modification. The researchers then calculated positive and negative predictive values by evaluating whether the participants showed early improvement by the end of the second week and whether they then achieved remission by the end of week 12. The values were determined by categorizing participant outcomes based on whether the patient had a true positive (they showed early improvement and achieved remission), false positive (they showed early improvement but did not achieve remission), true negative (they neither achieved early improvement nor remission), and false negative (they did not show early improvement but achieved remission).

The researchers found that early improvement in patients resulted in a positive predictive value of 38.2% and a negative predictive value of 92.6%; the latter means that if the patient does not show improvement by the end of the second week on a medication, the chance of achieving remission at the end of the 12th week is less than 8%. “The odds of achieving remission, response, and greater than minimal improvement was higher among individuals who exhibited early improvement,” the authors wrote.

They noted, however, that it is also important to analyze the characteristics of the patients who did not experience early improvement but did ultimately achieve remission by the end of the 12 weeks. Those patients were more likely to have lower baseline scores, fewer adverse childhood experiences, lower baseline Beck Anxiety Inventory Score, lower Columbia-Suicide Severity Rating Scale scores, and a higher baseline quality of life.

“A lack of early improvement at the end of week 2 of antidepressant therapy can be used to inform clinical decisions on the likelihood of nonremission of depression during the subsequent 10 weeks, even when dosage optimization is incomplete,” the authors concluded.

For related information, see the American Journal of Psychiatry article “General Predictors and Moderators of Depression Remission: A VAST-D Report.”

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Wednesday, October 9, 2019

Bacterial Infection in Pregnancy Linked to Psychosis in Offspring as Adults

Children of mothers who contract a bacterial infection such as pneumonia during pregnancy are significantly more likely to have a psychotic disorder in adulthood compared with those not exposed to infection in utero, according to a report in AJP in Advance.

The risk of psychosis in adulthood is even greater when pregnant women have an infection that impacts multiple body systems such as sepsis and is especially high for males.

Lead author Younga H. Lee, Ph.D., of Brown University and colleagues said more research with larger sample sizes could help uncover how gestational bacterial infection may directly or indirectly cause adult psychosis. “If replicated, our findings would also call for public health and clinical efforts that focus on preventing and managing bacterial infection in pregnant women,” they wrote.

Lee and colleagues analyzed data on 15,421 live births between 1959 and 1966 in Boston and Providence, R.I., as part of the Collaborative Perinatal Project (now known as the New England Family Study). Information about exposure to bacterial infection was recorded during perinatal visits beginning at the time of registration for prenatal care, at intervals of four weeks during the first seven months of pregnancy, every two weeks at 8 months, and every week thereafter until birth.

Of 15,421 cohort mothers in the sample, 3,499 (23%) had bacterial infection; of these, 3,191 (21%) had localized infections, 399 (3%) had multisystemic infections, and 91 (<1%) had both. Localized bacterial infections included tuberculosis (n=8); pneumonia (n=83); syphilis (n=66); gonorrhea (n=15); and kidney, ureter, and bladder infections (n=1,203); and vaginitis (N=2,136).

A total of 116 offspring were diagnosed with a psychotic disorder in adulthood.

Offspring of mothers who experienced a multisystemic infection were almost three times as likely to have a psychotic disorder in adulthood compared with those whose mothers experienced no infection. Offspring of mothers who had any kind of infection during pregnancy—localized or multisystemic—were 1.8 times as likely to have a psychotic disorder as those whose mothers had no infection.

The risk was especially high for males; male offspring of mothers who experienced a multisystemic infection during pregnancy had a five times greater risk of psychosis than males whose mothers did not have infection, and nearly three times the risk of psychosis when mothers had had any kind of bacterial infection.

A large body of research has implicated viral infections during pregnancy in psychosis among offspring; the new AJP study extends that work to bacterial infections. “These findings could be an important first step to motivating large-scale national register-based investigation” of the role of both viral and bacterial infections in psychosis, the researchers wrote.

For related information, see the Psychiatric News article “Maternal Infection, Later Childhood Infection Linked to Psychosis in Offspring.”

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Tuesday, October 8, 2019

Study Highlights Long-Term Benefits of Deep Brain Stimulation for Refractory Depression

Deep brain stimulation (DBS) of a region called the subcallosal cingulate appears to be safe and effective at reducing symptoms of depression in patients with treatment-resistant depression over time, according to a small study in AJP in Advance.

Previous studies suggest that up to one-third of all patients with major depression have treatment-resistant depression (that is, they fail to experience symptom improvements during two or more antidepressant trials). “Given that patients with treatment-resistant depression are highly susceptible to recurrent depressive episodes, the ability of DBS or any treatment to support long-term maintenance of antidepressant response and prevention of relapse in severe and intractable depression would be an important treatment advance,” wrote Andrea Crowell, M.D., of Emory University School of Medicine and colleagues.

Crowell and colleagues analyzed long-term follow-up data from an open-label trial of 28 patients aged 27 to 65 who underwent subcallosal cingulate DBS surgery. (The subcallosal cingulate is a small brain region rich in serotonin transporters that is believed to be a key regulator of mood.) Of this group, 20 had been diagnosed with major depressive disorder, and seven had been diagnosed with bipolar II disorder; one patient in the major depression subgroup was later reclassified as having bipolar II disorder. To be included in the trial, patients were required to have a score ≥20 on the 17-item Hamilton Depression Rating Scale (HAM-D) and a score <50 on the Global Assessment of Functioning Scale (GAF). Patients with a history of psychosis, personality disorders, or imminent risk for suicide were not included in the trial.

A psychiatrist evaluated study participants weekly for 32 weeks, beginning about four weeks prior to DBS surgery. After this point, a psychiatrist assessed study participants every six months for two to eight years. All 28 participants who underwent DBS surgery completed at least one year of follow-up. Fourteen participants completed at least eight years of study participation.

After two years, the average HAM-D scores of the patients dropped by over 50% (from about 23 to 10) and remained steady over the remaining years. Likewise, the average GAF score rose from about 34 (indicating major impairment in several areas of functioning) to 70 (indicating mild symptoms but with overall good functioning) after two years and remained steady. Crowell and colleagues noted that 20 participants (71%) “demonstrated consistent improvement of ≥25% from baseline depression severity ratings throughout the study. … Among the eight patients with bipolar disorder, five showed a favorable response pattern, and three exhibited limited antidepressant response over time.”

While no adverse events were attributable to acute or chronic stimulation, 19 serious adverse events were related to surgery, or 0.7 events per participant—a medical complication rate “comparable to that seen with DBS for other indications,” they continued.

Crowell and colleagues concluded, “Identifying factors associated with long-term response is an important next step in [subcallosal cingulate] DBS research. … Beyond this, more qualitative studies of DBS patient characteristics and the quality of patients’ experience of depression before and after DBS are needed in order to optimize patient selection for DBS in the [subcallosal cingulate] and other brain targets.”

For more on deep brain stimulation, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Deep Brain Stimulation and Cognitive Outcomes Among Patients With Parkinson’s Disease: A Historical Cohort Study.”

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Monday, October 7, 2019

Psychiatrists Can Do More to Help Patients Quit Smoking, Addiction Experts Say

Several medications are proven to help people stop smoking, but few patients with tobacco use disorder are being offered them, according to addiction experts at APA’s IPS: The Mental Health Services Conference in New York.

Despite the higher rates of smoking by people with mental illness compared with those without mental illness, only a quarter of facilities that treat patients with substance use disorders in the United States offer nicotine replacement therapy or medication treatment, and two-thirds allow tobacco use on their grounds, explained session chair Michael Brus, M.D., a clinical instructor of psychiatry at Icahn School of Medicine at Mount Sinai, during the session “The Deadliest Drug Epidemic: How Psychiatrists and the Media Miss the Boat on Tobacco Addiction, and What to Do About It.” Brus called for psychiatrists to do more to address tobacco use in this population.

To help patients successfully quit tobacco, Jill Williams, M.D., director of the Division of Addiction Psychiatry at the Rutgers University-Robert Wood Johnson Medical School, said psychiatrists should regularly ask patients about their tobacco use, and if they do use tobacco, advise patients on the risks of such use and refer them to treatment such as behavioral counseling.

Psychiatrists should also strongly consider prescribing smoking cessation medications, including varenicline, which is underused despite strong evidence of safety and efficacy.

Brus highlighted a 2016 study known as EAGLES that found varenicline to be superior to bupropion and the nicotine patch in helping smokers achieve abstinence (the study did not show a significant increase in adverse psychiatric events in patients taking varenicline compared with those with nicotine patch or placebo). Yet in the three years since that study, prescription rates of varenicline have ticked up only marginally, Brus said.

Williams highlighted another study that found that varenicline could promote smoking abstinence even in patients whose initial goal was only to reduce their smoking levels. “There’s also evidence that varenicline can lessen dependence and reduce withdrawal symptoms, so prescribing this medication can be a useful harm-reduction strategy even in people not looking to quit,” she said.

For psychiatrists who may still have concerns with varenicline, Brus and Williams pointed out that combination nicotine replacement (combining a long-acting patch with rapid-acting lozenges or gum) has been shown to be as effective as varenicline when combined with counseling. The current data are inconclusive about whether a combination of varenicline plus nicotine replacement therapy promotes better abstinence than either treatment alone. There is emerging evidence that varenicline plus bupropion may elevate quit rates, but more research is needed.

For related information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco” and the Psychiatric Services article “Low-Burden Strategies to Promote Smoking Cessation Treatment Among Patients With Serious Mental Illness.”

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Friday, October 4, 2019

E. Fuller Torrey, M.D., Details Mistakes That Led to Today’s Public Mental Health Crisis

American psychiatry and the public mental health system must work to correct policy mistakes of the past that have led to today’s public health travesty: criminalization of people with mental illness by placing them in jails and prisons and the failure to treat homeless individuals with serious mental illness (SMI).

So said E. Fuller Torrey, M.D. (pictured above), the keynote speaker at yesterday’s Opening Session of APA’s IPS: The Mental Health Services Conference in New York. Torrey, the founder of the Treatment Advocacy Center and associate director for research at the Stanley Medical Research Institute, has been a fierce advocate for people with SMI for five decades.

During his address, he detailed a history of tragic public policy blunders that led to the current crisis: the emptying of state psychiatric hospitals, passage of the Community Mental Health Act (CMHA) with no mandated provisions for care after people with SMI were discharged from state hospitals, and federal financial incentives that encouraged states to abdicate responsibility for this population.

“In summary, we emptied the state hospitals and provided federal fiscal incentives to make sure it happened,” Torrey said. “We began a new program of community mental health centers that was targeted to prevent mental illness but ignored patients being discharged from the state hospitals. And we partially federalized what had been a state and county responsibility with no provisions for the most seriously mentally ill.”

Torrey drew attention to a grim irony: The founders of APA 175 years ago were concerned about and discussed the practice of locking up people with mental illness in jails and prisons. These discussions were instigated by Dorothea Dix, who had been outraged by what she saw when she toured the prisons of Massachusetts. This year, Torrey said, a detention center in Georgia became the first jail to be accredited as a mental health facility by the National Commission on Correctional Health Care.

Torrey wondered, “What would Dorothea Dix say of us today?”

He emphasized that the motives that led to deinstitutionalization were good. And he noted that the process of emptying the state hospitals did not begin with the CMHA but with the introduction of chlorpromazine (Thorazine). However, he said, the vast majority of community mental health centers created by the CMHA, having no mandates to treat discharged patients, operated as private psychiatric clinics focused on prevention rather than treatment.

Torrey said IPS is a crucial venue for addressing the problems created by the past and looked to young psychiatrists in the audience for solutions. “Rarely have so many well-meaning people been so wrong,” Torrey said. “My generation made major mistakes in emptying the state hospitals without thinking about how to treat the seriously mentally ill in the community. It is up to the next generation to solve those problems.”

For related information, see the Psychiatric News articles “Mental Illness in America’s Jails Also Made Headlines 50 Years Ago” and “Signs of Problems With Access: Homelessness and Incarceration.”

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Thursday, October 3, 2019

Early Psychosis Treatment Succeeding but Challenges Remain for Sustainability

Early treatment of psychosis has moved out of the research arena into on-the-ground community practice, said Lisa Dixon, M.D., a professor of psychiatry at Columbia University and editor of the APA journal Psychiatric Services. She spoke yesterday at the “Early Psychosis Preconference” held in conjunction with APA’s IPS: The Mental Health Services Conference in New York.

There has been success reaching patients in need and improvements in the course of their illness and treatment outcomes, but achieving long-term sustainability is a challenge for early psychosis programs, requiring advocates to pay attention to public health policy, funding, and reimbursement. “In order to be successful, we must of course focus on patient care. But we need to do more,” Dixon said.

The preconference brought together some 350 mental health professionals involved in the identification and treatment of individuals with psychosis and included a rich variety of presenters.

Dixon presented an overview and evaluation of OnTrackNY, a program of the Center for Practice Innovations at Columbia University/New York State Psychiatric Institute and the New York State Office of Mental Health. Established in 2013, it now includes 23 sites in New York state and serves individuals aged 16 to 30 who have experienced nonaffective psychosis for less than two years.

OnTrackNY is one of the most well-established early psychosis programs in the United States, according to Dixon. Using a framework developed by health services researchers to evaluate program implementation known as RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), Dixon noted some of the lessons learned from the program to date:

Reach: OnTrackNY has served over 1,600 patients since 2013; the program has the capacity to care for 900 patients at a time. “While the growth of OnTrackNY has been remarkable, the actual need may be closer to 2,000 slots based on assumptions about the incidence of schizophrenia and nonaffective psychosis,” Dixon said.

Effectiveness: Rates of participation in treatment, data on rehospitalization, work and school status, and overall functioning are positive, but there is substantial variability across clinics. Also, more needs to be done to identify and help patients with poorer outcomes.

Adoption: The program has thrived in a diversity of sites and locations across the state, but the ability to serve individuals in rural areas remains a challenge.

Implementation: OnTrackNY developed training models to ensure “fidelity,” or the ability of clinics to abide by a model of treatment standardized across sites. Most teams within OnTrackNY have met that standard; the most common unmet domains are metabolic screening of patients and use of peer supports.

Maintenance: OnTrackNY has been fortunate in having the financial support of the state, but long-term funding remains a challenge. There is a need for a more systematic approach to discharge patients, step-down to less intensive services, and long-term follow-up.

“Progress in the implementation of early intervention programs for individuals experiencing early psychosis is palpable,” Dixon said. “The lessons learned inspire strategies for ongoing improvement.”

More coverage of the early psychosis conference and IPS will appear in future issues of Psychiatric News.

For related information, see the Psychiatric Services article “Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes.”

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Wednesday, October 2, 2019

Children Living With Undocumented Parents May Need Additional Support

Children living in the United States with undocumented parents are at heightened risk of poverty, food insecurity and malnourishment, and adverse childhood experiences compared with their peers. Such adverse experiences include parental arrest and deportation, which can increase the rates of posttraumatic stress disorder, anxiety, and depression in these youth.

“Health care providers who work with the children of undocumented immigrants must be aware of the [many] vulnerabilities [these children face] to provide holistic, comprehensive, compassionate, and effective care,” wrote Shawn S. Sidhu, M.D., of the University of New Mexico and Suzan J. Song, M.D., M.P.H., Ph.D., of George Washington University Medical Center in an article in the October Journal of the American Academy of Child & Adolescent Psychiatry

The authors highlighted several clinical considerations to keep in mind when working with this patient population:

  • Communication is key to working with children of undocumented parents and their families. “The ease of efficient communication is critical to forming a therapeutic alliance with families, and bilingual mental health providers and/or easy access to high-quality interpreter services can help to facilitate communication with families.”
  • Knowledge of a family’s immigration status can help with treatment planning, but such conversations need to be carried out “in a careful and thoughtful way,” as forcing the issue could cause fear for children and their parents, the authors advised. “Providers can explain their rationale in asking this information so that additional referrals for services can be made for the family. Child and adolescent psychiatrists should explain that immigration status is protected information under the Health Insurance Portability and Accountability Act (HIPAA), and that child and adolescent psychiatrists do not have any legal mandate to report this information.”
  • The clinical care of the children of undocumented parents will likely involve family therapy. “The trauma experienced by the children of undocumented parents is transgenerational and historical in nature. Thus, a family-centered approach, which could include components of family therapy, allows the entire family unit to heal simultaneously while enhancing the family’s ability communicate with one another and support one another through difficult transitions.”

“Many undocumented parents and their children may refrain from speaking out for fear of retaliation, and therefore their voices may not be heard at a local and national level. This may especially be the case in areas where immigration raids, arrests, detention, and deportation are more prevalent,” Sidhu and Song wrote. “Physicians can play an effective role in advocating for policies that promote the mental health and wellness of children residing with undocumented parents in America.”

For more on actions being taken by psychiatrists to support immigrant families, see the Psychiatric News article “Grassroots Movement of Psychiatrists Arises to Support Asylum-Seeking Families,” by Shawn Sidhu, M.D. For related information, see the Psychiatric Services article “Caring for Families Separated by Changing Immigration Policies and Enforcement: A Cultural Psychiatry Perspective.”

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Tuesday, October 1, 2019

Use of Consultation-Liaison Psychiatry May Reduce Hospital Patients’ Length of Stay

The use of proactive consultation-liaison psychiatry, along with clinically informed screening and integrated mental health care delivery, appears to help reduce patients’ average length of stay in the hospital, according a report in General Hospital Psychiatry.

“The unmet need for psychiatric care in the general hospital is substantial and compromises the quality and delivery of care,” wrote Mark Oldham, M.D., of the University of Rochester Medical Center and colleagues. “Proactive mental health screening offers an opportunity for timely identification and clinical attention to improve outcomes.”

Researchers systematically reviewed studies from Pubmed, Embase, PsycINFO, and Cochrane Library published through May 2019, seeking studies that examined how early mental health screening of hospitalized adults impacted patients’ length of stay. Though initially yielding 738 results, only 12 studies were included in the systematic review after researchers “evaluated the level of evidence and defined the study sample, means of group allocation, screening process, interventions, and outcomes.”

The studies used various screening and intervention methods for patients. In some, psychiatrists met with all patients in a given setting, such as after hip fracture surgery, while in others, patients were identified using standardized instruments as needing mental health care. In most studies, the intervention “was a formal psychiatric consultation by services variously staffed by psychiatrist, trainees, nurses, and research personnel.”

Most of the studies reported reduced length of stay for patients; two studies also reported “favorable returns on investment that more than offset the increased costs of providing this level of enhanced care,” Oldham and colleagues wrote. While the authors noted that “the heterogeneity across study designs makes it difficult to attribute this to any one study element in isolation,” they added that three interrelated elements of each of the studies appear to be tied to positive outcomes: “screening that draws upon mental health care expertise, integrated care delivery, and unit- or service-level analysis.”

“All studies investigating models wherein care delivery was integrated with primary services—either as embedded psychiatrists or multidisciplinary team-based care—reported either a statistical reduction in LOS [length of stay] or a trend in favor of reduced LOS,” they wrote.

For more information, see the Psychiatric News article “The Role of C-L Psychiatrists in Caring for Cardiac Patients.”

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