APA Refutes PLoS Article on DSM-5 Conflict-of-Interest

An article in the online journal Public Library of Science (PLoS) has misrepresented facts about conflicts of interest among members of the DSM-5 Task Force and work groups, according to APA. And it has ignored the extent to which industry influence has been eliminated or greatly reduced because of strict financial disclosure requirements mandated by APA.

In a statement, APA President John Oldham, M.D., said the article “does not take into account the level to which DSM-5 Task Force and work group members have minimized or divested themselves from relationships with the pharmaceutical industry.”

The article, “A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations With Industry: A Pernicious Problem Persists,” can be accessed here. Oldham’s response is on the APA Web site here. For information about the DSM-5 financial disclosure policy, see Psychiatric News here.

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High Court to Vote on Constitutionality of Individual Insurance Mandate

The U.S. Supreme Court will vote today on the constitutionality of the individual insurance mandate in the Patient Protection and Affordable Care Act (PPACA)—but the outcome will not likely be made public until later this year. The Court wrapped up a week of hearings on the mandate, which requires individuals to buy health insurance or pay a penalty, and on other aspects of the PPACA that have been challenged on constitutional grounds.

The hearings, which received around-the-clock coverage in the media, seemed to indicate that the nine justices—five conservatives and four liberals—would split along ideological lines. But as the Washington Post reports today, sometimes the tone of hearings can be misleading in terms of predicting the ultimate decision. The Post reports that the Court's decision will likely be made public in June. 

For information about legal challenges to the PPACA see Psychiatric News here. Also, American Psychiatric Publishing has published “Health Care Reform: A Primer for Psychiatrists,” see information about it here.

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Webinar to Review Results of Opioid Addiction Treatment Study

The Physicians’ Clinical Support System-Buprenorphine (PCSS-B) will present a webinar on April 10 from noon to 1:00 p.m. (EST) titled "The Use of Buprenorphine in the Treatment of Prescription Opioid Dependence." The webinar will be given by Roger Weiss, M.D., a professor of psychiatry at Harvard University and chief of the Chief, Alcohol and Drug Abuse Treatment Program at McLean Hospital.

This webinar will review results of the Prescription Opioid Addiction Treatment Study (POATS), the first large-scale treatment study for patients dependent on prescription opioids. POATS, which was conducted under the auspices of the National Institute on Drug Abuse Clinical Trials Network, studied combinations of different lengths of buprenorphine and different intensities of counseling to treat 653 patients dependent on prescription opioids. The presentation will review the design of the study, the main outcomes, and the role of chronic pain and a history of heroin use as prognostic factors. The PCSS-B is operated by the American Academy of Addiction Psychiatry, the American Osteopathic Academy of Addiction Medicine, and APA with funding from the Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment.

Register for the webinar here, and visit www.pcssb.org/ for a variety of clinical resources, including recordings of previous webinars.

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FDA Clarifies Dosing and Warning Recommendations for Celexa

The Food and Drug Administration (FDA) issued an announcement yesterday to clarify dosing and warning recommendations for the antidepressant Celexa (citalopram; also available in generic form). In August 2011, the FDA issued a Drug Safety Communication stating that citalopram should no longer be used at doses greater than 40 mg per day because it could cause potentially dangerous abnormalities in the heart's electrical activity. Citalopram use at any dose is discouraged in patients with certain conditions due to risk of QT prolongation, but because it may be important for some of those patients to use citalopram, the drug label has been changed to describe the caution needed when citalopram is used in such patients. The revised label also advises that the maximum recommended dose of citalopram should be 20 mg per day for patients who have hepatic impairment, are over age 60, are CYP 2C19 poor metabolizers, or are taking concomitant cimetidine (Tagamet) or another CYP2C19 inhibitor, because these factors lead to increased blood levels of citalopram, increasing risk of QT interval prolongation and Torsade de Pointes.

Read the FDA Drug Safety Communication here.

In March of last year, the Pfizer subsidiary Greenstone announced a voluntary recall of some lots of its generic citalopram because some bottles labeled as citalopram actually contained the drug finasteride, used to treat benign prostatic hyperplasia. Read more about it in the Med Check column of Psychiatric News, here.

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Some Develomental Problems May Lead to Mental Ones

Children diagnosed with probable developmental coordination disorder (DCD) at age 7 have an increased likelihood of having mental health problems by age 9 or 10, according to a study by British and Dutch researchers in the April issue of Pediatrics. They analyzed data on 6,902 children from the Avon region in Britai, and found 346 with functional limitations in activities of daily living or handwriting. They excluded children with neurological or other medical problems or low IQ scores. Children with probable DCD were twice as likely to report depression, and their parents were four times more likely to say their children had mental health difficulties than other children.

“Children with DCD need to be screened for mental health difficulties,” concluded the authors. “Interventions focusing on increasing self-esteem, tackling bullying, and enhancing social interaction may alleviate some of the risk of depression and behavioral difficulties in children with DCD.”

For more about developmental coordination disorder, see Concise Guide to Child and Adolescent Psychiatry, Fourth Edition, from American Psychiatric Publishing.

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Disasters Cause Symptoms in Therapists of Victims

A small exploratory study of clinicians who provided mental health services after the September 11, 2001, terrorist attacks in New York found that they experienced “intense and unprecedented” secondary traumatic stress symptoms. Those symptoms may arise when psychiatrists, social workers, psychologists, or other therapists react to their exposure to the pain and suffering of others.

“[Symptom] levels among clinicians who provided care to victims of 9/11 were high 30 months after the attacks,” wrote Mary Pulido, Ph.D., of the New York Society for the Prevention of Cruelty to Children in the U.S., published online in the Clinical Social Work Journal.

Pulido attributes some of these reactions to a lack of experience in disaster relief mental health care. “For many professionals, these interviews, conducted several years after the attacks, served as the first time they had discussed their 9/11 work and the stresses they encountered,” said Pulido. “This factor alone speaks volumes for the lack of support that they received while providing such intense clinical support for their clients.”

For more about preparing for and responding to mental health aspects of disasters, see the American Psychiatric Publishing book, DisasterPsychiatry: Readiness, Evaluation, and Treatment.

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Concern Raised Over Sequelae of Synthetic Marijuana Use

Psychiatrists who hear from patients or other individuals that synthetic marijuana is a safe product might want to refer them to a study in the April issue of Pediatrics suggesting that this is far from the case. In fact the American Association of Poison Control Centers has said that in 2010-2011 it logged about 4,500 calls related to use of these synthetic cannabinoids, which have in the past been sold in convenience stores, gas stations, and online under names such as K2, Spice, and Blaze. The Pediatrics report presents case studies of adolescents who suffered severe sequelae after smoking or ingesting one of these products and discusses symptoms of synthetic cannabinoid intoxication and how the products act on the brain and neurotransmitters. The researchers note that "Recognition of signs and symptoms of patients with synthetic cannabinoid ingestion can help physicians who treat adolescents be better prepared to diagnose and manage patients presenting with this toxicity."

See the Med Check column in the next issue of Psychiatric News for an update on the Drug Enforcement Administration's emergency decision to extend control of these products as Schedule I subtances.

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ADHD Diagnoses Rise 66 Percent Over 10-Year Period

In 2010, 10.4 million children and adolescents were diagnosed with attention-deficit/hyperactivity disorder (ADHD) during an outpatient visit, a substantial jump from the 6.2 million ADHD diagnoses made in 2000. These data come from a new study published in the March/April Academic Pediatrics. For the study, Craig Garfield, M.D., of Northwestern University led a team of researchers in reviewing ADHD diagnosis and treatment data from the IMS Health National Disease and Therapeutic Index. The rise in ADHD diagnoses has been accompanied by an increase in the treatment of these patients by specialists, such as child psychiatrists, rather than primary care physicians, the researchers found. Garfield noted in an interview with HealthDay that the surge in ADHD diagnoses may be attributable to increased public awareness and media coverage of the disorder and to pharmaceutical companies advertising products to treat ADHD. Read more about the increasing number of ADHD diagnoses in Psychiatric News.

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Experimental Gene Therapy Studied for Rett Syndrome

A potential therapeutic approach for Rett syndrome, an autism spectrum disorder, was published March 18 in Nature. Since a mutation in a gene called the MECP2 gene causes Rett syndrome, scientists transplanted bone marrow from healthy mice, which expressed a healthy MECP2 gene, into mice modeled to have Rett syndrome. The treatment was found to reduce disease symptoms, such as breathing and movement abnormalities, as well as to increase the lifespan of the mice.

More information about Rett syndrome and other autism spectrum disorders, as well as experimental and alternative therapies for them, can be found in American Psychiatric Publishing's Textbook of Autism Spectrum Disorders. To read proposals for changes to diagnostic criteria for autism spectrum disorders in the next edition of APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), see Psychiatric News.

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Abnormalities Found in Brains of Children at Risk for Schizophrenia

Children at risk for schizophrenia because of having a parent with the illness have been found to have disordered brain networks, scientists report in the March Archives of General Psychiatry. They examined the brains of children who had a parent with schizophrenia, as well as the brains of children who did not, while the children looked at pictures of human faces. Those with a parent who had schizophrenia were found to have reduced and disordered neural network responses compared with the other children.

"Our results...provide direct evidence of dysfunctional interactions within the corticolimbic network...that may reflect the effects of vulnerabilility genes for schizophrenia...," the scientists concluded. Yet whether the children with the abnormal network responses will eventually develop schizophrenia remains to be determined.

Much more information about the biology and other aspects of schizophrenia can be found in the new book Essentials of Schizophrenia, from American Psychiatric Publishing. Read about other issues involved in schizophrenia risk in Psychiatric News.

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APA Supports Liability Relief Bill Passed by House

APA is supporting the Help Efficient Accessible Low-cost Timely Healthcare Act (H.R. 5) which was approved by the House of Representatives yesterday. In a memorandum sent to the APA Board of Trustees yesterday, APA’s Division of Government Relations (DGR) said H.R. 5 will provide needed relief for physicians burdened by medical malpractice insurance costs by capping noneconomic damages at $250,000. An amendment was also adopted that would grant liability protection to health professionals who volunteer at federally declared disaster sites. 

The bill was combined with the Medicare Decisions Accountability Act (H.R. 452) which, as reported by Psychiatric News Alert this morning, would eliminate the Medicare Payment Advisory Board established under the health care reform law. “APA has expressed significant concern regarding the controversial panel, which will have unprecedented power to make cuts in Medicare physician reimbursement without congressional approval or appropriate oversight,” DGR said in its memo to the Board. For more information about APA's support of medical liability reform, see Psychiatric News here.

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AMA Applauds Vote to Eliminate Medicare Payment Board

The AMA is applauding a vote by the House of Representatives yesterday to eliminate the Independent Payment Advisory Board (IPAB), established in the health reform law to set payment policies for the Medicare program. AMA President-elect and past APA Assembly Speaker Jeremy Lazarus, M.D., said that while the AMA continues to support the health reform law, “elimination of the IPAB is an important change that must be made.

In a statement yesterday Lazarus said, “This new, arbitrary system is not what we need when patients and physicians are already struggling with a looming cut of nearly 30 percent from the broken Medicare physician payment formula. Ending the ongoing threat of drastic cuts from the physician payment formula and preventing new cuts from IPAB are important first steps to stabilize the Medicare system for patients.” The Senate has yet to vote on IPAB, and its fate there is uncertain.

When Lazarus was running for AMA president, he told Psychiatric News, "Physicians are already subject to an expenditure target and other potential payment reductions as the result of the Medicare physician payment formula. We don't need another expenditure target." For more information see Psychiatric News, here.

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Study Provides Clues for Designing New Anti-Addiction Medications

Scientists are one step closer to developing anti-addiction medications with new research that provides a better understanding of the properties of the kappa opioid receptor (KOR), the only member of the opioid receptor family whose activation counteracts the rewarding effects of addictive drugs. Because the KOR is not associated with the development of physical dependence or the abuse potential of opiate drugs such as heroin and morphine, medications that act at the KOR could have broad therapeutic potential. The leading therapeutic compound is JDTic; its specific binding to the KOR has been shown to reduce relapse to cocaine seeking in animal models. JDTic is in clinical trials to assess its safety and tolerability in humans.

Now, researchers based at the Scripps Research Institute in La Jolla, Calif., have produced a high-resolution three-dimensional image of JDTic bound to the human KOR. The emerging picture reveals critical new information that helps explain why JDTic binds so tightly and specifically to this particular opioid receptor. Their findings were published online March 21 in Nature.

“Drug abuse and addiction remain devastating public health challenges in the United States,”  “This research could aid in the development of effective medications for the treatment of drug addiction, particularly to stimulants like cocaine," said NIDA Director Nora Volkow, M.D.

To read about another medication that shows promise for treating opioid addiction, see Psychiatric News here.

(Image: Yekaterina Kadyshevskaya, The Scripps Research Institute)

Cancer Survivors Have Lower Alzheimer’s Risk

New results from the Framingham Heart Study suggest that cancer survivors have a lower risk of developing Alzheimer’s disease. Researchers reported online March 12 in the BMJ the results of their 1986 to 1990 study of 1,278 participants with and without a history of cancer who were aged 65 or older and free of dementia at baseline. They concluded that cancer survivors had a lower risk of Alzheimer’s disease than those without cancer, and patients with Alzheimer’s disease had a lower risk of incident cancer. The risk of Alzheimer’s disease was lower in survivors of smoking-related cancers and was not primarily explained by survival bias. “This pattern for cancer is similar to that seen in Parkinson’s disease and suggests an inverse association between cancer and neurodegeneration,” said the researchers.

Learn more about the neurodegeneration associated with Alzheimer’s disease in the Clinical Manual of Alzheimer Disease and Other Dementias, available from American Psychiatric Publishing here.

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Scientists Pinpoint Site in Brain for Rare Personality Disorder

National Institute of Mental Health scientists have pinpointed the site in the brain of a rare genetic disorder that makes those who have it both too friendly and too anxious. Williams syndrome is caused by a deletion of genes that are important for migration and maturation neurons in the brain. Combining genetics, brain scans, and personality rating scales tied abnormalities in brain structure to overt symptoms, wrote Karen Berman, M.D., and colleagues in the Proceedings of the National Academy of Sciences, published online March 12.

Magnetic resonance imaging revealed that patients had less gray matter in the bottom front of the insula, an area that integrates mood and thinking. However, they also had increased gray matter in the top front part of the insula, a region linked to social/emotional processes. Other imaging systems tracked abnormal activity patterns in the brain. “[T]hese genetically determined alterations of anterior insula structure and function predicted the degree to which the atypical Williams syndrome personality profile was expressed in participants with the syndrome,” concluded Berman.

To read more about neuroimaging and anxiety disorders in the American Journal of Psychiatry, click here.

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War Veterans Unfairly Mislabeled as "Dangerous"

The idea of the “dangerous” war veteran, disabled by posttraumartic stress disorder (PTSD), appears to be making a comeback. A staple of popular media and public opinion after the Vietnam War, the image has only minimal basis in reality but still hampers job prospects for troops returning from Iraq and Afghanistan, according to an article on the Department of Veterans Affairs’ (VA) blog.

Only a small minority of veterans have broken the law, but since only 1 percent of the U.S population has served in uniform in recent years, too many civilians only know about military personnel through often-sensationalized headlines. "As long as such language remains prevalent and acceptable, college admission offices [and] future employers. . .can peg todays veterans as ‘running amok’. . .widening the divide further between veterans and civilians,” said the author.

VA officials emphasize that treatment for PTSD and other war-related problems can help returning vets adjust to a productive place in civilian life.

To read more in Psychiatric News about public-health approaches to treating returning troops for PTSD and other conditions, click here.

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Finding a Piece of the ECT Puzzle

Psychiatrists have for decades successfully used electroconvulsive therapy (ECT) to treat severe depression that fails to respond to medication therapy, but precisely how it improves depression symptoms has remained a mystery. Researchers in Scotland report in the Proceedings of the National Academy of Sciences that they may have uncovered an answer, namely that it downregulates average global connectivity in the left dorsolateral prefrontal cortical region, an area that has been linked to major depression. It also decreased connectivity of brain networks in this region. Using fMRI scans, they found that this downregulation occurred at the same time the patients were experiencing depressive symptom improvement. The authors suggest that "a mechanistic understanding of ECT could allow researchers to replicate its therapeutic effects in a less-invasive fashion."

Read more about the use of ECT to treat severe depression in Psychiatric News, and for an in-depth review of ECT treatment see American Psychiatric Publishing's Clinical Manual of Electroconvulsive Therapy.

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Medicare Beneficiaries Benefit From Shrinking Donut Hole

More than 5.1 million Medicare recipients saved over $3.2 billion on prescription drugs in 2011 as a result of health reform measures, including $106 million in savings on psychiatric medications. This according to a recent announcement from Health and Human Services Secretary Kathleen Sebelius. The savings included a $250 rebate check to beneficiaries who hit the Medicare Part D coverage gap—commonly referred to as the “donut hole”—in 2010, as well as a 50 percent discount on covered brand-name drugs in the donut hole in 2011, said Sebelius. Read more about Medicare Part D and how its implementation has led to a decreased reliance on inpatient care in Psychiatric News.

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Lithium Boosts Clock Rhythms

For many years, lithium has been a mainstay treatment for bipolar disorder. But exactly how it benefits bipolar patients has not been clear. Now scientists have found, in cell/tissue studies, that lithium increases the amplitude, or strength, of body-clock rhythms. "Our findings...offer a novel explanation as to how lithium may be able to stablize mood swings in bipolar patients," the researchers wrote in a press release accompanying the publication of their paper March 12 in PLoS One.

Furthermore, lithium's biological and psychological benefits may not be limited to people with bipolar disorder. Two other studies have found that lithium in drinking water may be able to provide some protection against suicide. For more information about these studies, see Psychiatric News. For an in-depth review of the latest knowledge about lithium and other treatments for bipolar disorder, see American Psychiatric Publishing's Handbook of Diagnosis and Treatment of Bipolar Disorders.

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Warm Temperatures May Harm Cognition in People With Multiple Sclerosis

Although the disease process in multiple sclerosis often becomes more active during warmer months, scientists have now found that warmer outdoor temperatures may impair the cognition of individuals with multiple sclerosis as well. The study, which appeared March 7 in Neurology, included 40 individuals with multiple sclerosis and 40 healthy controls over a calendar year. The former were found to perform significantly worse on tasks involving processing speed and memory on warmer days than on cooler ones. This was not the case for healthy controls.

Other studies have also suggested that various weather and climate factors can unfavorably impact mental health. For example, in one study, scientists linked suicides with a lower barometric pressure and with air pollutants such as sulfur and ozone. For more information about this study, see Psychiatric News .

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Psychosis-Like Symptoms in Some Depressed Patients Call for New Approach

When is psychosis not psychosis? Perhaps when psychosis-like symptoms show up in depressed patients from a specific ethnic group.

A review of 37 published articles found that 22% to 46% of depressed Latino patients experience atypical psychotic symptoms such as mild auditory or visual hallucinations, or paranoia, wrote psychiatrists Paolo Cassano, M.D., Ph.D., Maurizio Fava, M.D., and David Mischoulon, M.D., Ph.D., of Massachusetts General Hospital in the March 15 Psychiatric Services in Advance. Just 9.5 percent of Latinos in general have those symptoms during their lifetimes. Psychosis-like symptoms were associated with more medical and psychiatric illness, as well as greater suicidality, functional impairment, and utilization of services.

So should clinicians treating depressed Latino patients augment antidepressants with an antipsychotic? The . . . atypical psychotic symptoms experienced by Latinos with major depressive disorder are nonpsychotic manifestations, and antipsychotic medication should be delayed unless treatment of depression fails to address the psychosis-like symptoms,” the authors concluded.

For more in Psychiatric News about ethnic and cultural factors in psychiatry, click here.

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APA Honors Sen. Whitehouse

The American Psychiatric Association presented U.S. Sen., Sheldon Whitehouse (D-R.I.) with its Jacob K. Javits Award for Public Service on March 13, at the U.S. Capitol.

The award recognizes Whitehouse’s leadership in support of two key pieces of legislation affecting mental health practice. The Behavioral Health Information Technology Act of 2011 would grant psychiatrists working in psychiatric hospitals, community mental health centers, and addiction treatment facilities the same critical Medicare or Medicaid rebates toward the purchase of electronic medical record systems for which other physicians are eligible. He also backed the Children’s Hospitals Education Equity Act, which makes a technical fix to the Children’s Graduate Medical Education (GME) Program, which currently excludes certain psychiatric hospitals from federal GME funding. The new bill would make several dozen additional psychiatric residencies across the country eligible for critical GME support.

To read about threats to Medicare funding of graduate medical education in Psychiatric News, click here.

(photo: office of Sen. Sheldon Whitehouse)

FDA Denies Seroquel Citizen Petition, AstraZeneca Files Suit

On March 7, the Food and Drug Administration (FDA) denied two citizen petitions filed by AstraZeneca September 9 that requested the FDA to require generic versions of its Seroquel antipsychotic (quetiapine) come with warnings about high blood sugar and suicidal tendencies. The FDA denied the requests "without comment," leaving AstraZeneca with no information about the FDA's intentions regarding the generic.

On March 12, AstraZeneca responded by filing a complaint and motion for summary judgment, saying that FDA's nonresponse violated the Administrative Procedure Act and should be set aside. AstraZeneca is asking for an injunction enjoining the FDA from granting final approval for generic versions of Seroquel or its extended form, Seroquel XR. AstraZeneca has argued that the omission of the information in the generic drug's labeling would make a generic product less safe and effective than the branded products. Prior to this action, a generic form of Seroquel was expected to be approved as early as late this month.

Concerns have recently been raised about the use of Seroquel as a sleep aid in soldiers returning from Iraq and Afghanistan. Read more about it in Psychiatric News, here.

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NIDA Seeks Solutions To Synthetic Drug Detection

The National Institute on Drug Abuse (NIDA) is seeking new ways of detecting “designer drug” use by promoting the development of biofluid drug screens based on pharmacological activity rather than chemical structure. Because drugs such as the synthetic cannabinoids (known as "K2" and "Spice") and the "bath salts" (methylenedioxypyrovalerone or its metabolite, pyrovalerone) are constantly evolving, they frequently evade available drug screens.

NIDA is also seeking solutions to a variety of other drug abuse issues. Specific topics of interest could include human brain neurochemical and molecular imaging, discovery of new chemical probes, and nanoscience-based design of therapies for substance abuse treatment. NIDA says high priority will be given to research that seeks to develop innovative technologies, methods, or tools, or to apply emerging and existing methods to develop medications to treat addiction. For more information, see the Omnibus Solicitation, issued by the U.S. Department of Health and Human Services.

For more about bath salts and synthetic cannabinoids, see Psychiatric News here and here.

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Benefits of Early Intervention for Psychosis Persist at Ten Years

Clinical benefits of early detection of schizophrenia previously seen at two and five years appear to persist into the 10 year after initial diagnosis, according to a report online March 8 in AJP in Advance.

A significantly higher number of individuals who received early intervention for a first-episode psychosis fulfilled recovery criteria than did individuals receiving usual care. Early detection patients were significantly more likely to be employed full-time, one of the most important indicators of recovery.

The 10-year results were from the Treatment and Intervention in Psychosis Study (TIPS), which had previously reported benefits of early detection at two and five years. The report of the study, “Long-term Follow-up of the TIPS Early Detection in Psychosis Study: Effects on Ten-Year Outcome,” can be found here. To read more about early intervention in first-episode psychosis, see Psychiatric News here.

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CMS Announces Emergency Psychiatric Demonstration Project

The Centers for Medicare and Medicaid Services (CMS) today announced that 11 states and the District of Columbia will participate in the Medicaid Emergency Psychiatric Demonstration, established under the Affordable Care Act, to test whether Medicaid beneficiaries who are experiencing a psychiatric emergency get more immediate, appropriate care when institutions for mental diseases receive Medicaid reimbursement. “This new demonstration will help ensure patients receive appropriate, high quality care when they need it most and save states money,” said CMS Acting Administrator Marilyn Tavenner.

This project will provide up to $75 million in federal Medicaid matching funds over three years to 11 states—Alabama, California, Connecticut, Illinois, Maine, Maryland, Missouri, North Carolina, Rhode Island, Washington, and West Virginia—and the District of Columbia to enable private psychiatric hospitals to receive Medicaid reimbursement for emergency care provided to Medicaid enrollees aged 21 to 64 who have an acute need for treatment.

For coverage of the health care reform law see Psychiatric News here and here. More information about the law can be found in the APA publication, Health Care Reform: A Primer for Psychiatrists.

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Soaring Prescribing Rates of Antipsychotics Put Under Microscope

The lead article in the Health section of today's Washington Post searches for answers to explain the dramatic rise in the last few years in prescribing second-generation antipsychotic medications. The article, written in conjunction with Kaiser Health News, raises concerns about the increasing use of these powerful medications for unapproved uses such as for sleep problems, anxiety, attention-deficit/hyperactivity disorder, and dementia. Off-label prescribing of these drugs more than doubled from 1995 to 2008, the article notes. And it raises alarms in particular about their use with children. The article quotes APA Medical Director James H. Scully Jr., M.D., who said that he agrees that misuse of these drugs is a problem and that their use should depend on data showing their effectiveness for off-label uses, but that among psychiatrists, they are prescribed in a desire to find an effective treatment for serious, often debilitating conditions. "All of the meds we use have their limits," Scully said. "If you're trying to help somebody, you think, 'What else might I be able to do for them?' " Read the entire article here.

For an in-depth review of antipsychotic medications in the treatment of mental illnesses, see The Evidence-Based Guide to Antipsychotic Medications, from American Psychiatric Publishing.

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Statins May Reduce Depression Risk

Cardiovascular disease is a known risk factor for depression. And it now appears that when people take statin drugs to lower their cholesterol levels, they experience a significantly reduced risk of major depression. The study was based on almost 1,000 people with stable coronary artery disease seen at outpatient clinics in the San Francisco area. Their statin use and depressive symptoms were tracked over six years. The finding, which was published February 21 in the Journal of Clinical Psychiatry, was the subject of coverage in the March 5 New York Times.

Another aspect of the strong link that exists between depression and cardiovascular disease is that depression appears to raise the risk of developing cardiovascular disease. For example, in a longitudinal study of young adults, subjects who had been depressed were twice as likely to experience a fatal cardiovascular event as those who had not been depressed. More information about this study can be found in Psychiatric News . 

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Sex and Aggression Are Closely Linked

Brain neurons responsible for aggression appear to be located close to the neurons responsible for mating, high-tech experiments on male mice have shown. This finding suggests that the control centers for sex and aggression are neighbors in the brain and might help explain why sexual and aggressive behavior come to be fused in many individuals.
More information about the study and its implications can be found in the March 2 Psychiatric News here.

Insights into the close link between sex and aggression are also discussed in a new American Psychiatric Publishing book called The Inseparable Nature of Love and Aggression: Clinical and Theoretical Perspectives by psychoanalyst Otto Kernberg, M.D., in which he examines the psychoanalytic and neurobiological underpinnings of sexual love, from the organization of brain structures and neurotransmitters to the overall systems of erotic activation, attachment, and bonding. Information about the book can be found here.

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Experts Focus on Remedies for Medication-Development Slowdown

Concerned about a serious decline in the number of medications being developed to treat psychiatric illnesses, APA on March 8 assembled leaders from academia, the pharmaceutical industry, venture-capital firms, advocacy groups, and government agencies to focus on ways to improve the pipeline for new treatments.

"Collaboration among leaders from these various groups...is the first step in planning for the future of psychiatric research," said Jeffrey Lieberman, M.D., APA's next president-elect and chair of the Department of Psychiatry at Columbia University. Lieberman moderated the summit along with Herbert Pardes, M.D., a former APA president and NIMH director who is president of the Scientific Board of the Brain and Behavior Research Foundation. "Our common goal is translating new science and technology into practice that enhances patient care," Pardes said. APA Medical Director James H. Scully Jr., M.D., emphasized that "Support for research into psychiatric diseases and innovative therapies is crucial for ensuring that physicians have the best tools possible for treating those suffering from mental illnesses." All funding for the "Pipeline Summit" was provided by the American Psychiatric Foundation.

Read more about the slowing of the psychiatric-drug pipeline in the latest issue of Psychiatric News.

Costs of Alzheimer's Care Expected to Reach $200 Billion

In 2012, the direct costs of caring for those with Alzheimer’s or other dementias to American society will total about $200 billion, including $140 billion in costs to Medicare and Medicaid, according to a report released today by the Alzheimer's Association.

Average per-person Medicare payments for an older person with Alzheimer’s or another dementia are nearly 3 times higher than for an older person without these conditions. Medicaid payments are 19 times higher. These costs will only continue to soar in the coming years given the projected rapidly escalating prevalence of Alzheimer’s disease as the baby boomers age, according to the report, titled, “2012 Alzheimer’s Disease Facts and Figures.” 

The report is online here. For extensive reporting about Alzheimer’s research see Psychiatric News here. And for more information about Alzheimer’s see The American Psychiatric Publishing Textbook of Geriatric Neuropsychiatry, Third Edition. Purchasing information is posted here.

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Two Reported Dead in Shooting at Leading Psychiatric Hospital

A gunman opened fire yesterday in the lobby of the Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh Medical Center.

   The Pittsburgh Post-Gazette reported today that one victim of the shooting has been pronounced dead and seven others have been wounded. The shooter himself, whose identity was not known as of this morning, was also killed after trading fire with University of Pittsburgh police.
   Armed with two semiautomatic handguns, the shooter entered WPIC shortly before 2 p.m. yesterday and started firing. The Post-Gazette reports that officials believe the shooter had never been a patient at WPIC, and that detectives were working to learn more about his identity, background, and motivations.
   To read about the association between violence and mental illness see Psychiatric News here and here.

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Drug Abuse Risk Rises in Some Adoptive Children

Adverse environments can be more pathogenic to individuals with high levels of genetic risk for drug abuse. Using nine Swedish databases (1961 to 2009) of adopted children and their biological and adoptive relatives, researchers found that the risk for drug abuse was significantly elevated in the adopted offspring of biological parents with drug abuse, in biological full and half siblings of adopted children with drug abuse, and in adoptive siblings of adopted children with drug abuse. A genetic risk index and an environmental risk index both strongly predicted the risk of drug abuse in adopted children. The study was reported online March 5 in the Archives of General Psychiatry.

The majority (85 percent) of adolescents experiment with substances prior to graduating from high school, and more than 10 percent of youth are in need of a clinical intervention for their substance use. Read more in the Clinical Manual of Adolescent Substance Abuse Treatment, available from American Psychiatric Publishing.

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Mild Brain Injuries Have Long-Lasting Effects in Children

Even "minor" concussions in children may have long-lasting repercussions. After studying 186 children aged 8 to 15 who suffered traumatic brain injury (TBI) and were admitted to one of two Ohio-area children's hospitals, researchers have concluded that many children with mild TBI show reliable increases in postconcussive symptoms that are associated with significant functional impairment in their daily lives. The children were evaluated up to 12 months postinjury. "Health care providers need to be able to identify children with mild TBI who are at risk for persistent postconcussive symptoms so that they can then target such children for appropriate management," wrote the researchers online March 5 in the Archives of Pediatric and Adolescent Medicine.

Experts predict that civilians will benefit from the military's extensive experience over the last several years in treating TBI patients. Read more on this topic in Psychiatric News, here.

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PTSD Raises Likelihood of Opioid Medication Use

Veterans of the wars in Iraq and Afghanistan who are diagnosed with mental disorders are about twice as likely to be prescribed opioid pain medications and to have worse clinical outcomes than their counterparts seen in the VA health system. A study of 141,029 veterans treated for noncancer pain found that 6.5 percent with no mental health diagnosis were prescribed opioids, compared with 11.7 percent of those with a mental health diagnosis but not PTSD, and 17.8 percent with PTSD. Vets with PTSD were also more likely to receive higher doses or more than one drug and were at significantly increased risk for depression, anxiety, an alcohol or drug use disorder, and traumatic brain injury.

“These findings support further efforts to improve care of patients with comorbid pain and PTSD because of the heightened risk of self-medication with opioids and substance abuse in veterans with PTSD,” wrote Karen Seal, M.D., M.P.H., of the University of San Francisco, and colleagues in the March 7 Journal of the American Medical Association. “These patients may benefit from biopsychosocial models of pain care including evidence-based nonpharmacologic therapies and nonopioid analgesics.”

For comprehensive information on the diagnosis and treatment of PTSD, see American Psychiatric Publishing’s Clinical Manual for Management of PTSD.

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ADHD or Just Younger and Acting Normally?

What a difference a year makes—or even a month.

A study in the Canadian Medical Association Journal of 937,943 children finds that boys born in December were 30 percent more likely to be diagnosed with ADHD than classmates born in January of the same calendar year. December-born girls were 70 percent more likely to have an ADHD diagnosis. Similar patterns existed for rates of ADHD prescriptions. The cut-off date of birth for school entry in British Columbia is December 31, so children born in December are almost a year younger than classmates born in January.

The researchers were concerned that these younger children were simply acting younger compared with their older classmates and may have been wrongly diagnosed. “These findings raise concerns about the potential harms of overdiagnosis and overprescribing,” they wrote.

For more on the diagnosis of ADHD in Psychiatric News, click here.

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Hospitals Fined Over Failure to Protect Staff From Violent Patients

Two California psychiatric hospitals are facing substantial fines for their failure to protect staff from patient violence. According to the Los Angeles Times, California's Occupational Safety and Health Administration is levying fines of $57,400 against Patton State Hospital and $38,555 against Atascadero State Hospital, citing inadequate staff protections against injuries that have led to an average of 20 patient-caused staff injuries a month at Patton and eight such injuries a month at Atascadero since January 2007. The state agency's report says these injuries include "severe head trauma, fractures, contusions, lacerations, and bites." Both hospitals' alarm systems were said to be grossly inadequate. Two years ago the state's Napa State Hospital was in the news when a psychiatric technician was killed on the grounds. The state Department of Mental Health is contesting the fines.

In response to instances of violence by patients in California's state hospitals, the Times reported that state legislator Sam Blakeslee introduced a bill to "keep drug users with temporary psychosis out of the facilities" and a second bill that would make it a felony for "mentally disordered offenders"—former state prisoners with mental illness who are deemed too dangerous to be paroled—to attack a staff member.

Read about strategies that have shown success in reducing attacks by patients in Psychiatric News.

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Childrens' Sleep Problems Linked to Behavioral, Emotional Problems

Behavioral and emotional problems in young children may be the result of sleep disordered breathing (SDB) problems that begin as early as infancy. In a large population-based study, Karen Bonuck, Ph.D., of Albert Einstein College of Medicine, and colleagues assessed parents' reports of children's snoring, mouth breathing, and apnea beginning at age 6 months and then periodically until age 69 months, as well as parents' responses to the Strength and Difficulties Questionnaire when the child was 4 and 7 years old.

In a finding with screening and treatment implications, they discovered that at age 4, the children with SDB had 40 percent more behavioral difficulties than their peers, and at age 7 had 60 percent more behavioral problems, which included hyperactivity and problems with conduct and peer interactions. The researchers also found a strong link between SDB and emotional problems. Even when the sleep problems peaked at 18 months and then resolved, the risk of behavioral problems at age 7 was elevated, indicating the crucial nature of intervening early when early childhood sleep problems are identified.

Read about treatment of childhood sleep disorders in Psychiatric News. 

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