Therapy Aimed at 'Cognitive Biases' May Avert Psychosis in At-Risk Individuals

A new cognitive-behavioral intervention specifically targeted at cognitive biases—the misleading or erroneous thoughts and ideas that accompany psychosis—appears to have a favorable effect on reducing the likelihood of an acute psychotic episode in individuals deemed to be at “ultra-high risk” for psychosis. That was the finding from a study, “Cognitive-Behavioral Therapy for Subjects at Ultrahigh Risk for Developing Psychosis: A Randomized, Controlled Clinical Trial,” appearing online in Schizophrenia Bulletin.

A total of 201 patients were recruited at four sites in the Netherlands and randomized to receive either cognitive-behavior therapy plus treatment as usual, or treatment as usual alone. (The cognitive-behavioral therapy was used as an add-on therapy because people were seeking help for a comorbid disorder.) The CBT was provided for 6 months, and the follow-up period was 18 months.

The CBT intervention is designed to address thoughts and ideas that are common to psychosis such as jumping to conclusions, selective attention to threatening stimuli, negative expectation bias and underrating of one’s capacities, and overrating the causal relationship between independent events.

Among patients receiving the CBT intervention, 10 transitioned to psychosis, compared with 22 who received only treatment as usual. At 18-month follow-up, the CBT group was significantly more often remitted from an at-risk mental state.

“In this group of UHR patients, a CBT intervention specifically targeting the appraisal of subclinical symptoms and teaching awareness of cognitive biases reduced the number of transitions to psychosis and increased the number of patients who no longer experience subclinical psychotic symptoms,” the authors state.

The study is posted here. For more information on this subject, see Psychiatric News here.

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DEA Targets Another Large-Chain Pharmacy for Violations

The U.S Drug Enforcement Administration (DEA) announced yesterday it had issued orders to show cause (OSC) to three Florida Walgreens pharmacies. An OSC is served as a notice to a DEA registered entity to provide it an opportunity to show cause as to why the DEA should not revoke its registration because its registration is deemed inconsistent with the public interest.  "These registrants have a responsibility to their customers, as well as to the community, to be an advocate against prescription drug abuse that has plagued Florida since 2009 and not contribute to the epidemic, said Mark Trouville, special agent in charge of the DEA's Miami Field Division. "(We) will continue to work with our local and state partners to assure that all prescription drugs are getting into the hands of legitimate patients for legitimate medical needs.” The Florida Department of Law Enforcement says that, on average, seven people die every day in Florida due to prescription drug abuse.

In September, the DEA revoked the registration of two Florida CVS pharmacies, the first time it had revoked the registration of a branch of a large national chain. The Centers for Disease Control and Prevention recently tasked states with achieving control over opioid pain prescriptions, saying that state agencies, as regulators of healthcare practice, have the responsibility and authority to monitor and correct inappropriate and illegal prescribing. Read more about it in Psychiatric News here.

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Intervention Soon After Trauma Cuts PTSD Symptoms

Clinicians have searched with mixed success for interventions shortly after trauma occurs to prevent later posttraumatic stress disorder (PTSD). In a newly reported study of the issue, Emory University researchers randomized 137 patients to review and process their trauma experiences under the guidance of a trained therapist.

The one-hour therapy began in the emergency room within 12 hours of the trauma and was repeated one and two weeks later. Symptoms were assessed at weeks 4 and 12. Significantly fewer patients in the intervention group met criteria for PTSD at week 12, compared with controls. There was no significant difference in PTSD severity at weeks 4 and 12 for victims of physical assault or transportation accidents, but victims of sexual assault did significantly benefit from the intervention at both follow-up times.

“[T]he modified prolonged exposure intervention presented here may be able to prevent the development of PTSD . . . by encouraging engagement with the trauma memory and providing an opportunity for fear habituation and processing of unhelpful cognitions, thus modifying the memory before it is consolidated,” wrote Emory’s Barbara Rothbaum, Ph.D., and colleagues in the December 1 Journal of Biological Psychiatry.

To read more about early interventions for PTSD, see Psychiatric News here. For information on recent research and clinical advances in PTSD, see Clinical Manual for Management of PTSD from American Psychiatric Publishing. For a study of prolonged exposure in PTSD treatment, see the American Journal of Psychiatry here.

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Men Sue Reparative Therapy Center Over Psychological Harm

Four young men have taken the rare step of suing a facility that provides so-called "reparative therapy," and the individuals who run it, claiming that the techniques used to "cure" their homosexuality included ones that inflicted psychological damage. The suit was filed yesterday in Hudson County (N.J.) Superior Court against the organization known as JONAH (Jews Offering New Alternatives for Healing), which is located in Jersey City. The suit charges the organization with falsely claiming to be able to rid the men of their sexual attraction to other men through proven scientific techniques. According to the suit, these techniques were demeaning and emotionally damaging and included having to remove their clothing and beat images of their mothers. One of the defendants, Chaim Levin, now age 23 but 17 when he sought out JONAH's services, told the Jersey Journal, "It was so awful and so degrading and so wrong in so many ways."

Commenting on the suit to Psychiatric News, psychiatrist Jack Drescher, M.D., said, "APA has raised concerns about the potential harm done by trying to change a person's sexual orientation. Anecdotal reports of harm include worsening of depression, anxiety, and even suicidal ideation—not to mention individuals entering into heterosexual marriages with the unrealized hope that these would lead to conversion. Unfortunately, many of the individuals, like the defendants named in this lawsuit, are unlicensed and not subject to professional regulation or censure. Hopefully, if the plaintiffs' suit is successful, it will have a chilling effect on the proliferation of unlicensed individuals offering false hope to unhappy individuals struggling with their sexual identities." Drescher is president of the Group for the Advancement of Psychiatry and editor emeritus of the Journal of Gay and Lesbian Mental Health.

In late September California passed a law banning reparative therapy in youth younger than age 18.

APA position statements on reparative therapy are posted at www.psychiatry.org under "Position Statements." For a comprehensive review of mental health issues affecting gay, lesbian, bisexual, and transgender individuals see The LGBT Casebook from American Psychiatric Publishing. (Drescher is a co-editor of the book.)

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Study Questions Long-Term, Off-Label Use of Atypical Antipsychotics in Older Adults

Four atypical antipsychotics that are commonly prescribed to adults over age 40 were found to have a high rate of serious and nonserious side effects while offering little significant long-term improvement in psychopathology.
That was the finding from a study of safety and long-term effectiveness of four commonly prescribed atypical antipsychotics—aripiprazole, olanzapine, quetiapine, and risperidone—that was published online yesterday in the Journal of Clinical Psychiatry. Patients were followed for up to two years.

The results were disappointing. There was a high rate of medication discontinuation before the two years were up, no significant improvement in psychopathology, and a high cumulative incidence of metabolic syndrome and of serious and nonserious adverse events for all atypical antipsychotics in the study.

The study included patients with psychosis related to schizophrenia, mood disorders, posttraumatic stress disorder, or dementia, diagnosed using DSM-IV-TR criteria. The FDA has approved the use of antipsychotics for schizophrenia and bipolar disorder, but not for PTSD or dementia; however, many older patients with psychosis related to dementia receive off-label prescriptions for atypical antipsychotics.

Study author and APA President Dilip Jeste, M.D., emphasized that the study results pertain to long-term safety and efficacy, not to short-term use. “In some cases, such as dementia patients with severe psychotic symptoms, short-term use of antipsychotics may be the best option,” Jeste told Psychiatric News.He is Distinguished Professor of Psychiatry and Neurosciences at the University of California, San Diego School of Medicine.

Jeste said the study results indicate that great caution should accompany long-term use, particularly for off-label indications. He urged clinicians when possible to consider psychosocial treatments that have been found useful for psychosis related to dementia. "When these medications are used off-label, they should be given in low dosages and for short durations and their side effects monitored closely," said Jeste. "Clearly, there is also a critical need to develop and test new interventions that are safe and effective in older people with psychotic disorders."

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Citicoline Appears to Offer No Improvement in TBI Patients

The nutraceutical citicoline doesn’t improve outcomes in patients with traumatic brain injury (TBI), said researchers at Harvard Medical School in the November 21 Journal of the American Medical Association. Results came from the Citicoline Brain Injury Treatment Trial (COBRIT), a phase 3, double-blind, randomized clinical trial. The trial was conducted from July 20, 2007, to February 4, 2011, in 1,213 patients at eight U.S. level-1 trauma centers. It was designed to investigate the effects of citicoline versus placebo in patients with mild, moderate, or severe TBI.

Patients received a 90-day regimen of daily enteral or oral citicoline (2,000 mg) or placebo, and both functional and cognitive status were assessed after 90 days using the TBI-Clinical Trials Network Core Battery. No improvement in functional or cognitive status was seen. Although there are no approved treatments for TBI in the U.S., citicoline is approved for use in TBI in patients in 59 other countries.

A recent study of the use of hyperbaric oxygen for TBI presented equivocal results. Read more in Psychiatric News here. See more on this topic in the Textbook of Traumatic Brain Injury, Second Edition, available from American Psychiatric Publishing here.

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Supreme Court Won't Hear Insanity Defense Case

The Supreme Court yesterday declined an opportunity to rule on whether criminal defendants have a legal right to invoke an insanity defense. This decision leaves in place an Idaho law that abolished the option of an insanity defense in trials in that state. Attorneys for convicted murderer John Delling had wanted to use an insanity defense since Delling, age 21 at the time of his trial, appeared paranoid and delusional, insisting that the men he killed were trying to steal his "energy." Unable to invoke an insanity defense, Delling pleaded guilty to murder and is serving a life sentence. He appealed to the Idaho Supreme Court arguing that the state's law abridged his right to present evidence in his own defense, but that court upheld Delling's conviction. Three of the Court's liberal justices, Stephen Breyer, Ruth Bader Ginsburg, and Sonia Sotomayor, voted in favor of hearing this case, but at least four justices must vote to do so.

In July APA and the American Academy of Psychiatry and the Law (AAPL) submitted an amicus brief supporting Delling's argument that he has a legal right to use an insanity defense and that the state cannot deny him that right. Idaho, Kansas, Montana, and Utah have passed laws abolishing the insanity defense. Paul Appelbaum, M.D., the Dollard Professor of Psychiatry, Medicine, and Law at Columbia University and chair of the APA Committee on Judicial Action, told Psychiatric News, "The Court's decision not to hear Delling leaves open the question of whether the insanity defense is constitutionally required for another day. We are encouraged that three justices voted to hear the case and that they cited the APA brief in support of their argument."

Read more about the Delling case and the APA/AAPL amicus brief in Psychiatric News. 

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Could There Be a Link Between Parasite and Suicidal Behavior?

In a large prospective study, an association was found between the parasite Toxoplasma gondii and suicidal behavior. The finding appears in the November Archives of General Psychiatry. The senior scientist was Teodor Postolache, M.D., director of the mood and anxiety program at the University of Maryland.

"This study is very interesting," Paul Links, M.D., a professor of psychiatry at Western University in London, Ontario, Canada, and a suicide expert, told Psychiatric News. "But what mechanisms might explain the association? Association does not necessarily mean that there is a causal relationship...."

Postolache agrees. "We obviously hypothesized that T. gondii can affect the brain and lead to suicide attempts," he said in an interview with Psychiatric News. "But it's also possible that people at risk for suicide might have an increased risk of becoming T. gondii-positive." For example, the major source of T. gondii in developed countries is undercooked meat, Postolache noted, "so it could be that people who are more impulsive [and thus more at risk of suicide] may also be more prone to eating a steak that is rare rather than well done."

T. gondii has also beeen implicated in some cases of schizophrenia. Read more about that link in Psychiatric News here and here.

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Many Youth With Bipolar Illness Will Attempt Suicide

Almost one-fifth of youngsters with bipolar disorder will make a suicide attempt. Two red flags at intake are a family history of depression and depression severity; three causes for concern over the short term are persistent depression, substance abuse, and mixed bipolar episodes. These findings, obtained in a five-year prospective study, are reported in the November Archives of General Psychiatry. The lead scientist was Tina Goldstein, Ph.D., of the University of Pittsburgh.

"I think it's an excellent study," Paula Clayton, M.D., medical director of the American Foundation for Suicide Prevention, said in an interview with Psychiatric News. Another valuable finding to emerge from the study, she believes, is that more than half the subjects were on psychotropic medications when they made their suicide attempts. The implication is thus "that treatment wasn't enough to prevent them from making an attempt. It was maybe too much, too little, or the wrong treatment.... [So if a child with bipolar disorder] makes a suicide attempt, then I think we should reexamine the medications."

Information about managing the care of children with bipolar disorder can be found in American Psychiatric Publishing's Clinical Manual for Management of Bipolar Disorder in Children and Adolescents and in the just-published Clinical Manual of Child and Adolescent Psychopharmacology, Second Edition. Click here and here to purchase those volumes.

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Younger Students More Likely to Get ADHD Drugs, Have Poorer Test Scores

The youngest children in their class are more likely than their older grade-level peers to be prescribed medication for attention-deficit/hyhperactivity disorder (ADHD) and more apt to score lower on tests of academic performance. This pattern holds well into puberty, according to a study published online November 19 in Pediatrics.

Researchers at Mount Sinai School of Medicine, Harvard School of Public Health, and the University of Iceland studied all children in Iceland who took standardized tests at ages 9 and 12 (n=11,785). The country's national registry of prescribed drugs was used to determine which students were prescribed medications to treat ADHD. The researchers found that mean test scores in math and language arts were lowest among the youngest children in fourth grade, though the differences moderated by seventh grade. In addition, they found that children in the youngest third of their class were 50% more likely than those in the oldest third to have been presceribed stimulants between ages 7 and 14. The researchers concluded that "relative age among classmates affects children's academic performance into puberty, as well as their risk of being prescribed stimulants for ADHD." They urged that this finding and the effects of maturity level be considered "when evaluating children's performance and behavior in school to prevent unnecessary stimulant treatment."

To read more on stimulant medications to treat ADHD, see Psychiatric News. More a review of medications to treat this and other psychiatric disorders of children and adolescents, see the Clinical Manual of Child and Adolescent Psychopharmacology from American Psychiatric Publishing.

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Mental Health Research Network Tries to Close Gap Between Research, Clinical Care

At a recent meeting at the National Institute of Mental Health (NIMH), researchers from its Mental Health Research Network (MHRN) discussed how the network is working to link research outcomes more quickly to day-to-day clinical practice than has traditionally been the case in the mental health field. Commenting on the network and its goals, NIMH Director Thomas Insel, M.D., noted,“MHRN is a network of 11 research organizations affiliated with nonprofit health care systems serving 12 million patients.... The idea is simple: understand what works in the real world of practice by using scientific methods, like randomization and statistical comparisons, to create a learning health care system. By linking health information databases and creating an efficient process for assessing outcomes, MHRN is working to transform the world of health care practice into a laboratory for research."

Current MHRN projects include studies of ways to treat perinatal depression and prevent suicide. The MHRN has created information management systems, agreed on standard definitions of mental health events, and developed a standard toolkit of mental health assessments. Now it will try to answer significant questions such as how to deal with complex, comorbid health conditions; reduce early mortality; and ensure fidelity to proven psychosocial treatments. “MHRN is providing an important new model for a learning health care system, one which does not need 17 years or even 17 months to bring research to better patient care,” said Insel.

To read more about how NIMH is influencing the future of psychiatric research, see Psychiatric News.

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In Snow Sports, Helmets Reduce Head Trauma

After several early snowstorms, it's shaping up to be a good winter for skiers and snowboarders, and researchers at the Johns Hopkins School of Medicine say there's no reason not to wear a helmet while engaging in those popular sports. Reporting in this month's Journal of Trauma and Acute Care Surgery, researchers at the school's Center for Surgery Trials and Outcomes Research said a review of published studies of the use of safety helmets by recreational skiers and snowboarders shows that the helmets clearly decrease risk and severity of head injuries and do not increase the risk of neck injury, cervical spine injury, or risk-compensation behaviors. The authors' recommendation, which is backed by the Eastern Association for the Surgery of Trauma's Injury Control and Violence Prevention Committee, is that all skiers and snowboarders should wear a safety helmet to reduce the incidence and severity of head injury. "Policies and interventions to increase helmet use should be promoted to reduce mortality and head injury among skiers and snowboarders," they said.

Advances in the treatment of brain injuries incurred by U.S. troops serving in Iraq and Afghanistan will eventually benefit civilians who suffer traumatic head trauma. Read more about it in Psychiatric News here.

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Zolpidem Increases Inpatient Falls, Study Finds

Use of the hypnotic agent zolpidem in inpatient hospital settings significantly increases the risk that a patient will fall. Reporting yesterday in the Early View Journal of Hospital Medicine, researchers based at the Mayo Clinic's Center for Sleep Medicine in Rochester, Minn., said that the fall rate among patients who were prescribed and received zolpidem was significantly greater than among patients who were prescribed but did not receive zolpidem. The patients who were taking zolpidem who experienced a fall did not differ from other hospitalized adult patients who fell in terms of age and use of opioids, antidepressants, sedative-antidepressants, antipsychotics, benzodiazepine, or antihistamines. "Zolpidem use was a strong, independent, and potentially modifiable risk factor for inpatient falls," they concluded. 

Researchers at the Scripps Clinic Viterbi Family Sleep Center in La Jolla, Calif., recently found that patients with prescriptions for hypnotics such as zolpidem had approximately 4.6 times the hazard of dying over an average observation period of 2.5 years, compared with nonusers of these drugs. Read more about that study in the Journal Digest feature of Psychiatric News here. 

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Birth Weight May Impact Brain Development

Even after controlling for age, gender, household income, and genetic ancestry, children with higher birth weights were found to have a greater brain surface in numerous regions and a greater brain volume than children who had weighed less at birth. Kristine Beate Walhovd, Ph.D., of the University of Oslo in Norway and her colleagues reported these findings today in the Proceedings of the National Academy of Sciences Online Early Edition. The study included 628 healthy American children.

This is one of several notable brain-development studies whose results have been reported recently. Preliminary imaging findings suggested, for example, that a distinct and pervasive course of white-matter development characterizes high-risk infants who then eventually develop autism symptoms. Read about that study in Psychiatric News. And in another study rat pups perinatally exposed to the SSRI antidepressant citalopram exhibited impaired social behavior and impaired response to novelty situations. See Psychiatric News to read more about that study as well.

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Dancing May Improve Teen Girls' Mental Health

Dancing appears to improve the mental  and physical health of adolescent girls, Swedish researchers report online this month in the Archives of Pediatric and Adolescent Medicine. A total of 112 girls with depressed mood, low self-worth, and/or psychosomatic symptoms participated in the study. Fifty-nine of them were randomized to a dance class twice a week for eight months. The remaining 53 received no dance class and served as controls during that period. The dance practice involved moderate to vigorous physical activity and included several different dance styles. Both groups were given a health self-rating instrument on which they described their mental and physical health at the start of the study and then again at the end of eight months. The dance group reported better health than the control group did. A significant difference between the groups remained a year after the intervention had ended.

Exercise has been found to benefit people's mental health in other ways as well. For example, the evidence is growing stronger that exercise can avert depression. See Psychiatric News. Exercise can likewise reduce amyloid plaques, the hallmark of Alzheimer's disease, in the brains of cognitively normal individuals, including those who carry the APOE-e4 gene variant—a risk factor for Alzheimer's. See that report in Psychiatric News.

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Smoking on Decline Among Teens

Teenagers' use of cigarettes showed a dramatic decline from 2002 to 2010 in 41 of the 50 states, finds a new report released yesterday by the Substance Abuse and Mental Health Services Administration (SAMHSA). This comes despite another of the survey's findings that the risk teens attach to cigarette smoking has changed little over this time period. The survey's teen respondents indicated that their perception of great risk of harm from smoking one pack or more a day increased from 63.7% to 65.4% overall from 2002 to 2010. Nationwide, teens' use of cigarettes dropped from 12.6% to 8.7%, but wide variations appeared among the states. At the extremes were Wyoming, where 13.5% of teens smoked cigarettes, and Utah where just 5.9% did so. Data come from SAMHSA's National Survey on Drug Use and Health (NSDUH).

"Although this report shows that considerable progress has been made in lowering adolescent cigarette smoking, the sad, unacceptable fact remains that in many states about 1 in 10 adolescents smoked cigarettes in the past month. The report also shows that we must collectively redouble our efforts to better educate adolescents about the risks of tobacco, and continue to work with every state and community to promote effective tobacco use prevention and recovery programs,” said SAMHSA Administrator Pamela Hyde.

To read about how smoking may take a toll on cognitive functioning, see Psychiatric News here. And to read mental-health related findings from the NSDUH, click here. 

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Opioid Receptor Antagonist May Help Binge Eaters

An opioid receptor antagonist reduces a preference for sweet, high-fat foods in binge eaters, British and American scientists reported online November 13 in Molecular Psychiatry. The finding was based on a double-blind, placebo-controlled, one-month study with 63 volunteers who were binge eaters and obese. "This study attempts to take advantage of an established finding from basic research that the endogenous opioid system is involved in the  control of food intake," B. Timothy Walsh, M.D., a professor of pediatric psychopharmacology at Columbia University and chair of the DSM-5 Eating Disorders Work Group, said in an interview. "The most provocative finding is that an experimental mu-opioid receptor antagonist reduced preference for sweet, high-fat foods.... This is a promising area for future research, including determining whether these findings will lead to useful clinical applications."

To read more about research on binge-eating disorder, see Psychiatric News here and here. Also see Clinical Manual of Eating Disorders from American Psychiatric Publishing.

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Study Finds Flu During Pregnancy May Increase ASD Risk

A Danish study published online in Pediatrics this week reported a possible link between mothers who have the flu and a high fever during pregnancy and increased risk of autism spectrum disorders (ASDs) in their offspring. Their findings were based on records of the births of 97,000 Danish children between 8 and 14 years of age. Only 1 percent of the children were diagnosed with an autism spectrum disorder, despite the increased risk.

Those results brought heightened anticipation of the results of the Study to Explore Early Development (SEED), a multiyear study funded by the Centers for Disease Control and Prevention (CDC). SEED is being conducted in diverse communities across the country, with sites in California, Colorado, Georgia, Maryland, North Carolina, Pennsylvania. It is believed to be the largest study in the United States to help identify factors that may put children at risk for ASDs and other developmental disabilities. As of July, more than 3,500 families were enrolled in the SEED study. A description of SEED's methodology was published in the October Journal of Autism and Developmental Disorders.

Another recent study suggested a link between a mother's metabolic health during pregnancy and the risk of an ASD in their child. For more information, see Psychiatric News here. See also Autism and Other Developmental Disorders, a new book from American Psychiatric Publishing.

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Prenatal Stress Increases Risk of Being Bullied

A British study of more than 8,800 children and their mothers indicates that maternal mental health problems and prenatal stress caused by family adversity—like financial difficulties, criminal involvement, or substance abuse—increases the risk of the children being bullied at ages 7 or 8, wrote graduate student Suzet Tanya Lereya and Dieter Wolke, Ph.D., a professor of psychology at the University of Warwick, Coventry, U.K., online in the Journal of Child Psychology and Psychiatry.

“Prenatal factors had significant direct and indirect effects on victimization via partner conflict and maladaptive parenting,” they said.

How might this happen? Neurohormones, such as cortisol and noradrenaline, are released into the blood during exposure to stress in pregnancy and may change the fetus’s own stress response system, suggest the authors. “Thus, altered stress reactivity and phenotypic behavior may make children more likely targets of bullies, as they easily show a stress reaction.”

They also argue that preventive measures during pregnancy and early childhood might target families living in high adversity or with prenatal mental health problems.

“Similarly, providing extra support for children known to experience maladaptive parenting or witness aggression at home may reduce bullying involvement,” they concluded.

For more information about bullying see Psychiatric News here and Preventing Bullying and School Violence published by American Psychiatric Publishing Inc.

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High-Pressure Oxygen No Help for mTBI, Study Finds

The most common injury to U.S. service members fighting in Iraq and Afghanistan is traumatic brain injury caused by improvised explosive devices.

Postconcussion syndrome is diagnosed when symptoms of mild traumatic brain injury (mTBI) persist for more than three months. One proposed therapy for mTBI is hyperbaric oxygen—oxygen under higher than normal pressure—based on an unproven hypothesis that some neurons “may return to normal function or near normal function by reactivating metabolic or electrical pathways,” writes David Cifu, M.D., of the Department of Physical Medicine and Rehabilitation at Virginia Commonwealth University and colleagues in the Journal of Neurotrauma online November 14.

The researchers conducted a single-center, double-blind, randomized, sham-controlled, prospective trial of 50 service members at the U.S. Air Force School of Aerospace Medicine at Lackland Air Force Base in Texas. They compared 30 sessions each of slightly pressurized room air with 100 percent oxygen at 2.4 times normal atmospheric pressure. Both groups improved equally, leading Cifu and colleagues to conclude that hyperbaric oxygen treatment “had no effect on postconcussive symptoms after mild TBI.”

To read more in Psychiatric News about hyperbaric therapy for mTBI, click here.

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AMA Approves Medicare Reform Plan

Delegates at the AMA House of Delegates Interim Meeting in Honolulu approved a report yesterday that expands on longstanding AMA policy supporting the concept of providing Medicare beneficiaries with “defined contributions” that would be adjusted to medical inflation and with a choice of health care plans from which to purchase coverage. The report also recommends a set of principles that should be included in a defined-contribution system to ensure that Medicare remains a viable program that provides affordable and accessible health insurance coverage for the poorest and sickest beneficiaries. Additionally, approval of the report puts the AMA on record as supporting Medicare funding of graduate medical education.

During the extensive reference-committee debate that led up to the report's approval, many delegates noted that Medicare is not sustainable as currently structured.

Pictured testifying during reference-committee hearings is psychiatrist John McIntyre, M.D., a past president of APA and a member of the AMA’s Council on Medical Services, which developed the report.

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Panel Addresses Challenges Facing Older Physicians

As physicians approach retirement age they are likely to face a unique set of challenges, including those associated with the cognitive decline that comes with aging and the need to maintain clinical competency, licensure, and certification. At the Interim Meeting of the AMA this week in Honolulu, a panel on "Assessing Clinical Competency in Senior Physicians," sponsored by the AMA’s Senior Physicians Group, addressed legal, regulatory, and other issues associated with these challenges.

Psychiatrist Barbara Schneidman, M.D., M.P.H., who spoke at the panel, told Psychiatric News that physicians can prepare for these challenges, and she  emphasized the importance of continuous self-assessment of clinical skills and keeping up with requirements for continuing medical education. “I think it’s important to find out what the requirements are in your state…and to participate in maintenance of certification, even if you already have a lifetime certification, as a way of keeping up with your clinical skills and being clinically active if there is a question that comes up [about competency] from your hospital, your practice, or your state licensing board."

To see a video in which Schneidman discusses the panel presentation and offers tips for aging physicians regarding maintaining clinical competency, click here.

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AMA Seeks NIMH Help in Developing Guidance for Use of Atypical Antipsychotics in Children

The AMA is urging the National Institute of Mental Health (NIMH) to assist in developing guidelines for physicians about the use of atypical antipsychotics in children.

At the Interim Meeting of the AMA’s House of Delegates yesterday in Honolulu, delegates unanimously approved a report by the AMA’s Council on Science and Public Health (CSPH) that outlines relevant literature on the benefits and side effects associated with atypical antipsychotics in children and calls on the AMA to encourage federally funded research, with a focus on studies of safety and long-term efficacy.  And specifically, the report urges NIMH to help in developing guidance for physicians.

“We have seen a dramatic increase in the use of antipsychotic medication in the treatment of children and adolescents, and as the CSPH report notes, much of this use is off-label,” said child psychiatrist David Fassler, M.D., in testimony at reference committee hearings on Sunday. (Fassler, who is treasurer of APA, is pictured testifying at the meeting.) “Patients and parents need more information about the safety and efficacy of these medications especially when used over an extended period of time. The recommendations will encourage ongoing research, monitoring, and education.”  

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AMA President Calls on Physicians to Embrace Values of Integrated Care

It’s a new era in American health care—one that calls for physicians to collaborate with other doctors and health care professionals in a new model of integrated care.

That’s what psychiatrist Jeremy Lazarus, M.D., president of the AMA, told delegates in a presidential address at the Interim Meeting of the AMA House of Delegates this week in Honolulu, Hawaii. He announced in his address that a new Integrated Physician Practice Section would be joining the House of Delegates to address issues faced by physicians working in group and integrated practices.

(Lazarus is pictured with Hawaii Gov. Neil Abercrombie at a reception Friday evening when he and other APA and AMA leaders met with Abercrombie and Hawaiian policymakers.)

“It once made sense for physicians to value autonomy, independence, and self-sufficiency,” Lazarus told the House of Delegates. “But the game has changed. Integrated care asks us to cultivate mutual trust, to recognize that each team member offers unique skills and knowledge and to support this trust with open and timely communication….And we must go all in to improve the quality of health care for our patients and the country. That means collecting, sharing, and analyzing data, leveraged to care for patients.

“Team-based care is just one aspect of our medical world, [but] it’s a big one—and its evolution depends on how well it keeps patients healthy, and how well it functions for physicians members….[F]or most physicians, these new systems can bring better results.”

AMA delegates are meeting this week to discuss the future of health care and Medicare reform and other issues of concern to psychiatrists and other physicians. Follow Psychiatric News for coverage.

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Ketamine Shows Increasing Promise in Treatment-Resistant Depression

An injection of the drug ketamine can produce a rapid antidepressant effect in subjects with treatment-resistant depression, Dennis Charney, M.D., dean of Mount Sinai School of Medicine, reported at a recent symposium of the Brain and Behavior Research Foundation in New York City. If he and his colleagues can determine the optimal dose of ketamine to use in patients with treatment-resistant depression, and how often and how long to administer it to them, then it may become available for treating this condition, Charney predicted. Ketamine is already available clinically to induce and maintain general anesthesia, usually in combination with a sedative, and as an analgesic and is generally well-tolerated.

The researchers are also studying intranasally delivered ketamine and considering delivering it by patch, Charney said.

More information about ketamine's impact on treatment-resistant depression can be found in Psychiatric News here and here. Also see a study on this topic in this month's American Journal of Psychiatry.

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Risperidone Most Effective in Youth With Bipolar Illness, Study Finds

Of three drugs often used to treat children with bipolar disorder—divalproex, lithium, and risperidone—risperidone appears to be the most effective, Karen Wagner, M.D., Ph.D., vice chair of psychiatry at the University of Texas Medical Branch in Galveston, reported at a Brain and Behavior Research Foundation symposium held recently in New York City. Wagner andcolleagues obtained this result in a randomized, controlled, eight-week trial of 279 youth with bipolar I disorder (manic or mixed phase). Higher response rates occured with risperidone (69 percent) than with lithium (36 percent) or divalproex (28 percent). But risperidone did lead to weight gain in the subjects, Wagner said. Moreover, researchers do not yet know what impact the use of risperidone or other psychotropic medications  over the long term might have on youth with bipolar disorder, Wagner indicated.

However, some other researchers have found that psychotropic medications may have the beneficial potential to attenuate or reverse brain-volume deficits in bipolar children. See information on that topic in Psychiatric News.

More information about helping youth with bipolar disorder can be found in American Psychiatric Publishing's Clinical Manual for Management of Bipolar Disorder in Children and Adolescents.

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College Students Discuss Mental Health Experiences

With colleges throughout the U.S. reporting dramatic increases in the number of students with mental health conditions in general and severe illnesses in particular, a new report from the National Alliance on Mental Illness (NAMI) may be valuable for colleges and universities as well as the students they educate. In the NAMI-conducted Web-based survey of students diagnosed with a mental health condition who were currently enrolled or who had dropped out in the preceding five years, nearly two-thirds of the drop outs said that they did so because of reasons related to their mental health. There was a wide range of ratings by the students of their school's mental health services and resources, with some schools rated as excellent and others as lacking in key areas that would benefit students with mental health problems. The report offers suggestions based on the students' survey responses for colleges on services and support programs that would increase the chances that students can remain on campus, since as the report points out, "[h]igher education is the foundation for securing stable employment and achieving financial independence."

In the survey, 82% of respondents were women; depression and bipolar illness were the most common diagnoses, accounting for 51% of the reported disorders. Substance abuse, at just 1% was the least reported disorder in the survey. Students described what would have helped them stay in school, why they chose to disclose or not disclose their illness to campus personnel, and how aware they were of the college's mental health services and supports. NAMI researchers provided tips for colleges in a range of categories. NAMI said the report "is the first step in a larger initiative to support colleges and students."

Read the full report here. For more on this topic, see articles in Psychiatric News and Psychiatric Services. For information on APA's College Mental Health Caucus, send an e-mail to abondurant@psych.org

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Florida Law Violates M.D.s' Free-Speech Rights, APA Tells Court

APA has joined the AMA and several medical specialty societies in an amicus brief urging a Florida appeals court to uphold a lower court's ruling that a law barring physicians from discussing gun ownership with their patients is an unconstitutional violation of First Amendment rights to free speech. The Florida law at issue, the Firearm Owners' Privacy Act, prohibits physicians from asking adult patients, or family members of pediatric patients, about the presence of guns in the home unless the physician can identify an immediate danger to the health and safety of the patient or family. This law, the medical groups argue, "prevents physicians from communicating with their patients so as to provide medical care under the accepted standards of the medical profession. Not only do physicians lose the right to express themselves freely, but their patients are deprived of the full range of medical care and professionalism that they should and do expect from their physicians." The physicians point out that "firearm-related deaths are one of the top three causes of death in American youth," and physicians "play a key role in educating parents about the risks associated with possession of firearms in homes with children." Violations of the law can result in revocation of a physician's license.

The brief also emphasizes that the law's ban on entering gun-related information into the medical record "prevents physicians from taking a routine precaution that might enhance their defense against charges of medical malpractice," thus prohibiting "conduct that would otherwise be lawful." In addition, the law does not indicate that its goal is to protect patients' health, the groups state. "Rather it is a ploy to accommodate the concerns of Floridians who fear exposure to speech that will offend their notions of political correctness; concerns that fall outside the purview of legal protection."

The full amicus brief is posted here. Read coverage about the Florida gag law in Psychiatric News here and here.

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Schizophrenia in Families May Be Risk Factor for Autism

There is some evidence of overlap between autism spectrum disorder (ASD) and schizophrenia, but studies testing that hypothesis have been small and produced mixed results. But now, a large study using Swedish population and patient data suggests that a family history of schizophrenia or bipolar disorder might be a risk factor for ASD.

The researchers compared data from more than 25,000 cases of patients with ASD with data from control subjects. Patients with ASD were 2 to 3 times more likely to have a parent or sibling with schizophrenia and about 1.5 to 2 times more likely to have one with bipolar disorder, reported Patrick Sullivan, M.D., of the Department of Genetics at the University of North Carolina at Chapel Hill, and colleagues in the November Archives of General Psychiatry. “Our findings indicate that ASD, schizophrenia, and bipolar disorders share etiologic risk factors,” the researchers said, "factors common to these disorders.”

To read more about this study, see Psychiatric News here. For a comprehensive review of autism etiology, diagnosis, and treatment, see Textbook of Autism Spectrum Disorders from American Psychiatric Publishing. 

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Study Identifies Suicide Risk in Youth With Bipolar Disorder

Young people with bipolar disorder are known to be at high risk for suicide attempts. Now a new study identifies factors that can signal that risk early on. Researchers from the Western Psychiatric Institute and Clinic at the University of Pittsburgh tracked 413 youths (average age, 12.6) with a diagnosis of bipolar disorder. Over five years, 76 (18 percent) made at least one suicide attempt.

The strongest indicators of a later suicide attempt were severity of depression at intake and a family history of depression, said Tina Goldstein, Ph.D., an assistant professor of psychiatry, in the Archives of General Psychiatry online November 6. After intake, more time with threshold depression, the presence of substance use disorder or mixed mood symptoms, and more time receiving outpatient psychosocial services, all indicated greater risk as well.

“In conclusion, these prospective data indicate pediatric bipolar disorder is associated with high rates of suicide attempts,” concluded Goldstein and colleagues. “These findings highlight the importance of suicide-prevention strategies in youth with bipolar disorder, including frequent and thorough suicide risk assessment and safety planning.”

For more in Psychiatric News about suicide risk in youth with bipolar disorder, click here. For a comprehensive review of bipolar illness in general, see American Psychiatric Publishing's Handbook of Diagnosis and Treatment of Bipolar Disorders. 

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Zebra Fish May Teach Us Something About Sleep

David Prober, Ph.D., of the California Institute of Technology is using the zebra fish to find out why humans and animals sleep. He announced some of his results at a Brain and Behavior Research Foundation symposium held recently in New York City. For example, a deficiency in the neurotransmitter hypocretin has been strongly implicated in narcolepsy. So Prober and his colleagues switched off the gene that makes hypocretin in zebra fish and found that they slept about only half as much as normal. Thus hypocretin may be involved in normal sleep as well as in narcolepsy. Prober and his colleagues are also using the zebra fish as they search for new drugs to treat insomnia. They currently have some candidates.

"Unfortunately sleep research has been underrecognized and underfunded," Dennis Charney, M.D., dean of Mount Sinai School of Medicine, commented after Prober's talk. "The zebra fish is potentially a good model."

Researchers are also studying sleep behaviors as they relate to parasomnias and the significance of insomnia in mood-disorder patients. Read research on those topics in Psychiatric News here and here. Much more about sleep disorders can be found in American Psychiatric Publishing's Clinical Manual for Evaluation and Treatment of Sleep Disorders.

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Answers About Antidepressant-Induced Mania in Youth Remain Elusive

Depression is a common first sign of bipolar disorder, especially in children. It appears that the younger the onset of depression, the greater the risk of bipolar illness. But treating the depression can lead to antidepressant-induced mania (AIM) in children, and little is known about why that happens and which children are vulnerable. "We don't know whether these antidepressants trigger bipolar disease in vulnerable children or how best to treat them," said Kiki Chang, M.D., who chaired a symposium at the annual meeting of the American Academy of Child and Adolescent Psychiatry. Chang is a professor at Stanford University School of Medicine and director of the Pediatric Bipolar Disorders Program at Lucile Packard Children's Hospital.

Chang described how rates of AIM appear higher in such specialty clinics than is recognized in the literature. There is no clear evidence that antidepressants accelerate the natural course of bipolar disorder development in overall samples, but Chang recommends that in individual cases prescribers proceed cautiously when using these drugs in youth already at risk for developing bipolar disorder, such as those with ADHD and mood dysregulation, a history of AIM or psychosis, or a family history of bipolar disorder.

A recent study shows that the prevalence of bipolar disorder in youth is similar to that in adults. Read more in Psychiatric News here. Read more about bipolar disorder in the Handbook of Diagnosis and Treatment of Bipolar Disorders from American Psychiatric Publishing.

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