APA Reiterates Stringent Rules on Accepting Pharma Support

APA today is reiterating the extraordinary measures it has taken to ensure that APA's DSM-5 and practice guidelines are free from industry-influenced bias.

In an official APA statement DSM-5 Task Force Chair David Kupfer, M.D., emphasized that as a precondition to appointment to work on DSM-5, all task force and work group members were required to disclose any industry interests or potentially conflicting relationships and must have pledged to abide by rules limiting their involvement with pharmaceutical firms or other industry groups.

The APA statement came in response to a December 26 article in the Washington Post examining pharmaceutical industry influence on decisions regarding DSM-5, especially a decision to remove the so-called “grief exclusion” from criteria for a diagnosis of major depression. The Post article alleged that the decision was influenced by ties to the pharmaceutical industry by some DSM-5 contributors and that the industry will reap a a large financial windfall as a result of the change in diagnostic criteria.

In  his statement, Kupfer strongly disagreed and emphasized the following crucial steps APA has taken to safeguard DSM-5 decision making from industry influence: 

• All DSM-5 Task Force and work group members agreed that starting in 2007 and continuing for the duration of their work on DSM-5, their total annual income derived from industry sources (excluding unrestricted research grants) would not exceed $10,000 in any calendar year. 
• Participants agreed not to hold stock or shares valued at more than $50,000 in any pharmaceutical or device company.
• All work group and task force members agreed to serve in a volunteer capacity without compensation for their efforts on DSM-5.
• Participants' disclosures have been updated annually and have been actively monitored during the duration of work on DSM-5.

Similar steps have been taken to ensure that APA's practice guidelines are free of industry influence.

With regard to the removal of the grief exclusion from DSM-5, Kupfer said the decision was guided by research demonstrating that major depression and normal grief are significantly different from each other. And he noted that the new criteria emphasize the need for clinicians to differentiate between normal grieving associated with a significant loss and a diagnosis of a mental disorder. “[I]t is important to realize that DSM-5 includes material to make sure that it is understood that sadness, grief, and bereavement are not things that have a time limitation to them or go away within 2 or 3 months,” Kupfer said in the statement. "These feelings and emotions can persist a year and perhaps beyond. We need to more clearly understand the differences between sadness and grief and those conditions that require intervention."

DSM-5 will be published in May. The complete statement by APA can be accessed here.

Hurricane Sandy Damaged and Disrupted New York's Mental Health System

New York City’s mental health system took a big hit from Hurricane Sandy, according to a report in the New York Times this week. The huge storm surge left several of the city's largest psychiatric hospitals unusable, disrupted outpatient services, and flooded scores of nursing homes and adult-care homes where many people with mental illness had found housing of last resort, according to the Times.

After Bellevue Hospital Center, NYU Medical Center, and the Veteran’s Affairs Medical Center were shuttered in the wake of the storm, other hospitals in the city were inundated by a sharp rise in psychiatric emergencies. For instance, Beth Israel Medical Center, recorded a 69 percent spike in psychiatric emergency room cases in November, with its inpatient slots overflowing capacity. Instead of admitting more than 1 out of 3 such cases, as it did the year prior, it admitted only one1 out of 4 of the 691 emergency arrivals this November. Capacity was so overtaxed that ambulances had to be diverted to other hospitals 15 times in the month, almost double the rate of last year, according to the Times.

Psychiatric News reported on the response of psychiatrists to the crisis caused by Hurricane Sandy. Read that report here.

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Concerns Raised About Security Breaches in Electronic Medical Record Systems

Many of the electronic medical record systems hospitals and physician groups are rushing to install are vulnerable to security breaches from hackers, finds a year-long investigation by the Washington Post reported in yesterday's edition of the paper. The report cited security researchers who warned that "intruders could exploit known gaps to steal patients' records for use in identify theft schemes and even launch disruptive attacks that could shut down critical hospital systems." Avi Rubin, technical director of Johns Hopkins University's Information Security Institute, said he has "never seen an industry with more gaping security holes." While major breaches of hospital record systems have been rare to date as hackers focus on corporate and military systems, Department of Homeland Security officials told the Post that they are concerned that medical systems offer "an inviting target to activist hackers, cyberwarriors, criminals, and terrorists."

Part of the problem, Rubin noted, is a lax security culture in which physicians and other medical staff "sidestep basic security measures, such as passwords, in favor of convenience." Vulnerabilities in medical records software from several manufacturers were identified during the investigation, with the companies acknowledging the gaps and fixing the problems. Last July, the report notes, a consortium of hospitals, health plans, pharmacies, drug companies, and government agencies responded to the growing security threat by establishing the Health Information Trust Alliance to defend against "cyber crime, cyber espionage, and cyber activism."

Read the full report here. For more information about electronic health record systems, see Psychiatric News here and here.

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Inflammation Biomarker Linked to Depression

Elevated levels in a common blood test used to measure inflammation are associated with increased risk for psychological distress and depression, according to Danish researchers writing online December 24 in Archives of General Psychiatry. Their study looked at the medical records of 73,131 people in Copenhagen. Odds ratios of distress, use of antidepressants, and hospitalization for depression were about double that of the general population for people with CRP levels above the standard cutoff of 10 mg/L.

How inflammation and depression interact is not well understood, wrote Børge Grønne Nordestgaard, M.D., D.M.Sc., of the Herlev Hospital, Copenhagen University Hospital in Denmark, but inflammation may cause depression by reducing levels of serotonin, or depression may cause inflammation by activating stress hormones.

“More research is needed to establish the direction of the association between CRP and depression,” said the researchers. In addition, intervention studies might test whether adding anti-inflammatory drugs to antidepressant treatment of depression would affect outcomes, they suggested.

To read more about recent research on the association between inflammation and psychiatric disorders, see Psychiatric News here and here.

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APA Objects to Comments of NRA President

APA strongly objects to language used by Wayne LaPierre, executive vice president and CEO of the National Rifle Association (NRA), in comments he made both Friday and today conveying the NRA’s response to the shooting at Sandy Hook Elementary School on December 14 in Newtown, Connecticut.

In a statement to the media distributed this afternoon, APA said that LaPierre’s assumption that horrendous crimes such as the one committed by shooter Adam Lanza are commonly perpetrated by persons with mental illness. In addition, he conflated mental illness with evil at several points in his talk and suggested that those who commit heinous gun crimes are “so possessed by voices and driven by demons that no sane person can ever possibly comprehend them,” a description that leads to the further stigmatization of people with mental illnesses.

APA President, Dilip Jeste, M.D., pointed out, “About one-quarter of all Americans have a mental disorder in any given year, and only a very small percentage of them will ever commit violent crimes. On today's ‘Meet the Press,’ Mr. LaPierre used the word ‘lunatic’ as a catchphrase for those who commit violent crimes. Such language is not only offensive, it further contributes to the idea that violent crimes are necessarily committed by people with mental disorders."

APA Medical Director and CEO James H. Scully, M.D., noted that contrary to LaPierre’s remarks, “people who are clearly not mentally ill commit violent crimes and perform terrible acts every day. Unfortunately, Mr. LaPierre’s statements serve only to increase the stigma around mental illness and further the misconception that those with mental disorders are likely to be dangerous.”

To read the full statement, click here.

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California Legislator Urges Biden to Consider State's Example in Funding Mental Health Services

In response to the mass shooting last week at a Newtown, Conn., elementary school, California State Senate President Pro Tem Darrell Steinberg told Vice President Joe Biden in a letter this week that the federal government should consider copying California’s strategy for funding mental health services. According to a report today in the Sacramento Bee, Steinberg told Biden that the federal government should adopt something similar to the Mental Health Services Act passed by California voters in 2004. That act levied a special tax on high-income residents to pay for housing, medication, therapy, and other services the mentally ill.

Steinberg, who cosponsored the legislation, said the act has been effective in promoting early and broad-ranging intervention. On Wednesday, President Obama instructed Biden to oversee the administration-wide review that also will consider gun-control legislation and ways to keep society from glamorizing guns and violence.

The program in California has not been without controversy. A 2010 study linked a drop in emergency psychiatric commitments in the state to the program’s effectiveness, but other reports have found that money has gone to programs not directly involved with early intervention for people with mental illness.

For more information about the program see Psychiatric News here.

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NIDA Finds Daily Marijuana Use by Teens Is Increasing

Continued high use of marijuana by the nation's eighth, 10th and 12th graders combined with a drop in perceptions of its potential harm was revealed in this year's Monitoring the Future survey, an annual survey of eighth, 10th, and 12th graders conducted by researchers at the University of Michigan. The survey was carried out in classrooms around the country earlier this year, under a grant from the National Institute on Drug Abuse (NIDA).

The 2012 survey shows that 6.5 percent of high school seniors smoke marijuana daily, up from 5.1 percent five years ago. Nearly 23 percent say they smoked it in the month prior to the survey, and just over 36 percent say they smoked it within the previous year. For 10th graders, 3.5 percent said they use marijuana daily, with 17 percent reporting past-month use and 28 percent reporting use in the past year.

The Monitoring the Future survey also showed that teens' perception of marijuana's harmfulness is declining, which can signal future increases in use. Only 41.7 percent of eighth graders see occasional use of marijuana as harmful; 66.9 percent see regular use as harmful.

There was good news in the report, however: compared with peak rates in the mid to late 1990s, daily cigarette use is down significantly among all three grades. Likewise, five-year trends showed significant decreases in alcohol use among nearly all grades and across all prevalence periods.

For more on the survey, click here. For information about reducing marijuana use, see Psychiatric News here.

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APA Responds to Issues Raised by Newtown Tragedy in Letter to Congress

APA President Dilip Jeste, M.D., sent a letter today on behalf of the Association to leaders of both the Senate and House of Representatives responding to the massacre in Newtown, Conn., and emphasizing that psychiatrists "stand ready to do whatever we can to help alleviate the suffering caused by the tragedy and to help the survivors cope with life after a trauma of this unimaginable magnitude."

Jeste also expressed APA's concern about proposals that have been voiced that target the mentally ill and media accounts that inaccurately portray people with mental illness. "Stigma remains one of the greatest barriers to early identification, intervention, and treatment for Americans seeking help for mental illness, and we hope that Congress will avoid making generalized assumptions about persons now in or seeking treatment for mental illness," he said. "The vast majority of violence in our society is not perpetrated by persons with serious mental disorders. Research suggests that individuals with mental illness engaged in regular treatment are considerably less likely to commit violent acts than those in need of, but not engaged in, appropriate mental health treatment." Highlighting the effectiveness of psychiatric treatment, Jeste urged policymakers to focus on the fact that "access to comprehensive, effective psychiatric treatment works. Yet at the very time of the Newtown tragedy, federal and state funding of critical mental health services is under siege," he said, pointing out that 29 states have eliminated a total of more than 3,200 psychiatric inpatient beds since 2008.

Jeste also called on Congress to address the abundance and easy availability of guns, saying that APA believes that "any discussion on fostering a robust mental health delivery system must not be isolated from discussions of streategies to reduce gun violence." He condemned laws to bar physicians from asking about the presence of guns in a patient's home and pointed out that APA has expressed support for "appropriately targeted proposals such as mental health registries and modified access to firearms as meaningful ways to curb gun violence."

The letter can be accessed on APA's Web site at http://www.psychiatry.org/advocacy--newsroom/advocacy/apa-sends-letter-to-congress-regarding-recent-shooting-in-newtownct.

(image: AP photo/Andrew Gombert, pool)

Stress-Related Gene and Child Abuse Can Interact to Raise PTSD Risk

A gene called FKBP5 is an important regulator of the stress hormone system. When individuals who possess a particular variant of that gene are victims of child abuse, they appear to be more susceptible to posttraumatic stress disorder (PTSD) later in life than individuals who possess another variant of the gene. This was a key finding of a study published in Nature Neuroscience, led by Elisabeth Binder of the Max Planck Institute of Psychiatry in Munich, Germany.

But how might the FKBP5 gene variant and child abuse interact to set the stage for such later sequelae? By changing DNA methylation in the FKBP5 gene,  Binder and her colleagues found. Such changes, according to other findings from the researchers, could then lead to a long-term dysregulation of the stress hormone system and impact brain areas associated with stress regulation.

Their results, they conclude, "provide insight into the molecular mechanisms and consequences of this gene x environment interaction, facilitating a better understanding of the pathophysiology of stress-related psychiatric disorders...and potentially aiding in the development of new treatments targeting this mechanism."

More information about epigenetics—the process by which genes are altered by the environment—and its influence on psychiatric disorders can be found in Psychiatric News here and here. Also read more on this topic in the American Journal of Psychiatry here.

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Meta-analysis of Chantix's Cardiovascular Risk Completed

The results are in, and they're not as daunting as expected. When the Food and Drug Administration (FDA) first expressed concerns about possible increased risk of cardiovascular adverse events associated with the smoking-cessation drug Chantix (varenicline) in a Drug Safety Communication (DSC) in June 2011, one of the steps the agency said it would take would be to require Pfizer, the drug’s manufacturer, to conduct a meta-analysis of controlled trials of the drug. The FDA has now presented the results of that meta-analysis, which showed a higher occurrence of major adverse cardiovascular events (a combined outcome of cardiovascular-related death, nonfatal heart attack, and nonfatal stroke) in patients using Chantix compared with those on placebo. These events, however, were uncommon in both the Chantix and placebo groups, and the increased risk was not statistically significant, which means it is uncertain whether the excess risk for the Chantix group was due to the drug or to chance.

The FDA advised health care professionals to weigh the risks of Chantix against its benefits, while noting that smoking is a major risk factor for cardiovascular disease, and Chantix is effective in helping patients quit smoking and abstain from it for as long as one year. “The health benefits of quitting smoking are immediate and substantial,” the agency emphasized in the communication. The Warnings and Precautions section of the Chantix label has been updated to include the results of the meta-analysis.

The DSC is posted at www.fda.gov/Drugs/DrugSafety/ucm330367.htm.

Data have also suggested that varenicline may be an effective treatment for patients with schizophrenia. Read more about that topic in Psychiatric News here. And for a study of genetic risk and smoking-cessation treatment, see the American Journal of Psychiatry here. 

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Autism Groups Renounce Speculation That Disorder Led to Violence in Newtown

As news of the Newtown, Conn., tragedy spread last week, one of the first questions to be answered was "Who was Adam Lanza, and why would he do this?" As friends and family members of Lanza and his mother described his odd and painfully shy personality, several mentioned that he might have had Asperger's syndrome or some other autism spectrum disorder. National autism groups were quick to point out that, although that may have been true, such diagnoses would have had nothing to do with his violent acts.

"The search for answers should not be a search for a scapegoat. Autism is no excuse or explanation to evil," said Autism Rights Watch on the organization's Web site. The group noted that autistic individuals are more likely to be victims, rather than perpetrators of violence, and urged the public and media outlets not to stigmatize these individuals and their families. "They already are facing segregation and prejudices on a daily basis," they said.

"Autism did not cause this horror," said Bob and Suzanne Wright, grandparents of a child with autism and founders of Autism Speaks, in a personal message on that organization's Web site. "The profound tragedy of these senseless murders will only be compounded if it results in unwarranted discrimination against people with autism."

For more information on this topic, see the new book Autism and Other Neurodevelopmental Disorders, available from American Psychiatric Publishing here.

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Connecticut Psychiatrists Mobilize in Newtown

The Connecticut Psychiatric Society (CPS) reacted swiftly to the tragic shooting at Sandy Hook Elementary School in Newtown, Conn., last Friday. CPS President John Santopietro, M.D., and Disaster Committee Chair Shaukat Khan, M.D., consulted that afternoon with APA experts on disaster psychiatry. Within hours, 100 CPS members responded to Santopietro’s e-mail requesting volunteers to help in the stricken town. By coincidence, CPS had conducted a disaster-response training session for members just a month before.

By Saturday afternoon, working through the Red Cross and state and local health agencies, CPS arranged for at least two psychiatrists to be on duty with other mental health professionals for three-hour shifts from 7 a.m. to 7 p.m. at a crisis-response center in Newtown. On Sunday, they met with more than 300 local children and adults.

More such help will be needed in the weeks, months, and years ahead to contain the suffering and anxiety caused by the shooting, said Santopietro.

“Concentric waves of psychological pain are rippling out from Newtown, and we want people to get excellent care,” he said. The CPS will continue working with area health and social-service agencies in that long-term effort.

More information about the APA's response to the tragedy in Newtown can be found on APA’s home page. Information about CPS is posted at www.ctpsych.org.

MH Care Access Blocked by Stigma, Ambivalence, Cost

In the wake of the Newtown, Conn., school shooting, APA President-elect Jeffery Lieberman, M.D., was interviewed by CBS News and "Charlie Rose" yesterday.

Why do these kinds of tragedies happen? Lieberman was asked in one interview. Perhaps some of this violence might be prevented if there were less stigma about mental illness and its treatment, he said. “We don’t do enough in our society to make available state-of-the-art mental health services,” he told CBS correspondent John Miller. Americans are still ambivalent or embarrassed about seeking mental health care. In addition, the nation still hasn’t developed the infrastructure to properly provide care, and inadequate insurance makes it difficult for many people to afford it.

The interview with Lieberman can be accessed here. For information that can be shared with patients, parents, and other members of the public, APA has posted a number of resources on its Web site regarding coping with tragedy. More information for psychiatrists can also be found in Disaster Psychiatry: Readiness, Evaluation, and Treatment

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APA Responds to Newtown Shooting

The shooting deaths of 20 children and six adults in Newtown, Conn., again reminded the nation of the need to help survivors, families of victims, and an entire community cope with overwhelming tragedy.

“On behalf of the leadership of the American Psychiatric Association and myself, I would like to convey our deepest sympathies to the families of the Connecticut victims touched by [Friday’s] unspeakable events,” said APA President Dilip Jeste, M.D. “APA stands ready to do whatever we can to help alleviate the suffering caused by the tragedy and help the survivors cope with life after a trauma of this unimaginable magnitude.” APA’s Committee on Psychiatric Dimensions of Disasters will be working with district branches and members to provide support materials and assistance, said Jeste.

In Connecticut, redeveloping a sense of safety for children was key for reducing the risk of deeper psychological trauma among the living, said child psychiatrist Louis Kraus, M.D., chair of APA’s Council on Children, Adolescents, and Their Families. Part of that effort means reestablishing routine. “You have to get them back to school," Kraus told Psychiatric News. “The longer they don’t get back, the longer it will take them to recover.”

Caring for survivors will be more complex because children respond to death differently depending on their developmental age, said Stephen Cozza, M.D., a professor of psychiatry at the Uniformed Services University of the Health Sciences. Cozza has studied and worked with children of military personnel who were killed or wounded. Children younger than age 6 may reenact the event or complain of somatic symptoms, like headaches or stomach aches, he said. “Others may exhibit magical thinking, believing they could have done something to prevent the event,” said Cozza. “We have to relieve the child of that misguided sense of responsibility.” Parents should minimize their children’s exposure to media stories about the event, said both Kraus and Cozza.

Parents of the child victims will have the extraordinary burden of living with their own grief while trying to care for their other children, said Cozza. “We know less about the effects of these events on siblings,” he said. “They can also feel survivors’ guilt and may feel responsible for continuing some tradition within the family that the victim once did.”

For more in Psychiatric News about mass shootings, click here. Also, see the book Disaster Psychiatry: Readiness, Evaluation, and Treatment from American Psychiatric Publishing. APA's homepage also contains a message from Jeste and valuable information about responding to mass tragedies.

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Study Finds Link Between Psychosocial Distress, Stroke Risk

Increasing levels of psychosocial distress appear to be related to excess risk of both fatal and nonfatal stroke in older black and white adults, according to a report published online yesterday in Stroke.   
Study author Susan Everson Rose, Ph.D., M.P.H., and colleagues at the University of Minnesota used data from the Chicago Health and Aging Project, a longitudinal population-based study conducted in three contiguous neighborhoods on the south side of Chicago. Baseline interviews were conducted in participants’ homes between 1993 and 1999 and included questions on medical history, cognitive health, socioeconomic status, behavioral patterns, and psychosocial characteristics.

There were 4,120 participants for whom there was follow-up data about fatal strokes and 2,649 for whom there was data on nonfatal stroke. Adjusting for age, race, and sex, the hazard ratio for an increase of one standard deviation in scores for "psychosocial distress" was 1.47 for stroke mortality and 1.18 incident stroke.

“This study identified a robust relationship between psychosocial distress and increased risk of stroke mortality and incident stroke in over six years of follow-up,” the authors said. “Moreover, a clear dose–response pattern of associations was evident, with the most distressed participants experiencing more than a 2-fold increased risk of stroke mortality and a 31% increased risk of incident stroke, compared with their least-distressed peers….”

For more information about a link between psychiatric illness and cardiovascular disease, see Psychiatric News here and here.  

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Canadian Forces Describe Multiple Mental Health Problems

Almost one in three members of Canadian Forces deployed to Kandahar, Afghanistan, and surveyed in 2010 reported suffering a stress, emotional, alcohol, or family problem, according to a report in the December Canadian Journal of Psychiatry. In the same survey, 8.5 percent of the 1,572 respondents’ described symptoms of acute traumatic stress, major depression, or generalized anxiety that exceeded civilian criteria, reported Bryan Garber, M.D., M.Sc., of the Directorate of Mental Health, Canadian Forces Health Services Group Headquarters, in Ottawa. Only 26 percent of respondents with a mental health problem expressed an interest in getting help.

Greater combat exposure and being based in more-isolated posts increased the prevalence of those three mental health or behavioral problems.

“The needs base for psychosocial support extends beyond personnel who meet conventional questionnaire criteria for traumatic stress, depression, or generalized anxiety,” concluded Garber and colleagues. “Future research is needed to understand what precise problems are driving this larger needs base and what precise supports (clinical or nonclinical) would be most appropriate.”

For more in Psychiatric News about research into military mental health, click here.

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Older Americans Concerned About Mental Health Care They Receive, Survey Finds

A survey released today of Americans aged 65 and older finds troubling gaps in the care these individuals receive for mental illnesses. Among the key findings are that 46% of seniors who are in treatment for a mental health problem said their provider did not follow up with them within a few weeks of their beginning treatment to see how they were doing and that 38% said that their provider had not discussed the possible side effects of prescribed medications. The findings are from a survey of more than 1,300 older adults conducted in November and published in a report by the John A. Hartford Foundation, which describes itself as "a committed champion of health care training, research, and service-system innovations that will ensure the well-being and vitality of older adults."

In addition, 33% of respondents said their provider failed to discuss treatment options, 40% said there was no discussion of how long treatment might last, and 34% said they were not told what steps to take if their condition seemed to worsen. The survey also asked survey participants about their knowledge of depression. Judging from the responses, considerably more education is needed, particularly regarding the links between depression and overall health. For example, only 34% were aware that depression is associated with a substantial risk of heart disease, a link that has been described in multiple studies and reported extensively.

To read more about the findings of this survey, click here. To read more about the relationship between depression and cardiovascular disease, see Psychiatric News here and here. Read more about depression and aging in the American Journal of Psychiatry here.

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Federal Rule Could Make It Easier for Thousands of Vets to Receive Benefits for TBI

The Department of Veterans Affairs this week issued a new proposed rule that will make it easier for veterans to receive health care and compensation for certain illnesses that have been linked to traumatic brain injury (TBI). The proposed rule lists Parkinsonism, unprovoked seizures, certain dementias, depression, and hormone-deficiency diseases related to the hypothalamus, pituitary, or adrenal glands as eligible for the expanded benefits. The proposed rule will be open to public comment for 60 days before being finalized. 

A December 7 New York Times article on the proposed rule notes that it could open the door to tens of thousands of veterans filing claims with the VA. Since 2000, more than 250,000 service members have received diagnoses of TBI. Though TBI is commonly thought to result from blast exposure, the vast majority of those injuries were diagnosed in nondeployed troops who were involved in vehicle crashes, training accidents, or sports injuries, according to the Times. The Department of Veterans Affairs says that a much smaller number of veterans—about 51,000—are receiving benefits for service-connected TBIs. However the department acknowledges that thousands more troops with TBI may be eligible for the expanded benefits.

The text of the proposed rule in the Federal Register is posted here. For more information on traumatic brain injury and the role of psychiatry in treating it, see Psychiatric News here. Also see the Textbook of Traumatic Brain Injury, Second Edition, from American Psychiatric Publishing.

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Discovery of "Pain Gene" Paves Way to Personalized Pain Treatment

In a genomewide association study of some 1,800 subjects, Japanese scientists have identified a gene on chromosome 2 that appears to influence both pain sensitivity and susceptibility to substance dependence. In fact, as the scientists write in Molecular Psychiatry, it appears to be the most potent gene associated with human opioid sensitivity that has been identified.

The scientists are also attempting to harness their discovery to create personalized treatment for pain. As the lead scientist, Kazutaka Ikeda, Ph.D., of the Tokyo Metropolitan Institute of Medical Science, explained to Psychiatric News, "We predict [before surgery] the  right amount of opioid analgesic each patient will need postoperatively according to [the variant of the pain gene they possesss] together with other information about height, weight, gender, and pain sensitivity. Furthermore, we will apply the equation to predict the adequate amount of analgesic for cancer pain in the future."

Information about how psychiatrists can help patients suffering from chronic pain can be found in Psychiatric News here, here, and here. In addition, the Clinical Manual of Pain Management in Psychiatry is available through American Psychiatric Publishing.

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Study Finds Link Between Air Pollution and Autism

Though the etiology of autism is complex but still unclear, scientists have linked a novel factor—traffic-related air pollution—with autism rates, according to a report in the Archives of General Psychiatry. Heather Volk, Ph.D., of the University of Southern California, and her colleagues found that children living in areas with high levels of traffic-related air pollution were three times more likely to have autism than were children in areas with low levels of such pollutants. Moreover, the children with autism in this study were twice as likely as controls to have been exposed to high levels of traffic air pollution during their mother's pregnancy and three times as likely to have been exposed to high levels of such pollution during their first year of life. The findings did not change after possibly confounding factors such as ethnicity, parental education, and maternal smoking during pregnancy were considered.

"This study is a major contribution to the literature regarding factors potentially involved in the cause of autism," Christopher McDougle, M.D., a professor of autism at Harvard Medical School, told Psychiatric News. "While we know that genetic contributions exist, it is clear that environmental factors are also important. To date, few environmental factors related to the cause of autism have been identified by rigorous scientific investigation."

Read more about autism risk factors in the American Journal of Psychiatry and in the Textbook of Autism Spectrum Disorders, published by American Psychiatric Publishing.

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Benzodiazepines May Increase Pneumonia Risk, Study Finds

Benzodiazepines were associated with an increased risk of, and mortality from, community acquired pneumonia (CAP), according to a report published online in the journal Thorax. British researchers looked at 29,697 controls and 4,964 cases of CAP from The Health Improvement Network, a U.K. primary care patient database, to investigate a reported link between benzodiazepines and pneumonia.

They found that diazepam, lorazepam, and temazepam, but not chlordiazepoxide, were associated with an increased incidence of CAP. As a class, benzodiazepines were associated with increased 30-day and long-term mortality in patients with a prior diagnosis of CAP. Individually diazepam, chlordiazepoxide, lorazepam, and temazepam affected long-term mortality in these patients.

“Benzodiazepines and zopiclone are commonly prescribed medications that have significant immune effects, the researchers said. “Our data…suggest that they may increase both the risk of and mortality from pneumonia. This is consistent with data from clinical trials and concerns expressed over the intensive care unit effects of these drugs leading to movement away from benzodiazepine sedation. Nonetheless, given the widespread use of benzodiazepine drugs, further studies are required to evaluate their safety in the context of infection.”

Read more about this study here. For more information about risks associated with benzodiazepines, see Psychiatric News. 

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Study Finds Resilience and No Depression Equal Successful Aging

Aging individuals who have mental and emotional resilience—and who do not suffer from clinical depression—report high rates of “successful aging” even in the face of worsening physical and/or cognitive functioning. 

The finding from a survey of older adults published online today in the American Journal of Psychiatry upends the stereotype of old age as a uniformly unhappy experience. And—even more surprising—the older the adult the more likely he or she was to report a high degree of successful aging. In fact, older age was associated with a higher rating of successful aging, despite worsening physical and cognitive functioning.

“It was clear to us that, even in the midst of physical or cognitive decline, individuals in our study reported feeling that their well-being had improved with age,” lead author and APA President Dilip Jeste, M.D., told Psychiatric News. “This counterintuitive increase in well-being with aging persisted even after accounting for variables like income, education, and marriage.”

In the Successful Aging Evaluation (SAGE) study, Jeste and colleagues surveyed 1,006 community-dwelling adults aged 50 to 99 in San Diego County, with an oversample of people over age 80. The adults answered a 25-minute telephone interview followed by a comprehensive mail-in survey of physical, cognitive, and psychological domains, including positive psychological traits and self-rated successful aging, scaled from 1 (lowest) to 10 (highest). The average self-rating of successful aging was 8.2, with older individuals in the cohort reporting higher rates of successful aging despite worsening physical and cognitive functioning. People with poor physical health but high resilience scores had self-ratings of successful aging similar to those of physically healthy people with low resilience. Likewise, people with poor physical functioning but no or minimal depression had scores for successful aging comparable to those of physically healthy people with moderate to severe depression.

Jeste said the message for clinicians is that an optimistic approach to the care of seniors may help reduce societal ageism. “There is considerable discussion in public forums about the financial drain on society due to rising costs of health care for older adults.... But, successfully aging older adults can be a great resource for younger generations,” he said. “Perfect physical health is neither necessary nor sufficient” for successful aging, Jeste said. “There is potential for enhancing successful aging by fostering resilience and treating or preventing depression.”

“Association Between Older Age and More Successful Aging: Critical Role of Resilience and Depression is here. For more information on this topic go here.

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Mental Health Disparities: Is It Who You Are or Where You Live?

Racial and ethnic disparities in medical care are well-documented reasons explaining many variations in health outcomes. But are race and ethnicity the only reasons for those disparities? Researchers tracked the introduction of the long-acting injectable antipsychotic risperidone for 2.5 years after its introduction into the drug formulary of the Florida Medicaid program.

Their study covered 13,992 Medicaid beneficiaries, of whom 25 percent were black, 37 percent Latino, and 38 percent white. Adjustment for need confirmed a disparity between Latinos and whites (odds ratio=.58). However, including geographic location in the model eliminated the Latino-white disparity but confirmed the role of geographic variation in adoption of the long-acting injectable version of risperidone, wrote the RAND Corporation’s Marcela Horvitz-Lennon, M.D., M.P.H., and colleagues in the just-released December Psychiatric Services.

The authors suggest that cultural or organizational factors may play a role in these geographic differences. Culturally, the views of opinion leaders among physicians or attitudes toward pharmaceutical promotion of a new medication version might have influenced adoption of this medication. Alternatively, a key organizational factor might have been geographic variations in the availability of nurses to administer these injections.

For an abstract of this article see Psychiatric Services. To read more about issues surrounding mental health disparities, see Psychiatric News here and here.

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Defense Bill Could Help Troops' Mental Health

The National Defense Authorization Act just passed by the U.S. Senate includes several new provisions affecting mental health care. The bill will allow family members to access some Department of Veterans Affairs (VA) mental health services, for example, and will increase oversight of the Integrated Disability Evaluation System jointly established by the Department of Defense and the VA.

In addition, the act includes an amendment proposed by Senate Veterans Affairs Committee Chair Patty Murray (D-Wash.) requiring the Pentagon “to implement a standardized and comprehensive suicide prevention program.”

The number of suicides by active-duty troops had risen to 166 by October 31, 2012, more than the total number for all of 2011. “[T]his amendment seeks to reduce wait times and improve access to mental health care; ensure proper diagnosis; and achieve true coordination of care and information between the U.S. Departments of Defense and Veterans Affairs,” said Murray in a statement. The House of Representative must now vote on the bill.

To read more about military-related mental health issues, see Psychiatric News  here and here.

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Study Refutes Claims of Inappropriate Psychotropic Prescribing in Youth

Over the last several years there have been charges—often based on anecdotal reports—that children and adolescents are frequently prescribed psychotropic medications for conditions they don't have or disorders for which a particular medication is not indicated. However, a new study by researchers at the National Institute of Mental Health (NIMH) of more than 10,000 U.S. teenagers refutes such claims. Their finding were published online Monday in the Archives of Pediatric and Adolescent Medicine. The research team, headed by Kathleen Merikangas, Ph.D., chief of the Genetic Epidemiology Research Branch at NIMH, collected data on specific medication use in the National Comorbidity Study—Adolescent Supplement, which is a face-to-face survey of youth aged 13 to 18. Their data focused on teens who met criteria for a variety of mental disorders; medications included antipsychotics, antidepressants, and stimulants.

They found that among teens meeting criteria for any mental disorder, just 14.2% said that they had been treated with a psychotropic medication. Those with ADHD had the highest rates of prescribed medication use at 31%, while 19.7% with a mood disorder like depression or bipolar disorder were taking psychotropic medication. Among those with eating disorders, about 19% were taking such drugs, and 11.6% of teens with anxiety disorders reported taking these medication. Very few reported use of antipsychotic medications. In addition, 2.5% of respondents who did not have a diagnosed mental disorder were prescribed a psychotropic medication, of whom 78% had a previous mental or neurodevelopmental disorder and associated psychological distress or impairment.

Thus, they concluded, "most adolescent youth who are taking psychotropic medications have serious behavioral, cognitive, or emotional disturbances."

For a comprehensive review of psychotropic medications in young patients, see Clinical Manual of Child and Adolescent Psychopharmacology, Second Edition, new from American Psychiatric Publishing.

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Does Poor Cardiovascular Fitness in Adolescence Raise Depression Risk?

A lack of cardiovascular fitness in men at age 18 may predict increased risk for serious depression years later. So suggests a Swedish prospective population-based study headed by Maria Aberg, M.D., Ph.D., of the University of Gothenburg. The study cohort included over 1 million male military conscripts born betweeen 1950 and 1987 who had no history of mental illness and who were followed from three to 40 years. Data on cardiovascular fitness at conscription were linked with Sweden's national hospital registers to calculate future risk of depression.

The study's findings "strengthen the theory of a cardiovascular contribution to the etiology of depression," the researchers wrote in their research report, which appears in the British Journal of Psychiatry. "Intervention studies are [now] needed to determine whether physical exercise in young adulthood can prevent future onset of depression."

There has been considerable research in the last few years on the link between cardiovascular factors and depression. Read more about that topic in Psychiatric News here and here.

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Reform Law Offers Opportunities for Better Mental Illness Prevention

With implementation of the Affordable Care Act (ACA) on the horizon, a group of prominent psychiatrists has identified multiple opportunities that the health care reform law provides for improved mental illness prevention and mental health promotion. Several of these opportunities arise in the integrated-care settings that the ACA fosters and for which it provides financial incentives. Writing in the new issue of Psychiatric Services, members of the Prevention Committee of the Group for the Advancement of Psychiatry (GAP) say that as a result of the ACA's twin focuses on integrated care and illness prevention, "psychiatry is in a position to advance the goal of prevention of mental illnesses and promotion of emotional and mental well-being." However for this to occur, psychiatrists "must strive to incorporate behavioral health promotion and prevention into these integrated care initiatives" through, for example, ensuring that mental health screening, such as with the nine-item Patient Health Questionnaire is an integral part of primary care visits, that brief interventions and referrals for substance abuse treatment are available, and that physicians discuss firearm safety with patients.

Among opportunities for psychiatrists opened up by the ACA, the committee points out, are collaborations with primary care on "culturally and developmentally sensitive methods of screening for risk factors and adverse health behaviors, such as substance abuse, domestic violence, and firearm ownership." In addition, "using a developmental perspective, psychiatrists could provide primary care–based interventions focused on enhancing strengths and protective factors among young people and their parents."

Read more about the recommendations of the GAP Prevention Committee in Psychiatric Services. Also see Psychiatric News for reports on psychiatry and collaborative care.

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Data Show Naltrexone Counters Smoking-Cessation Weight Gain

Naltrexone, a mu opioid receptor antagonist, appears to be the first medication shown to counter weight gain resulting from smoking cessation, according to a study published in Biological Psychiatry. The lead researcher was Andrew King, Ph.D., a professor of psychiatry at the University of Chicago. The study included 700 subjects who had stopped smoking. Six to 12 weeks after the quitting date, the subjects were randomly assigned to receive either naltrexone or a placebo. The subjects' weight was evaluated at baseline, six months later, and finally a year later.

Female subjects who had received naltrexone gained 40% less weight six months later and 20% less weight a year later than did those who had received a placebo. Naltrexone had no impact on weight gain in male subjects, however. The reason why it helped women, but not men, the researchers suggested, may be because "the opioid system has been shown to be involved in sweet and palatable food intake, eating hedonics, and sugar bingeing, [and] women are more likely than men to have disordered eating and binge on high-fat and sweet foods."

Naltrexone also reduces alcohol craving by blocking the mu opioid receptor. It was approved by the Food and Drug Administration more than a decade ago for treating alcohol dependence. See Psychiatric News for information on that topic. However, naltrexone seems to benefit certain individuals with alcohol dependence more than others depending on which variant of the gene that makes the mu opioid receptor they've inherited. Read more about that in Psychiatric News as well. To read about a naltrexone implant in drug addiction patients, see the American Journal of Psychiatry.

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Physiological Explanation for "Chemo Brain" Suggested

Some cancer patients who receive chemotherapy complain that their brains don't function as well as they used to. A physiological basis for such so-called "chemo brain" complaints now may have been identified. The finding was reported at a recent Radiological Society of North America meeting by Rachel Lagos, D.O., a diagnostic radiology resident at West Virginia University. Lagos and her colleagues used PET/CT brain imaging as well as special software to compare brain metabolism after chemotherapy with brain metabolism before chemotherapy in 128 breast cancer patients. Results showed two brain regions with decreased metabolism post-chemotherapy—the superior medial frontal gyrus and the temporal operculum.

"The superior medial frontal gyrus is known to be responsible for prioritizing, problem-solving, and organizing," Lagos told Psychiatric News. "The temporal operculum is responsible for long-term memory. Chemotherapy patients who describe 'chemo brain' often describe deficits in these tasks."

More information about "chemo brain" and the broader interface between cancer and psychiatry can be found in Psychiatric News here and here.

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APA Board of Trustees Approves DSM-5

At its December meeting today, APA’s Board of Trustees approved the final diagnostic categories and criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The trustees’ action marks the end of the manual’s comprehensive revision process, which has spanned over a decade and included contributions from more than 1,500 experts. These final diagnoses and descriptive criteria will be available when DSM-5 is completed and published in May 2013.

“The Board of Trustees approval of the criteria is a vote of confidence for DSM-5,” said Dilip Jeste, MD, president of APA. “We developed DSM-5 by utilizing the best experts in the field and extensive reviews of the scientific literature and original research, and we have produced a manual that best represents the current science and will be useful to clinicians and the patients they serve.”

“We have sought to be very conservative in our approach to revising DSM-5. Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry,” said David J. Kupfer, M.D., chair of the DSM-5 Task Force. “I’m thrilled to have the Board of Trustees’ support for the revisions and for us to move forward toward the publication."

The manual will include approximately the same number of disorders as were included in DSM-IV. The manual is composed of three sections:

•  Section 1 will give an introduction to DSM-5 with information on how to use the updated manual.

•  Section 2 will outline the categorical diagnoses according to a revised chapter organization.

•  Section 3 will include conditions that require further research before their consideration as formal disorders, as well as cultural concepts of distress, the names of individuals involved in DSM-5’s development, and other information.

Key decisions made by the Board of Trustees include the following:

•  Overall Substantive Changes

o   Chapter order

o   Removal of multiaxial system

•  Section 2 Disorders

o   Autism spectrum disorder

o   Binge eating disorder

o   Disruptive mood dysregulation disorder

o   Excoriation (skin-picking) disorder

o   Hoarding disorder

o   Pedophilic disorder

o   Personality disorders

o   Posttraumatic stress disorder

o   Removal of bereavement exclusion

o   Specific learning disorders

o   Substance use disorder

 

•  Section 3 Disorders

o   Attenuated psychosis syndrome

o   Internet use gaming disorder

o   Nonsuicidal self-injury

o   Suicidal behavioral disorder

•   Disorders Not Accepted for Sections 2 or 3

o   Anxious depression

o   Hypersexual disorder

o   Parental alienation syndrome

o   Sensory processing disorder

Click here to read a message about DSM-5’s development by APA President Dilip Jeste, M.D. More information will be published in the December 21 issue of Psychiatric News.