APA Battles Bill Allowing Psychologists to Prescribe in Illinois

APA is working with the Illinois Psychiatric Society (IPS) to contest against a bill recently introduced to the Illinois Senate that would allow psychologists to prescribe medications to their patients. The bill (SB 2187) stipulates that the Illinois Psychological Society is to provide 20 percent of the training psychologists would need to prescribe in the state. The psychologists would also be overseen by the Illinois Psychological Licensing Board instead of the state medical licensing board (which is the case for Louisiana and New Mexico, the only other states allowing psychologists to prescribe).

“As it was deliberately drafted, the bill directly financially benefits the Illinois Psychological Association,” said Lisa Rone, M.D., a past president of the IPS and a current IPS representative to the APA Assembly in a recent interview with Psychiatric News, “this is an appalling conflict of interest.”

The bill would require “graduation with a master’s degree in clinical psychopharmacology from a regionally accredited institution,” which could be interpreted to include online programs.

To read more on this bill, read the advanced article from Psychiatric News here. 

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Preschoolers With ADHD Maintain Symptoms

Four-year-olds with attention-deficit/hyperactivity disorder (ADHD) still retain significant levels of symptoms when they reach age 10, according to the latest report from a long-term study of children with the disorder, reported in the March Journal of the American Academy of Child and Adolescent Psychiatry. Researchers led by Mark Riddle, M.D., a professor of psychiatry and behavioral sciences at Johns Hopkins Hospital, followed 207 children (75 percent male) from an average age of 4.4 to an average age of 10.4 as part of the Preschool ADHD Treatment Study (PATS).

Symptom severity declined from ages 4 to 7, but changed little afterwards. Whether the children were taking medications made little difference in severity of symptoms after age 7. A diagnosis of oppositional defiant disorder and/or conduct disorder increased the risk of an ADHD diagnosis by 30 percent at age 10. Even with the use of medications, symptoms and impairment remain, concluded the researchers. “Development of more effective ADHD intervention strategies is needed for this age group.”

For more in Psychiatric News about ADHD in young children, click here. Also see the American Journal of Psychiatry here.

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New Evidence Found for Pathways of Schizophrenia

In a search for causes of schizophrenia, Jong Yoon, M.D., of the University of California, Davis, and colleagues used functional magnetic resonance imaging to examine brain activity in the prefrontal cortex and basal ganglia of 18 people with schizophrenia and 19 healthy controls, according to a science update from the National Institute of Mental Health. The basal ganglia include the ventral tegmental area and the substantia nigra, major sources of dopamine, as well as the striatum, an important site for the action of dopamine.

Yoon and colleagues found increased activity in the substantia nigra along with less activity in the prefrontal and striatal regions among the schizophrenia group, compared with controls. At the same time, there was less prefrontal functional connectivity with the basal ganglia regions in those with schizophrenia. Patients with greater connectivity between the substantia nigra and the striatum had higher levels of psychosis as well.

“These results suggest that functional impairments of the prefrontal striatonigral circuit may be a common pathway linking the pathogenesis of cognitive deficits and psychosis in schizophrenia,” concluded the authors, in an earlier report in Biological Psychiatry.

To read more about the neuroanatomical basis of schizophrenia, see Psychiatric News here.

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Prevention of Metabolic Disease in Schizophrenia Easier Early in Disease

Patients having their first episode of schizophrenia have a significantly lower risk of cardiovascular disease than chronic schizophrenia patients, according to a meta-analysis in the February Schizophrenia Bulletin. The study suggests that clinicians should focus on preventing initial cardiometabolic risk because subsequent reduction in this risk is more difficult to achieve.

Belgian researchers conducted a systematic search of studies looking at cardiometabolic risk in first-episode and chronic patients through December 2011. Twenty six studies examined first-episode patients and 19 included unmedicated patients). For comparison, they identified 78 publications involving chronic patients who were already established on antipsychotic medication. They found that in first-episode and unmedicated patients, all metabolic components and risk factors—diabetes, hyperglycemia, overweight, hypertriglyceridemia, high blood pressure, and smoking—were significantly less common than in those already established on antipsychotic medication. Some of the risk factors, such as waist size, smoking, and blood pressure were significantly lower in unmedicated patients than in first-episode patients who had started medication.

“Some metabolic risk factors...may be present soon after diagnosis but most metabolic complications will take time to develop, offering an important target for prevention,” the researchers said. “Weight gain is a key target that accumulates soon after starting antipsychotic medication. Clinicians should focus on preventing initial cardiometabolic risk because subsequent reduction in this risk is more difficult to achieve, either through behavioral or pharmacologic interventions.”

For more information about metabolic disease and antipsychotic medication, see Psychiatric News here.

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Sequestration Looms With Consequences for Mental Health

Unless Congress and the White House agree on a package of revenue increases and spending reductions by March 1, sequestration—automatic across-the-board spending cuts—will be imposed that can have a dramatic impact on APA members and their patients. In a memorandum to the APA leadership yesterday, APA Director of Government Relations Nicholas Meyers said at present action to avert the sequestration appears remote.

Meyers noted that the Obama administration has said cuts to the Mental Health Block Grant would mean that some 373,000 seriously mentally ill adults and children will not receive needed mental health services. Among other consequences, NIH research would face project cancellations and thousands of potential layoffs, and the FDA would face delays in new drug approvals. And Medicare—including payments to physicians—faces a 2 percent across-the-board reduction.

APA president Dilip Jeste, M,D., told Psychiatric News that he is “very concerned that the sequestration will have a damaging impact on the care of seriously mentally ill patients, who already lack adequate access to needed services." The proposed cuts in Medicare and NIH funding would also adversely affect clinicians and researchers across the country, Jeste said. “I still hope that this cascade of unfortunate events can be avoided by prudent action on the part of Congress and the administration."

Members who want to review the likely impact on their home state can click here. Members who have not already done so should use the link here to access the Action Alert page and select the sequestration alert. (You may need your member ID to access the Alert.)

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Discovery Could Point Way to New Mood-Stabilizing Drugs

The neuropeptide cholecystokinin may play a key role in mania, Colleen McClung, Ph.D., an associate professor of psychiatry at the University of Pittsburgh, and her colleagues report in Molecular Psychiatry. They engineered a mouse model of bipolar disorder. Then using these mice, they found that the ventral tegmental area of the brain is crucial for mania. The ventral tegmental area—a group of neurons in the center of the brain—sends information to the nearby nucleus accumbens. The  ventral tegmental area and the nucleus accumbens are the reward circuit of the brain. The researchers then found a decreased expression of cholecystokinin in the ventral tegmental area and that an increase in cholecystokinin in this area is necessary for lithium to counter mania.

Thus "it is possible that the decreased cholecystokinin levels in the ventral tegmental area of the mice are responsible for their mania," McClung and her colleagues said. "The hope is that these studies will help identify more selective therapeutic targets for the development of novel mood-stabilizing medications, which may be more effective with fewer side effects than current treatments."

More information about the mouse model of bipolar disorder that was engineered by McClung and her team can be found in Psychiatric News. More information about bipolar disorder can be found in a new American Psychiatric Publishing book, Clinical Guide to Depression and Bipolar Disorder.

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APA Responds to NRA's Mischaracterization of People With Mental Illness

APA is responding once again to mischaracterization of people with mental illness within the context of the current debate on firearms. In a recent interview on NPR’s "Weekend Edition," David Keene, president of the National Rifle Association, spoke about mental illness as it relates to crime, saying “…we destroyed our mental health care system.... There are more people in our prisons who have been diagnosed as severely mentally ill than in all the public and private mental health facilities in that state. And it's those people … who are slipping into that state that we really need to deal with.”

In a letter to Rachel Martin, host of NPR's "Weekend Edition Sunday," APA President Dilip Jeste, M.D., wrote: "While it is an unfortunate truth that there is a serious need for better mental health care in America, and many with mental illness end up in prison, Mr. Keene’s insinuation that the mentally ill pose a greater risk of violence than the general population is just plain wrong. More than 90 percent of violent acts are committed by people without a mental illness, and a majority of the mentally ill people in prison are incarcerated for nonviolent crimes. Mentally ill individuals are far more likely to be victims of crime than perpetrators. In the current debate on reducing gun-related violence, one should not make people with serious mental illnesses a convenient target of attack."

Jeste called on Martin to help end the stigma against people with mental illness by acknowledging his letter on the air "in order to give hope to the nearly one-fifth of your listenership who struggle every day with a mental illness."

The full content of Jeste's letter to Martin can be accessed here.

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APA Election Results Announced

APA's Committee of Tellers met today and approved the following results for APA's 2013 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its March 23-24 meeting in Arlington, Va.

President-Elect
Paul Summergrad, MD

Secretary

Maria Oquendo, MD

 

Minority/Under-Represented (M/UR) Trustee

Gail Robinson, MD

Area 3 Trustee
Brian Crowley, MD

Area 6 Trustee

Marc Graff, MD

Member-in-Training Trustee-Elect (MITTE)
Lara Cox, MD, MS

Nicotine Vaccine Study Describes Promising Results

Researchers at the Yale School of Medicine published promising results of their study of a nicotine vaccine today in AJP in Advance. Irina Esterlis, Ph.D., an assistant professor of psychiatry and of diagnostic radiology at Yale, and colleagues immunized 11 patients with a vaccine against nicotine, considered the most addictive constituent of cigarettes. The vaccine causes the production of antibodies specific to the nicotine molecule. The nicotine-antibody complexes are too large to cross the blood-brain barrier, reducing the amount and rate of nicotine in the brain and, consequently, the reinforcing and addictive effects of nicotine. The researchers found that immunization was associated with significant reductions in cigarette use and craving in the smokers.

The nicotine vaccine is owned by Nabi Biopharmaceuticals of Rockville, Md. In 2011, the company reported disappointing results from a phase 3 clinical trial, which found the vaccine to be no more effective than a placebo. Esterlis and colleagues present several potential explanations for the discrepancy in outcomes, including the possibility that the levels of antibody titers may have been suboptimal in the majority of the smokers in the clinical trial.

A similar approach has been used to create a vaccine against cocaine. Read more in Psychiatric News here.

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Bullying's Sequelae Don't Fade With Age

Bullying may be a common ordeal of childhood, but its consequences are serious and last well into adulthood in the form of multiple psychiatric disorders. In one of the only long-term prospective studies of the effects of bullying—whether as a bully, a victim, or both—William Copeland, Ph.D., of the Department of Psychiatry and Behavioral Sciences at Duke University, and colleagues followed 1,420 subjects from childhood into adulthood to determine effects of bullying on mental health. Subjects were assessed four to six times from ages 9 to 16, and three times from ages 19 to 26. In the childhood and adolescent assessments, the child and primary caregiver indicated whether the youngster had been bullied or had bullied others. Psychiatric outcomes in adulthood were determined through interviews using the Young Adult Psychiatric Assessment.

They researchers found dramatic differences in psychiatric outcomes in young adulthood between those who had bullying involvement and those who reported no bullying history, according to their report yesterday in JAMA Psychiatry. After controlling for psychiatric history and family hardship, they found, for example, that those who were only victims had higher rates of depression, anxiety disorders, panic disorder, and agoraphobia as adults. Panic disorder findings were especially troubling, being 14.5 times more likely than among those with no bullying involvement. Those who were bullies and victims showed higher rates of depression and anxiety disorders, as well as suicidality, with nearly 25% reporting suicidality in adulthood, compared with 5.7% of those without involvement. Those who were bullies but not victims were 4.1 times more likely to have antisocial personality disorder as adults than peers unexposed to bullying.

Child and adolescent psychiatrist and APA Treasurer David Fassler, M.D., told Psychiatric News that "The findings underscore the importance of early detection, intervention, and prevention programs. Despite increased education and awareness, bullying is still a common experience for many children and adolescents. As this study demonstrates, there are often lasting consequences for both bullies and their victims, including increased rates of depression, anxiety, and antisocial personality disorder."

To read more about psychiatric consequences of bullying, see Psychiatric News here and here. 

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Final Rule on Essential Health Benefits Issued

The Final Rule on essential health benefits (EHBs), which describes the parameters of plans that will be included in the federal and state health insurance exchanges mandated by the Affordable Care Act (ACA), was published yesterday by the Department of Health and Human Services (HHS), and APA is encouraged by several modifications and clarifications from an earlier version. Of particular interest to psychiatrists and their patients is that the Final Rule confirms that the federal mental health parity law will apply to nongrandfathered small group and individual plans that are not self-insured. There is also a mandate for inclusion of mental health and substance abuse services.

In addition, in comments submitted to HHS in December 2012, APA urged a better floor for prescription drug coverage, one that follows Medicare Part D's "all or substantially all" standard, which requires plans to include six classes of prescription drugs. HHS did not accept such a broadening of the standard, sticking with its proposed mandate that an EHB's prescription drug category include the greater of one drug per class or what is currently covered in a given state's prescription drug category for its EHB benchmark plan. It did, however, provide for EHB plan beneficiaries to engage in an appeals process with their plan issuer when seeking a "clinically appropriate" medication not covered by their EHB benchmark plan. The Final Rule also states that when a state's benchmark EHB plan doesn't have a mental health and substance abuse disorder services category, HHS will require the state to supplement this category with a mental health and substance abuse category from another HHS-approved benchmark plan.

Commenting on the Final Rule, HHS Secretary Kathleen Sebelius said that, not only will the ACA's insurance exchanges help more people get the health care they need, but it will soon be "easier to compare and enroll in health plans with better coverage, greater quality, and new benefits."

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Study Finds Link Between ADHD and Substance Abuse in Teens

Teenagers with attention-deficit/hyperactivity disorder (ADHD) have higher rates of substance abuse and cigarette use than their peers without ADHD, according to a study published online in the Journal of the American Academy of Child and Adolescent Psychiatry.

At an average age of 15, 35 percent of the adolescents with ADHD in the study reported using at least one substance, compared with 20 percent of those without ADHD, said lead author Brooke Molina, Ph.D., a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine. About 10 percent of those with ADHD met criteria for a diagnosis of substance abuse disorder or dependence. About 17 percent of the ADHD group smoked cigarettes, twice the rate (8 percent) of teens without ADHD.

“As researchers and practitioners, we need to do a better job of helping parents and schools address these risk factors that are so common for children with ADHD,” Molina said.

To read more about the link between ADHD and substance abuse, see Psychiatric News here. Also see ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults, from American Psychiatric Publishing.

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Some Veterans Not Getting Best Drug for PTSD

Mental health clinicians in the Veterans Health Administration too often prescribe medications for posttraumatic stress disorder (PTSD) that are not supported by guidelines, report researchers from the U.S. Department of Veterans Affairs (VA). The guidelines jointly used by the VA and the Department of Defense recommend use of selective serotonin–norepinephrine reuptake inhibitors (SSRI/SNRIs) for veterans with PTSD. They also recommend against routine use of benzodiazepines or second-generation antipsychotics.

After examining 2009 data on 356,958 veterans with PTSD, the researchers found that 66 percent were prescribed SSRI/SNRIs. However, 26 percent were prescribed second-generation antipsychotics, and 37 percent were prescribed benzodiazepines. Between 70% and 80% of these prescriptions were written by mental health clinicians, wrote Thad Abrams, M.D., M.S., and colleagues in the February Psychiatric Services.

Many factors contribute to the misalignment between guidelines and actual practice, said the authors. These might include “service providers’ attitudes, lack of organizational leadership, and insufficient resources dedicated to practitioner education and clinical staff development.”

To read more about guidelines for treating PTSD, see Psychiatric News here. Also see Clinical Manual for Management of PTSD from American Psychiatric Publishing.
 

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Poor Facial-Emotion Recognition Can Signal Risk for Psychosis

Youth at high risk for schizophrenia may exhibit an inability to correctly interpret facial expressions—a trait that can exacerbate psychotic-like symptoms, but can also be targeted with early intervention efforts. That was the finding of a study published in Schizophrenia Bulletin January 31.

Researchers at Kings College, London, examined 34 children aged 9-14 who presented with symptoms known to be antecedents for schizophrenia—motor and speech delays, internalizing or externalizing problems, and psychotic-like experiences—and 34 typically developing children who presented with none of those antecedents. The children were given a test to assess correct recognition of happy, sad, angry, fearful, and neutral expressions.

Compared with the typically developing children, children with the risk factors for schizophrenia showed an overall impairment in facial-emotion recognition. They misattributed neutral expressions to faces displaying other emotions and more often mislabeled a neutral expression as sad compared with healthy peers. The researchers concluded that the inability to accurately discriminate subtle differences in facial emotion and the misinterpretation of neutral expressions as sad may contribute to the initiation and/or persistence of psychotic-like experiences. “Interventions that are effective in teaching adults to recognize emotions in faces could potentially benefit children presenting with antecedents of schizophrenia,” they said.

To read more about recent research in schizophrenia, see Psychiatric News here. For the latest information on treating that disorder, see Clinical Manual for Treatment of Schizophrenia from American Psychiatric Publishing.

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Obama Proposes Major Brain Research Initiative

The Obama administration is proposing a major new scientific effort to understand the human brain and map its activity in a way similar to what the Human Genome Project did for genetics.

The New York Times today reported that the project, which the administration has been looking to unveil as early as March, will “include federal agencies, private foundations. and teams of neuroscientists and nanoscientists in a concerted effort to advance the knowledge of the brain’s billions of neurons and gain greater insights into perception, actions and, ultimately, consciousness.” The project could help unravel the mysteries of Alzheimer’s disease and Parkinson’s, as well as find new therapies for a variety of mental illnesses. It is expected to be part of the president’s budget proposal next month, and the Times quoted scientists and representatives of research institutions who said they had participated in planning for what is being called the Brain Activity Map project.

The details are not final, and it is unclear how much federal money would be proposed or approved for the project in a time of fiscal constraint or how far the research would be able to get without significant federal financing.

The Times article is posted here. For information on brain research and its relationship to understanding mental illness and substance abuse see Psychiatric News here.

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Depression May Diminish Response to Shingles Vaccine

Patients with untreated depression may have a higher risk of developing shingles, may develop more severe cases of shingles, and be less responsive to the vaccine against shingles. Researchers at the Cousins Center for Psychoneuroimmunology at the UCLA Semel Institute for Neuroscience in Los Angeles presented results of their recent study in the online February 13 Clinical Infectious Diseases.

The Depression Substudy of the Shingles Prevention Study (SPS) was designed to evaluate the association between major depression and immune responses to a high-titer live attenuated varicella zoster virus (VZV) vaccine (zoster vaccine), which boosts cell-mediated immunity (CMI) to VZV and decreases the incidence and severity of herpes zoster (HZ). The depression substudy was a two-year longitudinal cohort study of 92 community-dwelling adults 60 years of age and older who were enrolled in the SPS, a large, double-blind, placebo-controlled Veterans Affairs Cooperative zoster vaccine efficacy study.
 

They found that depressed patients have diminished VZV-CMI responses to zoster vaccine, and treatment with antidepressant medication was associated with normalization of these responses. “Because higher levels of VZV-CMI correlate with lower risk and severity of HZ, untreated depression may increase the risk and severity of HZ and reduce the efficacy of zoster vaccine,” they concluded.

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Teen Prescription Abuse Prevention Lasts Into Adulthood

Middle-school students from small towns and rural communities who received any of three community-based prevention programs were less likely to abuse prescription medications in late adolescence and young adulthood, according to research funded by the National Institute on Drug Abuse (NIDA) and published yesterday in the American Journal of Public Health.

The article presents the combined research results of three randomized, controlled trials of preventive interventions – termed “universal” because they target all youth regardless of risk for future substance abuse. All three studies involved rural or small-town students in grades six or seven, who were randomly assigned to a control condition (receiving no prevention intervention) or to a family-focused intervention alone or in combination with a school-based intervention.The researchers said the intervention effects were comparable or even stronger for participants who had started misusing substances prior to the middle-school interventions, suggesting that these programs also can be successful in higher-risk groups.

Read more about the prescription drug abuse epidemic in Psychiatric News here.

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Most Gun Deaths Are Suicides

Since the schoolhouse massacre in Newtown, Conn., much of the nation’s attention has focused on mass shootings. But deaths involving guns are very likely to involve one victim—the shooter.

A report in the New York Times today, drawing on statistics from the federal Centers for Disease Control and Prevention, notes that nearly 20,000 of the 30,000 deaths from guns in the United States in 2010 were suicides.

Experts quoted by the Times emphasize that guns are particularly lethal. And it cites statistics from the Harvard Injury Control Research Center showing that suicidal acts with guns are fatal in 85 percent of cases, while those with pills are fatal in just 2 percent of cases.

“Suicidal acts are often prompted by a temporary surge of rage or despair, and most people who attempt them do not die,” according to the report. “In a 2001 study of 13- to 34-year-olds in Houston who had attempted suicide but were saved by medical intervention, researchers from the CDC found that, for more than two-thirds of them, the time that elapsed between deciding to act and taking action was an hour or less. The key to reducing fatalities, experts say, is to block access to lethal means when the suicidal feeling spikes.”

The Times article is here. For more on the subject of suicide see Psychiatric News here.

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Brain Scans Reveal Changes Linked to PMDD

A new study supports the clinical relevance of the proposal that dorsolateral prefrontal cortex dysfunction represents a substrate of risk for premenstrual dysphoric disorder (PMDD). When women with PMDD and women without the disorder were given a cognitive task, the dorsolateral prefrontal cortex of the former became significantly more activated than did the prefrontal cortex of the latter.

So reports Karen Berman, M.D., and Peter J. Schmidt, M.D., of the National Institute of Mental Health Intramural Research Program, and their colleagues in AJP in Advance.  It thus looks as though the dorsolateral prefrontal cortex "plays an important role in PMDD," they conclude.

"PMDD is not a diagnosis without controversy in women's mental health circles," Claudia Reardon, M.D., an assistant professor of psychiatry at the University of Wisconsin and an expert on women's issues, told Psychiatric News. "Studies like this that start to look at objective data will hopefully help us move toward a more informed understanding of the nature of the underlying dysfunction."

Researchers have also linked specific variants in an estrogen receptor gene to PMDD. See Psychiatric News.

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Folic Acid Linked to Lower Autism Risk

A study of 85,176 Norwegian children finds that women who took folic acid supplements beginning a month before conception through eight weeks into pregnancy had a 40 percent lower risk of giving birth to children with autism.

Folic acid has long been recommended for women who may become pregnant because it reduces the risk of neural tube defects in their babies.

Among children whose mothers took folic acid, only 0.10 percent (64/61,042) were diagnosed with autistic disorder, compared to 0.21 percent (50/24,134) among those whose mothers did not take folic acid, wrote Pål Surén, M.D., M.P.H., of the Norwegian Institute of Public Health in Oslo, in the February 13 issue of the Journal of the American Medical Association.

Use of folic acid did not have an effect on rates of other autism spectrum disorders. Starting folic acid supplements midway through pregnancy had no effect, and there was no correlation with maternal intake of folate through food.

“The study does not prove that folic acid supplements can prevent childhood autism,” said Surén, in a statement. “However, the findings are so apparent that they constitute a good argument to further examine possible causal mechanisms.”

For more in Psychiatric News about risk factors for autism, click here.

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Daily Tobacco Use Declines, but Not Uniformly for All Groups

Individuals with substance use disorders or major depressive disorder and Native Americans reported higher rates of past-year daily tobacco use than the general population, according to a study that appears this month in Psychiatric Services (February 2013).
Using data from the National Longitudinal Alcohol Epidemiologic Survey, conducted in 1991–1992, and the National Epidemiologic Survey on Alcohol and Related Conditions, conducted in 2004–2005,  researchers at Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute examined changes in the prevalence of daily tobacco use in the United States between 1991–1992 and 2004–2005 by sociodemographic characteristics and psychiatric disorders.

They found that although the overall prevalence of past-year daily tobacco use decreased significantly, the reduction was not uniform across all segments of the population. In both surveys, past-year daily tobacco use was higher among respondents with a drug use disorder, an alcohol use disorder, and major depressive disorder and among individuals from socioeconomically disadvantaged groups. Declines in use were slower among individuals with a lifetime alcohol use disorder or major depressive disorder. The prevalence of past-year daily tobacco use did not decrease among Native Americans.

These findings suggest the need to emphasize specific interventions for these groups. “Health care providers should consider encouraging patients who have significant depressive symptoms or depression histories to seek smoking-cessation services that include both typical smoking-cessation treatments and behavioral mood anagement,” the researchers write.

“Trends in the Prevalence of Tobacco Use in the United States, 1991–1992 to 2004–2005” is posted here. For more information about smoking and mental health, see Psychiatric News here.

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Experimental Form of Brain Stimulation May Improve Efficacy of Antidepressant Treatment

An experimental form of electrical brain stimulation, when used in combination with the antidepressant sertraline, appears to improve treatment response compared to sertraline alone. Further, use of the experimental treatment, known as transcranial direct current stimulation (tDCS), alone had comparable efficacy to sertraline alone.

Those were the findings of a study by researchers in Sao Paulo, Brazil, published last week in the Journal of the American Medical Association. tDCS involves a low-level charge of about one-400th of that used in electroshock treatment and is given for 20 to 30 minutes continuously while patients are conscious.

Study subjects consisted of 120 antidepressant-free patients with moderate to severe, nonpsychotic, unipolar major depressive disorder (MDD) and were randomized to receive tDCS and sertraline together, one of the two treatments alone, or a placebo and/or a sham treatment of tDCS. The primary outcome measure was the change in Montgomery-Asberg Depression Rating Scale score at 6 weeks.

The researchers found that there was a significant difference in scores when comparing the combined treatment group (sertraline/active tDCS) versus sertraline only. When comparing tDCS alone and sertraline alone, the scores were comparable though not statistically significant.

“In MDD, the combination of tDCS and sertraline increases the efficacy of each treatment,” the researchers state. “The efficacy and safety of tDCS and sertraline did not differ.”

An abstract of the study can be accessed here. For more information about electroconvulsive therapy, see Psychiatric News here.
   

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Cardiac Disease May Lead to Cognitive Impairment

The study included 1,450 subjects ages 70 to 89 years. All were cognitively normal at the start of the study, and a number did have cardiac disease. The subjects were evaluated every 15 months to see whether they developed mild cognitive impairment. Follow-up was on average four years. The researchers looked to see whether there was a link between having cardiac disease at the start of the study and developing mild cognitive impairment. The answer was yes, particularly in women.

"Cardiac disease may contribute to cerebrovascular disease through microemboli to the brain from atrial fibrillation or hypoperfusion of the brain from impaired cardiac function," Petersen and his team conclude in their paper, which appears in JAMA Neurology. "These adverse events may lead to neuronal injury and to an increased risk of mild cognitive impairment."

Risk factors that predict the occurrence of stroke, such as high blood pressure, smoking, or diabetes, also predict the development of mild cognitive impairment, Indiana University researchers and British researchers have found. See Psychiatric News here and here.

Information about mild cognitive impairment, Alzheimer's disease, and other dementias can be found in  American Psychiatric Publishing's Clinical Manual of Alzheimer Disease and Other Dementias.

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Pediatric Bipolar Disorder Plus ADHD May Be Distinct

When youngsters have both bipolar disorder and attention-deficit/hyperactivity disorder (ADHD), it may be because they have a distinct genetic subtype of both, Joseph Biederman, M.D., a professor of psychiatry at Harvard Medical School, and colleagues propose.

They studied a large cohort of children with bipolar disorder, ADHD, or both, as well as the relatives of the children. They found that when children had bipolar disorder alone, their relatives were also more likely to have bipolar disorder alone, and that when children had ADHD alone, their relatives were also more likely to have ADHD alone. And when youngsters had both bipolar disorder and ADHD, their relatives were also more likely to have both.

"The co-segregation findings suggest that ADHD plus bipolar disorder is a distinct familial entity and, perhaps, a distinct disorder," Biederman and his colleagues write in their paper, which appears in the January Journal of Psychiatric Research . "The idea that ADHD comorbid with bipolar disorder is a distinct disorder is further supported by emerging neurobiological findings." For example, the gene that codes for the dopamine transporter has been linked with both ADHD and bipolar disorder.

More information about pediatric bipolar disorder and pediatric ADHD can be found in
Psychiatric News and in a new American Psychiatric Publishing book--
Clinical Manual of Child and Adolescent Psychopharmacology, Second Edition.

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Lack of Community-Based Treatment Options Leads to Involuntary Commitment

For individuals in crisis, involuntary hospitalization can be lifesaving—but also life disrupting. In a study published February 1 in the online Psychiatric Services, researchers from the University of Virginia asked emergency services clinicians throughout Virginia to complete a questionnaire following each face-to-face evaluation of individuals experiencing a mental health crisis over a one-month period in 2007. Data from the more than 2,600 evaluations showed that a lack of intensive community-based alternatives to hospitalization, such as temporary housing and voluntary crisis stabilization, was a significant predictor of the decision to commit. The researchers concluded that "investing in a continuum of crisis stabilization and other intensive outpatient services would reduce the need for involuntary interventions."

Other recent research has shown that temporary detention orders that are 48 hours or shorter are sometimes inadequate to evaluate patients fully after they have suffered a mental health crisis. This can lead to involuntary hospital commitments that can increase stigma and trauma. Read more in Psychiatric News here.

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FDA Provides New Guidance on Developing Alzheimer's Drugs

The Food and Drug Administration (FDA) today issued a proposal designed to assist pharmaceutical companies engaged in developing new treatments for individuals who are in the early stages of Alzheimer's disease—that is, before the onset of overt dementia. The guidance explains the agency's current thinking on how researchers can identify and select patients for participation in clinical trials of new medications. According to Russell Katz, M.D., director of the Division of Neurology Products in the FDA Center for Drug Evaluation and Research, the guidance reflects the agency's belief that "it is critical to identify and study patients with very early Alzheimer's disease before there is too much irreversible injury to the brain. It is in this population that most researchers believe that new drugs have the best chance of providing meaningful benefit to patients."

Katz noted as well that the guidance, which is still in draft form and available for public comment, "is intended to serve as a focus for continued discussion between the FDA and pharmaceutical sponsors, the academic community, advocacy groups, and the public."

The complete text of the FDA guidance can be read here. To read about treatment and diagnosis of Alzheimer's disease, see Clinical Manual of Alzheimer Disease and Other Dementias, from American Psychiatric Publishing.

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First Study of New DSM Diagnosis Published

Disruptive mood dysregulation disorder is a diagnosis that is being added to the upcoming revision of APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the first published study of the disorder's prevalence, comorbidity, and correlates finds that the disorder is uncommon after early childhood, is frequently comorbid with other psychiatric disorders, and meets the standards for psychiatric "caseness."

In the study, published in the February American Journal of Psychiatry, William Copeland, Ph.D., of the Department of Psychiatry and Behavioral Sciences at Duke University, and colleagues estimated prevalence rates from three community sites involving 7,881 observations of 3,258 participants aged 2 to 17. They diagnosed the disorder using structured psychiatric interviews. Criteria for the disorder include severe temper outbursts three or more time a week combined with persistently negative mood between the outbursts. The researchers found three-month prevalence rates ranging from 0.8% to 3.3%, with the highest rates appearing among preschool-aged children, and that it was comorbid "with all common psychiatric disorders." Children diagnosed with the disorder showed "elevated levels of social impairment, school suspension, service use, and poverty." The researchers concluded that disruptive mood dysregulation disorder "identifies children with severe levels of both emotional and behavioral dysregulation."

Read more about this study in the American Journal of Psychiatry.

Project Is RAISEing New Approaches to Schizophrenia Treatment

Taking a broad, systems-based approach to early intervention in schizophrenia might provide advantages over narrowly focused strategies. That’s the premise of the Recovery After an Initial Schizophrenia Episode (RAISE) project, an initiative of the National Institute of Mental Health (NIMH).

Others are thinking along the same lines. Researchers from Janssen Research and Development recently proposed “a comprehensive model that includes early detection, better access to care, monitoring, and patient-reported outcomes,” according to NIMH Director Thomas Insel, M.D. “They aren’t just suggesting new health care policy, they are recommending that pharmaceutical [research and development] redefine innovation around a holistic approach to patient needs rather than a singular focus on molecular targets,” wrote Insel yesterday in his blog.

Patients with first-episode psychosis can often be successfully treated with medications, but additional psychosocial interventions known to be useful (such as family education, supported employment, cognitive therapies, assertive case management, or psychiatric rehabilitation) are used only sporadically, if at all, said Insel.

Several groups are now testing the RAISE model to learn how the combination of medication and psychosocial care might benefit both patients and society. “It’s time to think beyond magic bullets,” concluded Insel.

For more information about early intervention in schizophrenia, see Psychiatric News here and here and Psychiatric Services in Advance here. Also see a study of treatment of first-episode schizophrenia in the new issue of the American Journal of Psychiatry here.

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APA Posts Analysis of Physician Payment Sunshine Act Rule

The Centers for Medicare and Medicaid Services (CMS) has adopted several of APA’s suggestions regarding the Physician Payment Sunshine Act in a final rule issued by the agency this week. And APA has prepared an extensive analysis of the act and the CMS final rule.

The Physician Payment Sunshine Act, approved as part of the Patient Protection and Affordable Care Act, requires applicable manufacturers of drugs, devices, biologicals, or medical supplies covered under Medicare, Medicaid, or CHIP to report annually in electronic format to the Secretary of Health and Human Services certain payments or other transfers of value they have made to physicians and teaching hospitals. The manufacturers and group purchasing organizations are subject to civil monetary penalties if they fail to comply with the reporting requirements of the statute. CMS must then submit annual reports to Congress and each state summarizing the data on physician and hospital payments that the companies have reported.

In response to an earlier CMS rule, APA urged the agency to strengthen its dispute-resolution process and to push back the beginning of the data-collection and reporting periods—advice that is reflected in the new final rule.

See APA’s analysis of the rule here. For more information about the Sunshine Act see Psychiatric News here.

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New Study Finds Parity Doesn't Raise Mental Health Care Costs

While the nation still awaits the Obama administration’s final word on regulations to implement insurance parity for mental health services, new research indicates that spending on mental health services remained the same or declined in one major health insurance system that already requires parity, the Federal Employees Health Benefits (FEHB) Program.

Researchers compared 19,094 FEHB enrollees with 10,521 privately insured enrollees unaffected by parity. In the FEHB Program, total spending was unchanged among enrollees with bipolar disorder and major depression but decreased for those with adjustment disorder,” wrote Alisa Busch, M.D., M.S., of Harvard’s McLean Hospital, in the February American Journal of Psychiatry. Out-of-pocket costs for all three diagnostic groups were lower, and total annual utilization—for medication management, prescriptions, and hospitalization—remained unchanged compared with the FEHB's pre-parity costs.

“Parity implemented under managed care improved financial protection and differentially affected spending and psychotherapy utilization across groups,” concluded Busch and colleagues. “There was some evidence that resources were preferentially preserved for diagnoses that are typically more severe or chronic and reduced for diagnoses expected to be less so.”

For more in Psychiatric News about parity, click here. An abstract of the article in the American Journal of Psychiatry is posted here.

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Brain Imaging During Memory Task May Predict Response to Antidepressant

Brain imaging of activity in the visual cortex while performing working-memory tasks may prove a biomarker for response to an experimental rapid-acting antidepressant, according to a National Institute of Mental Health (NIMH) study in the Journal of the American Medical Association. 

Scopolamine, better known as a treatment for motion sickness, has been under study since its fast-acting antidepressant properties were first reported in 2006. But not all patients respond. So Maura Furey, Ph.D., and colleagues developed a strategy for identifying patients likely to respond to the drug. The acetylcholine system, on which scopolamine works, plays a pivotal role in working memory by influencing the processing of information through the visual cortex. Furey and colleagues hypothesized that depressed patients would show aberrant visual cortex activity in response to a working-memory task; they also expected to find that patients with more dysfunctional acetylcholine systems would respond better to scopolamine treatment.

In their study, depressed patients and healthy subjects performed a working-memory task while brain activity in the visual cortex was monitored via MRI; the subjects then received either placebo or scopolamine. The researchers’ hypothesis proved correct: scopolamine treatment reduced depression symptoms by 63%, and the strength of this response correlated significantly with visual cortex activity. “We have discovered a potential neuroimaging biomarker that may eventually help to personalize treatment selection by revealing brain-based differences between patients," explained Furey.

Read an abstract of the study here. For more information about how brain imaging may predict treatment response in mental illness, see Psychiatric News here. 

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Ten Percent of Americans Believed to Be Child Sexual Abuse Victims

Approximately 10 percent of American adults were sexually abused as children, according to a study reported in Comprehensive Psychiatry. Moreover, they are more at risk of psychopathology and suicide attempts than are adults who were not sexually abused as children. The study was headed by Carlos Blanco, M.D., a professor of clinical psychiatry at Columbia University. It included a large national sample of the United States population—some 34,000 individuals aged 18 or older. They were interviewed face to face, and psychiatric diagnoses were made according to DSM-IV criteria.

"Our study has clinical and preventive implications," Blanco and his colleagues said. "The initial effects of child sexual abuse include...sleep and eating disturbances, fears and phobias, depression, shame, guilt, anger...school problems, truancy, running away, and inappropriate sexual behavior. Therefore, clinical screening for child sexual abuse is important for early treatment to reduce the impact of psychological trauma."

For information about diagnosing and treating victims of child sex abuse, see Psychiatric News. Some guidelines on how to interview children suspected of being sexually abused can be found in American Psychiatric Publishing's Principles and Practice of Child and Adolescent Forensic Mental Health.

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