APA Members Urged to Register CPT Coding Abuse by Insurers

APA is strongly encouraging its members to inform the Association of any problems of which they are aware stemming insurers' refusal to pay for services in accordance with the new psychiatry CPT codes that went into effect January 1. In an e-mail to members earlier this week, APA stated that "CPT code changes were intended to more accurately reflect the work psychiatrists do and improve patient access to care, but instead have been used as an excuse by some payors to discriminate against psychiatric patients and their psychiatrists in violation of the Mental Health Parity and Addiction Equity Act (2008). The issues differ from state to state and from carrier to carrier. The APA Board of Trustees has committed significant APA resources, both financial and staff, to understand the situation and use all reasonable means, including litigation, to correct the abuses taking place."

To ensure that insurers comply with the law, APA wants members' input as soon as possible so the Association can pursue action with the insurers in question, including filing of lawsuits to force compliance. "APA members must be willing to register their complaints with APA, and a few must be willing to participate as plaintiffs in a lawsuit if one is needed. This would require very little of your time and be at APA's expense," the message explained. Members can register complaints either by completing the form online here or by sending an e-mail to cptparityabuses@psych.org that includes the member's name, location, the insurance company in question, and details about the CPT coding problem. APA and its district branches/state associations have already begun actions against insurers in California, Connecticut, and New York.

Read about the changes to CPT psychiatry codes in Psychiatric News here and here.

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New Data Help Explain Weight Loss After Gastric Bypass

Harvard University researchers said yesterday that gastric bypass surgery leads to weight loss not simply due to decreased caloric intake or absorption, but likely also due to alteration of the gut flora as a result of the surgery. Reporting online yesterday in Science Translational Medicine, the group said studies in humans and rats have already shown that the Roux-en-Y gastric bypass (RYGB) procedure restructures the gut microbiota, prompting the hypothesis that some of the effects of RYGB are caused by altered host-microbial interactions. The researchers used a mouse model of RYGB to demonstrate that transfer of the gut microbiota from RYGB-treated mice to nonoperated, germ-free mice resulted in weight loss and decreased fat mass, potentially due to altered microbial production of short-chain fatty acids. The researchers said they hope that finding ways to manipulate microbial populations to mimic those effects could become a valuable new tool to address obesity. 

A study by researchers at the University of Pittsburgh led to cautions, however, on the use of RYGB surgery in some patients, finding that it can also lead to alcohol use disorder. Read about that study in Psychiatric News here. 

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Genetic Pattern Affects Long-Term Smoking Behavior

A cluster of genetic risk factors appears to influence how heavily and persistently people smoke cigarettes, but has no effect on starting smoking, according to a new study by an international group of researchers. They developed a genetic risk score (GRS) for smoking based on genes already known to affect nicotine response, metabolism, and dependence. They compared the GRS with smoking behavior in a group of 1,004 New Zealanders born in 1972 and 1973 and studied periodically from ages 11 to 38.

Once they started smoking, people at higher genetic risk were much more likely to progress rapidly to consuming at least 20 cigarettes a day. They also smoked more over their lifetimes, were more likely to develop nicotine dependence, had problems quitting, and used smoking more often as a means to cope with stress, reported Daniel Belsky, Ph.D., a postdoctoral fellow at Duke University’s Center for the Study of Aging and Human Development, and colleagues today in JAMA Psychiatry. Family smoking history and genetic risk had an additive effect on smoking behavior. It is, however, still too soon to use the GRS to assess individual risk in clinical practice, said Belsky. The study is titled "Polygenic Risk and the Developmental Progression to Heavy, Persistent Smoking and Nicotine Dependence."

High genetic risk does not guarantee future addiction, nor are children who are at low genetic risk immune to addiction, he said. “Public-health policies that make it harder for teens to become regular smokers should continue to be a focus in antismoking efforts.”

To read about research on a vaccine to fight smoking addiction, see Psychiatric News here and the American Journal of Psychiatry here.

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Brain Imaging Might Help Identify Individuals at Risk of Suicide

It might eventually be possible to use brain imaging to help identify individuals at risk of suicide, as a result of a new finding reported in Biological Psychiatry by Jeffrey Miller, M.D., an assistant professor of clinical psychiatry at Columbia University, and colleagues. Using PET brain imaging, they found that depressed suicide attempters had significantly lower binding of the serotonin transporter in the midbrain region than did depressed individuals who did not attempt suicide and control subjects who did not have a psychiatric disorder.

This finding is "important," Fabrice Jollant, M.D., Ph.D., an assistant professor of psychiatry at McGill University in Canada and an imaging expert, told Psychiatric News, explaining that it might someday be possible for brain imaging to help identify individuals at risk of suicide before they act on it. That development will depend, however, on a longitudinal prospective study showing that low serotonin transporter binding is indeed predictive of a higher risk of suicide attempts. Miller told Psychiatric News that and he and his colleagues already have such a trial underway.

While research is studying whether technology can help prevent suicides, other research has shown the efficacy of several prevention strategies and tools. Read more about suicide prevention in Psychiatric News here and here. In addition, guidance on preventing suicides can be found in American Psychiatric Publishing's Preventing Patient Suicide: Clinical Assessment and Management. 

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Stroke-Related Infectious Agents May Also Raise Risk for Cognitive Decline

Individuals exposed to common infectious pathogens that put them at risk for vascular disease—such as Chlamydia or herpes—may also be at risk for cognitive impairment, according to a report in Neurology. Researchers at Columbia University developed a composite serologic score—known as the infectious burden (IB) index—measuring exposure to common pathogens (such as Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, and herpes simplex virus 1 and 2) that are associated with vascular risk. They performed serologic and cognitive assessments on 1,625 participants in the Northern Manhattan Study, a prospective study of stroke and stroke risk.

A higher IB index was associated with worse cognition in the study cohort. In an editorial accompanying the Neurology article Timo Strandberg, M.D., Ph.D., and Allison Aiello, Ph.D., say, “Several chronic diseases, such as peptic ulcer, certain cancers, and autoimmune conditions, have established infectious etiologies, either bacterial or viral, but mainstream cognitive disorder research has not fully considered microbial involvement.”

Some evidence has also emerged suggesting that infectious pathogens may be related to some cases of schizophrenia. To read more about that topic, see Psychiatric News here. An abstract of the Neurology report, "Infectious Burden and Cognitive Function: The Northern Manhattan Study,” can be read here.

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Study Finds No Link Between SSRI Use in Pregnancy and Infant Growth

Neither an expectant mother's major depression nor her use of SSRI antidepressants affected infant growth with respect to weight, length, or head circumference from birth through 12 months of age, according to a March 20 report in AJP in Advance. Katherine Wisner, M.D., director of the Asher Center for the Study of Depression at Northwestern University Feinberg School of Medicine, and colleagues evaluated pregnant women at 20, 30, and 36 weeks gestation. The women were divided into three groups—those who had no depression and no exposure to SSRIs, those exposed to SSRIs, and those with major depression but no exposure to SSRIs. The researchers then evaluated mother and infant pairs at 2, 12, 26, and 52 weeks postpartum. Infant weight, length, and head circumference were measured.

Wisner and colleagues found that neither antenatal major depression nor SSRI exposure was significantly associated with any of the infant measurements they assessed. "Consideration of the impact of both antenatal SSRI and depression exposures on fetal and infant growth is an understudied component of the risk-benefit decision process for developing treamtent plans for depressed pregnancy women," they said.

 “Does Fetal Exposure to SSRIs or Maternal Depression Impact Infant Growth?” is posted here.  To read more about SSRI use during pregnancy, see Psychiatric News here and here.

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Hippocampus Changes May Be Factor in Positive Symptoms of Schizophrenia

New research reported in the March Brain suggests the possibility that a deformed hippocampus drives the psychotic symptoms of hallucinations and delusions. Researchers found that a shrunken left hippocampus, as well as a deformity in the CA1 subfield of the left hippocampus, was linked with positive symptoms such as hallucinations and delusions, but not with negative symptoms, in a sample of 32 schizophrenia subjects. The same changes were not found in a group of 34 healthy control subjects. Moreover, the smaller the left hippocampus and the more deformed its CA1 subfield, the more prominent were the schizophrenia subjects' delusions and hallucinations and the higher were the doses of antipsychotic medications that the subjects needed to quell their these symptoms.

The finding has clinical implications, the lead scientist, Kolja Schiltz, M.D., an adjunct associate professor at Otto von Guericke University in Magdeburg, Germany, told Psychiatric News. The left hippocampus, and particularly its CA1 subfield, could be monitored longitudinally in a patient, he explained. If the hippocampus and CA1 subfield became more deformed, it might indicate that the patient needs more efficacious antipsychotic treatment.

Psychiatric News has reported on research into other factors associated with schizophrenia in addition to hippocampus size, such as genes or the parasite Toxoplasma gondii. Read that coverage here and here. For another study on genetic links to schizophrenia, see the American Journal of Psychiatry.

 

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Mass Shootings Increasing Mental Illness Stigma

Intense and widespread news coverage of mass-shooting events like the one in Newtown, Conn., last December often mention that the killer had some type of serious mental illness. In the spring of 2012, researchers at the Johns Hopkins Center for Gun Policy and Research surveyed about 1,800 people to determine their reactions to hypothetical news stories. They were asked about attitudes towards people with mental illness and about their views on gun-control measures. The report was published online March 20 in AJP in Advance.

Among control subjects who read no such story, about 33 percent said they would not live with or live near a person with a serious mental illness and believed they were more dangerous than other people. About 70 percent favored banning mentally ill individuals from owning guns, and 50 percent were willing to ban high-capacity magazines. Those percentages all ratcheted up even higher after subjects read one of three stories about a mass-shooting event, an event that mentioned gun restrictions for the mentally ill, or a shooting event plus a ban on large-capacity magazines.

“These portrayals of the shooting events raise public support for gun control policies but also contribute to negative attitudes toward those with serious mental illness,” concluded Emma McGinty, M.S., writing in AJP in Advance.

To read about the psychiatric response to the Newtown, Conn., school shooting, see Psychiatric News here. To read the AJP in Advance article, click here.

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APA Supports Senate Bill on Student Mental Health

U.S. Senator Amy Klobuchar (D-Minn.) has introduced a bill to provide support for teachers to learn about the key warning signs of mental health problems in students as well as the impact that mental health conditions can have on a student's ability to learn and behave in the classroom. The Helping Educators Support All Students Act would create a four-year discretionary grant for state education agencies to provide training for teachers and other school staff in recognizing mental health issues. Training could be provided by qualified specialized instructional school personnel or in partnership with a community mental health program.

In a letter sent to Klobuchar today, APA Medical Director and CEO James H. Scully Jr., M.D., expressed APA's support for the bill, saying the initiative "paves the way for highly successful and evidence-based training initiatives...to empower more of these professionals with the knowledge of mental illness, the ability to detect warning signs, and the ability to take appropriate action in linking adolescents to the services they need." Read Scully's letter here.

The American Psychiatric Foundation's "Typical or Troubled?" school mental health program is already training school personnel to recognize students who show signs of having a mental health problem or psychiatric disorder and refer them for treatment. The Miami-Dade County public school system has recently adopted this program for use in all of its public middle and high schools. Read more about how the program is being used here.

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Weight-Loss Program Shows Success in Psychiatric Patients

Obesity is common in people with psychiatric illnesses and is a likely contributor to the increased mortality rates in this population. Medications appear to play a role, but so do poor exercise and eating habits. However, the introduction of lifestyle changes through a targeted behavioral intervention may help counteract the extra pounds, suggests a new study published March 21 in the New England Journal of Medicine. Overweight and obese participants with mental illnesses participating in a diet and exercise program experienced moderate and progressive weight loss over the course of 18 months.

Led by Gail Daumit, M.D., of Johns Hopkins University, the behavioral program, termed the ACHIEVE trial, was based on lifestyle changes known to be effective in the general population and was amended to account for cognitive deficits present in mental illness. Nearly 300 people with schizophrenia, bipolar disorder, or major depressive disorder were divided into two groups—half participated in a program focused on improving eating and exercise habits, while the other half received no special training. Those in the intervention group lost an average of 7 pounds more over the course of the study compared with the control group, suggesting that despite the significant hurdles of psychiatric illness, weight loss is achievable with proper training and guidance. The study was supported by NIMH.

To read recent research about a link between gastric bypass surgery for weight loss and alcohol addiction, see Psychiatric News here.

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Sharfstein Says Suicide, not Homicide Is Greatest Gun Danger

Former APA President Steven Sharfstein, M.D., writing in the Baltimore Sun earlier this week, emphasizes that while laws aimed at keeping guns out of the hands of people with mental illness, which are being debated in Maryland, would have little effect on the homicide rate in the United States, they could have a major impact on the suicide rate.

Sharfstein, who is president and CEO of Sheppard Pratt Health System in Baltimore, emphasized that, "In the intense debate on gun violence and mental illness, with a focus on the extremely rare event of mass murders such in Newtown, Conn., and Aurora, Colo., what is lost...is the serious suicide epidemic we experience in the United States every year due to gun violence." He pointed out that 20,000 of the 30,000 annual gun-related deaths in this country are suicides. "If you try to kill yourself with a gun, you will be successful 80 percent of the time, as compared with suicide attempts by overdose, in which the success rate is less than 2 percent." He also said there is a strong link between the availability of guns, their presence in a home, and suicide, noting that "75 percent of guns used in youth suicides are accessible in the home or the home of a friend."

To bring down the gun suicide rate, strong barriers to availability of guns are needed, he said. Though depression is the greatest suicide risk factor, "Many people who commit suicide by gun are momentarily desperate and panicked rather than classically depressed," Sharfstein noted.

Sharfstein's complete op-ed column in posted here. To read articles published yesterday in the American Journal of Psychiatry's AJP in Advance about the recent mass shootings and how psychiatrists should respond, click here and here.

People With Mental Illness in Criminal Justice System Incur Higher Costs

Costs for people with mental illness who are involved with the criminal justice system are nearly double those for individuals without such involvement, according to a study of state mental health records in Connecticut. Of the 25,133 adults served by the Connecticut Department of Mental Health and Addiction Services (DMHAS), 6,904 had been arrested and convicted of a crime or were in prison, on parole or probation, in a jail-diversion program, or spent time in a forensic psychiatric setting. They were diagnosed with schizophrenia (37 percent) or bipolar disorder (63 percent), and 65 percent had a substance use disorder.

The researchers added up costs from the DMHAS and the state judiciary, the Departments of Correction and Public Safety, and Medicaid. The justice-involved individuals each incurred total costs of $48,980 on average, compared with $24,728 per person for those not involved with the criminal justice system, said Jeffery Swanson, Ph.D., and colleagues, writing in Psychiatric Services in Advance. The study’s findings should help state health officials better plan, coordinate, and deliver services to these populations, the researchers concluded.

To read more about issues concerning people with mental illness in the criminal justice system, see Psychiatric News here.

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Psychiatrist's Letter to the Editor Prompts Dialogue on Diagnosis

In a letter to the editor published in Tuesday's New York Times, psychiatrist Ronald Pies, M.D., took issue with critics who view psychiatric diagnoses as the equivalent of "myths" or "socially constructed labels." Troubled by controversy generated by critics of DSM-5, the next edition of APA's Diagnostic and Statistical Manual of Mental Disorders, to be published in May, Pies points out that, "Critics typically reply that other medical specialties have 'objective' criteria for diagnosis of disease, whereas psychiatrists merely apply 'labels' to behaviors they (or society) find offensive. But in truth, numerous medical and neurological diagnoses, such as migraine headache, are based on the same type of data that psychiatrists use: the patient’s history, symptoms and observed behaviors. I believe that psychiatric diagnoses are castigated largely because society fears, misunderstands and often reviles mental illness."

"Diagnosis," he emphasized, "means knowing the difference between one condition and another. For many patients, learning the name of their disorder may relieve years of anxious uncertainty. So as long as diagnosis is carried out carefully and respectfully, it may be eminently humanizing. Indeed, diagnosis remains the gateway to psychiatry's pre-eminent goal of relieving the patient's suffering." Pies is a professor of psychiatry at SUNY Upstate Medical University and Tufts University.

In response to Pies' letter, the Times has invited readers to respond to the issue he raised by Thursday, March 21, and plans to publish responses and a rejoinder from Pies in its Sunday Review section. Responses should be e-mailed to letters@nytimes.com.

In a joint statement to Psychiatric News, APA President Dilip Jeste, M.D., and President-elect Jeffrey Lieberman, M.D., strongly urge APA members to respond to the Times' invitation. “We want to call your attention to the excellent letter from Dr. Ron Pies that was in yesterday's New York Times, as well as the editors' invitation to establish a dialogue on DSM diagnoses with psychiatrists to be published in the Sunday Times. We encourage APA members to take this opportunity to inform and educate readers about the nature of mental illnesses described in DSM. By responding in this way, we hope that you will convey to readers the importance and value of DSM-5 in serving the needs of mental health care providers and patients with mental illness around the world.”

 Read Pies letter to the editor here.

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Higher Risk of Mental, Physical Illness Found in Kids With Jailed Parent

Children with a parent who has spent time in jail or prison have significantly increased risks of depression, posttraumatic stress disorder, anxiety, high cholesterol, asthma, migraines, HIV/AIDS, and fair or poor health in general, according to a study by researchers from the Centers for Disease Control and Prevention published online March 18 in Pediatrics. Rosalyn Lee, Ph.D., M.P.H., and colleagues used data collected in 1994 and 1995 (when the children were about age 16 on average) and in 2007 and 2008 (when they were about age 28) as part of the National Longitudinal Study of Adolescent Health. The 2.3 million U.S. inmates are parents to 1.7 million children under age 18.

These findings "suggest the need for additional research on mechanisms linking [parental incarceration] to both physical and mental health outcomes to identify whether [parental incarceration] is linked to childhood adversity and violence-related factors,” concluded Lee and colleagues.

Psychiatrists and other researchers have for several years focused attention ways to prevent mental illness. For more in Psychiatric News about preventing mental illness, click here.

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Dementia Second-Largest Contributor to Death

One in three seniors dies with Alzheimer’s or another dementia in the United States, according to an Alzheimer's Association report released today. The new report shows that while deaths from other major diseases, such as heart disease, HIV/AIDS, and stroke, continue to decline, Alzheimer’s deaths continue to rise — increasing 68 percent from 2000 to 2010.

The report examined  the contribution of individual common diseases to death using a nationally representative sample of older adults and found that dementia was the second-largest contributor to death trailing only heart failure. Among 70-year-olds with Alzheimer’s disease, 61 percent are expected to die within a decade. Among 70-year-olds without Alzheimer’s, only 30 percent will die within a decade. "Unfortunately, today there are no Alzheimer’s survivors. If you have Alzheimer's disease, you either die from it or die with it,” said Harry Johns, president and CEO of the Alzheimer’s Association, in a statement. “Urgent, meaningful action is necessary, particularly as more and more people age into greater risk for developing a disease that today has no cure and no way to slow or stop its progression.”

For much more information on this topic, see American Psychiatric Publishing's A Clinical Manual of Alzheimer Disease and Other Dementias here. Also see coverage in Psychiatric News here and here.

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Untreated Depression Can Lead to Decreased Survival for Transplant Recipients

Untreated depression has been associated with multiple consequences for an individual's physical health, and a new study adds to that concern showing that it is the factor most strongly linked to long-term mortality after liver transplantation, said researchers at the University of Pittsburgh online in the American Journal of Transplantation. They prospectively assessed 167 patients who received transplants for alcohol-related liver disease from 1998 to 2003. Depression symptoms were measured with the Beck Depression Inventory throughout the first posttransplant year, and adequacy of antidepressant treatment was measured with the Antidepressant Treatment History Form. Liver-transplant recipients were classified as having no depression, adequately treated depression, or inadequately treated depression. After a median follow-up of 9.5 years, those with adequately treated depression had no significant difference in survival when compared with the nondepressed group. Recipients with inadequately treated depression, however, had decreased survival times compared with nondepressed liver recipients.

In addition to playing a role in recovery from organ transplantation, mental health is a crucial factor in making transplant decisions. To read more about that topic, see Psychiatric News here.

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rTMS Appears to Counter Schizophrenia Memory Deficits

Repetitive transcranial magnetic stimulation (rTMS), which was approved by the Food and Drug Administration in 2008 to treat depression that hasn't responded to other interventions, can also counter working-memory deficits caused by schizophrenia. This finding was published March 15 in Biological Psychiatry. "If replicated, the findings may offer important new treatment approaches for memory symptoms that are often resistant to conventional treatments," the senior scientist, Jeff Daskalakis, M.D., Ph.D., an associate professor of psychiatry at the University of Toronto, said during an interview with Psychiatric News.

Since rTMS targeted over the dorsolateral prefrontal cortex has been found to improve working memory in healthy subjects, Daskalakis and his colleagues decided to try it in a four-week, randomized, double-blind, sham-controlled pilot study on 27 individuals with schizophrenia. They found that rTMS, but not the placebo sham, significantly improved the subjects' working memory. Moreover, the subjects' improved memory was comparable to that of healthy individuals.

"We are involved in a replication study that will also endeavor to examine biomarkers of treatment change," Daskalakis said.

To read about recent research exploring whether rTMS may also have role in treating addictions, see Psychiatric News. More information about schizophrenia treatment can be found in American Psychiatric Publishing's Clinical Manual for Treatment of Schizophrenia.

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Gene Variant Linked With Bipolar Psychosis May Lead to New Therapies

A new finding about bipolar disorder plus psychosis, which is reported in Molecular Psychiatry, may "pave the way for new therapies" for the condition, the lead scientist, Martin Schalling of the Karolinska Institute in Sweden, writes.

Why do some individuals with bipolar disorder experience psychosis? It is likely determined, at least in part, by heredity, since prior research has shown that a high degree, up to 80 percent, of this comorbidity is attributable to genetic factors. Now Schalling and colleagues have identified a particular gene variant that may explain this susceptibility toward psychosis. They found that bipolar patients with this variant had twice the risk of experiencing psychotic episodes as did bipolar patients without the variant. The gene in question makes an enzyme that produces kynurenic acid, a substance that affects several signaling pathways in the brain and that is integral to cognitive function. The gene variant in question makes higher amounts of kynurenic acid, and individuals with bipolar disorder plus psychosis were already known to have elevated levels of kynurenic acid in their brains.

To read about diagnostic criteria for both bipolar disorder and psychosis in DSM-5, which will be published in May, see Psychiatric News here. In addition, a new book about bipolar disorder and other mood disorders, Clinical Guide to Depression and Bipolar Disorder: Findings From the Collaborative Depression Study, will be available from American Psychiatric Publishing in May and will update research on the course, outcome, and treatment of mood disorders.

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APA, Connecticut Physicians Protest Insurer's Practices

The Connecticut Psychiatric Society (CPS), the Connecticut State Medical Society, and APA are protesting what they say are violations of federal laws, including the Mental Health Parity and Addiction Equity Act (MHPAEA), by Anthem Blue Cross Blue Shield of Connecticut. In a joint letter to the company, they say the company’s way of implementing new CPT codes increases the financial and time burden on patients who seek treatment from psychiatrists and discourages psychiatrists from providing psychotherapy services to their patients.

The three organizations claim that Anthem is violating state and federal laws and regulations, including the MHPAEA, the Connecticut Parity Law, HIPAA, and Unfair Insurance and Unfair Trade Practices laws as they pertain to treatment of patients with a mental or substance use disorder. They maintain that the company is covering only patient visits that are to be reported for medical evaluation and management while not covering psychotherapy as a separate and equal category for payment. In addition, the organizations say that there is a significant disparity between the reimbursement rates that Anthem is paying to psychiatrists and those paid to other medical/surgical network providers.

“We will not allow insurance companies to deny coverage that patients and their employers have paid for, nor will we ask psychiatrists to provide medically necessary psychotherapy for free to insured patients,” said CPS Executive Director Jacqueline Coleman. “These practices are both unethical and illegal, said APA Medical Director James H. Scully, Jr., M.D. “We worked very hard to enact mental health parity laws, and it is now clear that Anthem is seeking a way to avoid compliance. We are not prepared to allow them to skirt their obligations under the law."

For more information about the parity law, see Psychiatric News here and here.

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New York Psychiatrists Sue Insurer Over Parity Law Violations

The federal mental health parity law was a hard-fought victory for people with psychiatric disorders and the clinicians who treat them, but only if insurance companies adhere to the law's requirements. The New York State Psychiatric Association (NYSPA) maintains that one of the country's largest health insurers, UnitedHealth Group, including its subsidiary United Behavioral Health, are not complying with the law and has filed a class-action lawsuit to remedy that situation.

Among the charges alleged in the suit, filed in U.S. District Court for the Southern District of New York, is that the insurer has curtailed psychotherapy for patients needing long-term treatment, "allowing no more than weekly psychotherapy for patients who have attempted suicide and been hospitalized...and refusing to cover more than one weekly session of psychotherapy for actively suicidal patients." The suit also says that beneficiaries have experienced “extreme difficulty obtaining initial and continuing authorizations for intermediate levels of care, such as intensive outpatient treatment and partial hospitalization for mental health and substance abuse disorders.” NYSPA also charges the insurer with putting roadblocks in front of patients who try to obtain both "initial and continuing authorizations" for psychiatric care. The suit also cites numerous complaints alleged by three individual beneficiaries insured by United.

Over the past year we have tried to work with United to resolve these complaints but have been unsuccessful,” said NYSPA Executive Director Seth Stein. “Enforcement of existing state and federal parity statutes is necessary to ensure that individuals with mental illness have access to appropriate care and treatment.” NYSPA President Glenn Martin, M.D. told Psychiatric News, “Our state and national associations have fought for years for parity legislation, and we were mostly successful. That was only the first step, and now we find that we have to fight for full implementation of the laws and regulations. This lawsuit allows us to go on the offensive in this struggle, and we are confident we will prevail to the benefit of our patients and colleagues.”

The complaint is posted at http://www.psych-appeal.org/img/Complaint.pdf.

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FDA Loosens Alzheimer's Drug Approval Process

The Food and Drug Administration (FDA) has announced that it is planning to adopt new standards for approving medications to treat Alzheimer's disease (AD) that could make it easier for pharmaceutical companies to get promising drugs to the steadily increasing number of people with the devastating illness. In an announcement in yesterday's online edition of the New England Journal of Medicine, Nicholas Kozauer, M.D., and Russell Katz, M.D., of the Division of Neurology Products in the FDA's Center for Drug Evaluation and Research pointed out that the focus of AD drug development has shifted to earlier stages of the disease, before overt dementia is evident, in part due to recent failures of once-promising products that have shown no benefit in late-stage disease when dementia has already appeared. "A leading theory," Kozauer and Katz explained, "posits that attempts at intervention may have been made too late in the progression of the disease, at a stage when neuronal damage had become too widespread."

However, improvement in function—a standard to which potential AD drugs have been held—"could lag substantially behind cognitive improvement mediated by pharmacological agents early in the course of the disease," they said. Thus the FDA is hoping to foster "innovative approaches to trial design and end-point selection." They said that "it might be feasible to approve a drug through the FDA's accelerated approval pathway on the basis of assessment of cognitive outcome alone."

"As the overall population is aging all over the world, the numbers of people with Alzheimer's disease will more than double in the next couple of decades, unless we can find ways to prevent it," APA President Dilip Jeste, M.D., told Psychiatric News. "I think this is an excellent decision on the part of the FDA. We should keep in mind though that the ultimate proof of the effectiveness of these drugs will lie in showing that the incidence of dementia in these patients is reduced significantly compared with the placebo group. Thus, longer term follow-up would be critical to assess the success of the new FDA proposal."

To read about recent attempts to develop drugs to treat AD, see Psychiatric News here and here.

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Delusions Plus Anger Leads Some to Violence

Are people with psychiatric delusions likely to become violent? To get the answer, researchers looked at 458 patients who had entered treatment for the first episode of a psychotic disorder. Most of the patients (62 percent) were not violent in the year prior to the study. However, 26 percent did engage in minor violence and 12 percent in serious violence, reported Simone Ullrich, Ph.D., of Queen Mary University of London, and colleagues, March 6 in JAMA Psychiatry online.

“Only three delusions demonstrated significant associations with serious violence,” the authors said. However, the violence was not attributable to the delusions alone but to the interaction of delusions and anger.

"Delusions of being spied on, persecution, and conspiracy were significantly mediated by anger due to delusions in their relationship with serious violence,” they said. “A subset of delusional beliefs appeared to lead to ‘tense situations,’ which are described as an important component in a causal model of mental illness and violence.”

Anger that is a reaction to delusional beliefs may be susceptible to treatment that targets anger, said the researchers. But anger intrinsic to the delusion would suggest that treatment must target the delusion and the associated anger at the same time.

To read more about research on anger and aggression, see Psychiatric News  here.

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Stroke Risk Varies With Use of Different Antipsychotics

Beginning a decade ago, researchers noticed an association between use of antipsychotics among elderly patients and an increased risk of stroke. Antipsychotics are given to older patients to treat not only psychosis, but also depression, anxiety, insomnia, and agitation. Antipsychotics act primarily on the D2 subtype of the dopamine receptors, but on others as well. Understanding the mechanisms by which these medications influence stroke risk might lead to safer treatment practices.

To shed more light on this issue, Susan Shur-Fen Gau, M.D., Ph.D. a professor of psychiatry at the National Taiwan University Hospital and College of Medicine, and colleagues, looked at insurance data on 14,584 patients to link stroke risk with receptor binding profiles. They found that patients taking antipsychotics had an odds ratio of 1.60 of increased stroke risk, said Gau in the March 1 Biological Psychiatry. “The use of antipsychotics with a high binding affinity of M1 muscarinic and α2 adrenergic receptors was associated with a greater risk of stroke than the use of other types of antipsychotics,” wrote Gau. “An increased risk of stroke with antipsychotic use was noted in the patients who were older and/or who suffered from dementia.”

To read more about the use of antipsychotics in individuals with dementia, see Psychiatric News here and here. 

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Insomnia Is Linked to Heart-Failure Risk

New research provides another reason why it is important to treat insomnia. It appears to be associated with an increased risk of heart failure, and the more insomnia symptoms a person experiences, the greater the risk, according to a new report in the European Heart Journal. In a study involving more than 54,000 men and women aged 20 to 89, Norwegian researchers collected baseline data on insomnia symptoms—including difficulty initiating sleep, difficulty maintaining sleep and having nonrestorative sleep—as well as on sociodemographic variables and health status, including established cardiovascular risk factors.

The researchers identified 1,412 cases of heart failure in the study population during an average follow-up of 11.3 years, either identified at hospitals or by the National Cause of Death Registry. There was a dose-dependent association between the number of insomnia symptoms and risk of heart failure, with the risk for heart disease increasing for people who had one, two, and three insomnia symptoms, compared with people who reported no insomnia symptoms. Until direct causation between insomnia and heart failure can be proved, the researchers urge physicians to evaluate patients for insomnia, noting that "evaluation of insomnia symptoms might have consequences for cardiovascular prevention."

For information about diagnosing and treating insomnia, see American Psychiatric Publishing's Clinical Manual for Evaluation and Treatment of Sleep Disorders. For more information on sleep and its relationship to other health problems see Psychiatric News here and here.

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"AP Stylebook" Adds Entry on Mental Illness for Journalists

The Associated Press (AP) has added a new entry about mental illness to the widely read “AP Stylebook,” clarifying how journalists should refer to mental illness and people with a mental illness in articles and stories, and admonishing reporters and editors to avoid stigmatizing terms and phrases.

The entry, which has been added immediately to the online "AP Stylebook" and will appear in the new print edition and "Stylebook Mobile" in the spring, includes—among others—the following instructions: “Do not use derogatory terms, such as insane, crazy/crazed, nuts or deranged, unless they are part of a quotation that is essential to the story,” and “Do not assume that mental illness is a factor in a violent crime, and verify statements to that effect. A past history of mental illness is not necessarily a reliable indicator. Studies have shown that the vast majority of people with mental illness are not violent, and experts say most people who are violent do not suffer from mental illness.” The "AP Stylebook" is widely used by writers, journalists, and editors for a broad array of publication types, and the new entry reflects a remarkable sensitivity to the way public perception of mental illness can be shaped by modern journalism. A full text of the new AP entry about reporting on mental illness is online here.

For more about how media shape perceptions of mental illness, see Psychiatric News here and here.

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Reducing Cerebrovascular Disease May Prevent Cognitive Decline

Which factor is a greater contributor to cognitive decline in seniors? Vascular brain injury or amyloid plaques? Vascular brain injury, a study headed by Natalie Marchant, Ph.D., of the University of California, Berkeley, and published in JAMA Neurology suggests. Marchant and colleagues used brain imaging on a sample of 61 older individuals, average age 78, who were cognitively normal, had mild cognitive impairment, or were mildly demented. They wanted to explore the relationship between vascular injury or amyloid plaque deposition and cognitive decline. They found that vascular injury was more influential in accounting for cognitive decline than amyloid plaques were.

"Although mild cognitive impairment is clearly a significant risk factor for Alzheimer's disease, the present data suggest that the impact of vascular brain injury should be  considered when defining the etiology of mild cognitive impairment," the researchers concluded. And more crucially, "Reductions in cerebrovascular disease may be important in preventing mild cognitive impairment," they asserted.

But previous research has shown that vascular injury and amyloid-plaque buildup aren't the only factors linked with cognitive decline. Data show that smoking may contribute to cognitive decline as well. To read research on that link, see Psychiatric News here. And as researchers learn more about the elements of cognitive decline, they have also discovered an association with hearing loss. Read about that research in Psychiatric News here.

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ADHD Diagnoses Appear To Be on Increase

The diagnosis of childhood attention-deficit/hyperactivity disorder (ADHD) may be on a rapid rise, according to a new study of more that 800,000 youth. The  study, based on Kaiser Permanente Southern California (KPSC) health plan records, included all children aged 5 to 11 who received care from KPSC from 2001 to 2010—approximately 843,000 youngsters. The rates of children who were diagnosed with ADHD in 2001 were compared with the rates of children diagnosed with ADHD in 2010. Data showed a 24 percent increase in such diagnoses over this period. White children of both genders, black girls, and youth living in high-income households were especially likely to receive an ADHD diagnosis.

Although the reasons for the increased rate of ADHD diagnoses are not clear, they may include "heightened ADHD awareness among parents and physicians, increased use of screening and other preventive services, and variability in surveillance methods among institutions," the researchers said in the March JAMA Pediatrics. The lead researcher was Darios Getahun, M.D., Ph.D., of the Department of Research and Evaluation in the KPSC Medical Group.

To read more on recent findings related to ADHD, see Psychiatric News here and here. And for an analysis of nonpharmaceutical interventions in ADHD, see the American Journal of Psychiatry here.

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Mental Disorders Greatly Increase Vulnerability to Homicide

In the wake of all the attention paid after recent mass shootings to the risk that people with mental illness will be perpetrators of deadly violence, a study by Stanford University researchers reveals that a risk that is overlooked is that people with mental illness are in fact more likely to be victims of homicide than are other individuals. People with mental disorders, including substance use disorders, anxiety disorders, or schizophrenia, have a greatly increased risk of being killed in a homicide, reported researchers in BMJ online March 5. 

They performed a nationwide cohort study of all people aged 17 or older who were living in Sweden on January 1, 2001 (n=7,253,516), identifying 615 homicide deaths during eight years of follow-up, including 141 among people who had been diagnosed with mental disorders. Men had twice the risk of being victims of homicidal death. The risk was more than twofold higher among people who were divorced or never married compared with those who were married or cohabitating. Other independent risk factors included low-education level, low income, being unemployed, and living in large cities rather than in medium-sized or small towns. 

The researchers noted that the homicide rate in Sweden (1.1 per 100,000 person years) is much lower than that of the United States (7.0 per 100,000 person years), and it is in the United States, they said, "where our findings are likely to have a larger public health impact."

To read a report of a recent Capitol Hill hearing on the relationship between mental illness and gun violence, see Psychiatric News here. The study reported in BMJ is posted here.

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APA Medical Director Interviewed by Bloomberg TV

The upcoming publication of DSM-5 was the focus of an interview on Bloomberg TV Wednesday featuring APA Medical Director and CEO James H. Scully Jr., M.D. During the five-minute segment, Scully had an opportunity to explain why the so-called bereavement exclusion, which prohibited a diagnosis of depression within two months of a loved one's death, would not be included in the next edition of the manual.

Asked about the level of controversy that has attended news of the upcoming revision to the diagnostic manual, Scully noted that criticism of the last two editions of DSM was even more heated, but now that the world of communication has given everyone a platform to air their views, the quantity of complaints and controversy has multiplied. He emphasized that the upcoming revision has been seven years in the making, involved hundreds of scientists and clinicians, and has gone through multiple layers of review. The moderator also asked him to respond to the Newtown school shootings and issues of mental illness and gun violence that have been raised in its wake. He pointed out that most gun violence is alcohol-fueled and that only 4% of gun-related violence is committed by people with mental illness.

To see the complete interview, click here.

New Study Explains Rise in Antipsychotic Use by Children

A major study assessing changes in pediatric use of antipsychotic medications found that in the decade from 1997 to 2006 their use in the Medicaid program nearly tripled, from 1.2% to 3.2%. The study of more than 450,000 children and adolescents who were insured continuously through Medicaid during the 10-year period is reported in the March issue of Psychiatric Services. The goal of the study, led by Julie Magno Zito, Ph.D., of the University of Maryland Department of Pharmaceutical Health Services Research, was to evaluate the impact on antipsychotic use over the decade in the following Medicaid-eligibility categories—foster care, State Children's Health Insurance Program (SCHIP), Temporary Assistance for Needy Families (TANF), and Supplemental Security Income (SSI).

They found that "expansion of antipsychotic use was most prominent among youths who were Medicaid eligible because of low family income (SCHIP)" followed by those eligible through the TANF program. This increase reflected a significant increase in prescription of antipsychotics for behavior disorders and bipolar disorder rather than for treatment of schizophrenia, other psychoses, or pervasive developmental disorders. In fact, the researchers pointed out, "youths with externalizing behavior disorders far outnumbered those with [schizophrenia and pervasive developmental disorders] and constituted the largest group of utilizers of antipsychotic medications." In addition, the increase was significantly greater among African Americans and Hispanics that among white youth.

Read the full report of the study in Psychiatric Services. To read much more about the use of antipsychotics in children and adolescents, see Psychiatric News here and here.

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Screening Urged for Anxiety Symptoms After Childbirth

While considerable attention has been paid in recent years to diagnosing and treating postpartum depression, too little has been focused on postpartum anxiety and its consequences, according to a new online report in the journal Pediatrics. Ian Paul, M.D., and colleagues at Penn State College of Medicine studied 1,123 women with an average age of 29 using an in-person interview during their postpartum hospital stays followed-up by telephone surveys at two weeks, two months, and six months after hospital discharge to assess health care use, breastfeeding duration, anxiety, and depression. Anxiety was evaluated with the State Trait Anxiety Inventory, and depression was evaluated with the Edinburgh Postnatal Depression Survey. The researchers noted that this is the first study of which they aware to evaluate prospectively the issue of postpartum anxiety and its impact on health care service use. 

The researchers found that anxiety was far more common during the postpartum hospital stay than depression was and remained so in the six months after women left the hospital. And the effects of that anxiety were associated with reduced breastfeeding duration and increased use of health care services by the mother. These services included hospital-based services such as inpatient stays and emergency room visits and unplanned outpatient medical visits. Very few women were found to have high scores on both the anxiety and depression measures. In light of how common postpartum anxiety is, they urged that screenings for it should be part of postpartum evaluations, giving health care providers opportunity to "potentially intervene, particularly among those most affected, such as first-time mothers."

To read about issues related to postpartum depression and treating depression during pregnancy, see Psychiatric News here and here. Also see the American Journal of Psychiatry.

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Multifamily Therapy Appears Helpful for Traumatic Brain Injury

Multifamily group treatment for veterans with traumatic brain injury (TBI) appears to be useful and effective, according to a small study appearing online in Psychiatric Services. Veterans at two Veterans Affairs medical centers were prescreened by their providers for participation in an open trial of multifamily group treatment for TBI. Enrollment was limited to consenting veterans with a clinical diagnosis of TBI sustained during the Operation Enduring Freedom–Operation Iraqi Freedom era, a family member or partner consenting to participate, and a score ≥20 on the Mini-Mental State Examination. The nine-month trial consisted of individual family sessions, an educational workshop, and bimonthly multifamily problem-solving sessions. Interpersonal functioning and symptomatic distress among veterans and family burden, empowerment, and symptomatic distress among families were assessed before and after treatment.

Eleven veterans participated. Treatment was associated with decreased anger expression by the vets and increased social support and occupational activity. Caregivers reported decreased burden and increased empowerment. “An open trial of an adaptation of multifamily group treatment for...veterans with TBI demonstrated significant improvement in anger management and use of social supports among veterans and in burden and empowerment among families, providing a rationale for mounting a randomized clinical trial,” the researchers stated.

"Implementation of Multifamily Group Treatment for Veterans With Traumatic Brain Injury" is posted here. American Psychiatric Publishing recentlyt published “Management of Adults With Traumatic Brain injury.” For purchasing information click here. And for more about traumatic brain injury, see Psychiatric News here.

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