Childhood Trauma, Psychotic Experiences Show Bidirectional Relationship

Exposure to childhood trauma predicted newly incident psychotic experiences, according to a report appearing online in AJP in Advance. The study, "Childhood Trauma and Psychosis in a Prospective Cohort Study: Cause, Effect, and Directionality," also provides the first direct evidence that cessation of traumatic experiences leads to a reduced incidence of psychotic experiences.

Researchers in the Department of Psychiatry at Ireland's Royal College of Surgeons and other institutions analyzed data from a nationally representative prospective cohort study of 1,112 school-based adolescents aged 13 to 16 who were assessed at baseline and at three-month and 12-month follow-ups for childhood trauma (physical assault and bullying) and psychotic experiences. The researchers found a bidirectional relationship between childhood trauma and psychosis, with trauma predicting psychotic experiences over time and vice versa. A dose-response relationship was observed between severity of bullying and risk for psychotic experiences. Moreover, cessation of trauma predicted cessation of psychotic experiences, with the incidence of psychotic experiences decreasing significantly in individuals whose exposure to trauma ceased over the course of the study.

An abstract of the AJP study is posted here. To read more about treatment of trauma, see Psychiatric News here. For research on the relationship between bullying and mental illness, see Psychiatric News here.

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Groundbreaking Mental Health Law to Take Effect in China

China is transforming the provision of mental health to its citizens under a new law that takes effect tomorrow. Its first national mental health legislation should have wide-ranging effects on provision of mental health services, but perhaps the most significant and controversial change is one that banishes most forms of involuntary treatment. The law also mandates strict limits on use of seclusion and restraints and ends the use of psychiatric admission as punishment or to enforce treatment of individuals who do not have a mental illness. It also forbids the practice of requiring patients to participate in labor or limiting their right to communicate with the outside world.

An editorial appearing online in AJP in Advance yesterday calls the new law visionary, but emphasizes that it will present China with many challenges—especially the need for more psychiatrists and community-based psychiatric services. “This new law is a high-water mark for Chinese psychiatry, and potentially for global mental health,” according to the editorial.

In comments to Psychiatric News today, lead author of the editorial Michael Phillips, M.D., said the new law is much more comprehensive than laws in other countries. “China's experience in providing a more holistic approach to mental health problems will, hopefully, generate lessons that all countries can learn from,” he said. Phillips, who is executive director of the World Health Organization's Collaborating Center for Research and Training in Suicide Prevention at China's Beijing Huilongguan Hospital, added, “Like the U.S., China is struggling with finding the right balance between the care and control of the mentally ill…. Both China and the U.S. need to work on finding the right balance between individual freedom, family responsibility, and protection of the community. There are no absolute answers to these issues, so the U.S. and China can learn from each other as they work towards finding the solutions that best fit their respective cultural and health-care environments.”

The AJP editorial, “China’s New Mental Health Law: Reframing Involuntary Treatment,” is online here.

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Is Suicide Screening Effective? Still no Clear Answer

Since adults who die by suicide have often visited their primary care physician within the previous month, could routine screening for suicide by primary care physicians prevent suicides? Unfortunately, "there is not enough evidence to make a definitive recommendation for or against screening," the U.S. Preventive Services Task Force—a volunteer panel of national experts in prevention and evidence-based medicine—concludes in a draft recommendation statement.

"Some past research has shown that improved recognition and treatment of depression in primary care has led to decreased suicide rates," Timothy Lineberry, M.D., an associate professor of psychiatry at the Mayo Clinic and a suicide expert, told Psychiatric News. "However, trying to separate out the large population at risk for suicide from those who go on to die by suicide is difficult, and as the U.S. Preventive Services Task Force found, there is currently a limited evidence basis for suicide-specific screening." Lineberry added, however, that "it is important to remember that for those primary care practices that use collaborative care for depression-treatment models, screening for depression is supported by the task force."

A recent study about primary care visits of those contemplating suicide found that a substantial percentage of members of the military visit a primary care physician in the month before attempting or dying by suicide. Read about that study in Psychiatric News here. More information about suicide prevention can be found in Psychiatric News here.

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Insurers Delay Hospitalization of Severely Ill Psychiatric Patients

Hospitalization of severely ill psychiatric patients can be delayed because of authorization required by insurance companies, a study reported in the Annals of Emergency Medicine has found. The study was headed by Amy Funkenstein, M.D., a child psychiatry fellow at Brown University, and J. Wesley Boyd, M.D., an assistant clinical professor of psychiatry at Harvard Medical School. (Funkenstein and her colleagues conducted the study while she was a psychiatry resident at Harvard Medical School.) The study included 53 severely ill psychiatric patients in the Cambridge Health Alliance Psychiatric Emergency Department. Psychiatry residents tending to the patients averaged 38 minutes from the time of first contact with an insurance company until authorization to hospitalize the patients was either granted or denied. Although half the authorization requests took less than 20 minutes to be approved, for about 10 percent of patients authorization requests took an hour or more, with the longest request taking five hours.

"Private insurers are obstructing care by requiring authorizations before a qualified psychiatrist can hospitalize a dangerously ill patient," Boyd said in a press statement. "With doctors, nurses, and emergency departments already overburdened, adding a time-consuming bureaucratic task that doesn't help patients is unconscionable."

To read more about the challenges that emergency psychiatrists face in their work, see Psychiatric News here and here. Also see Clinical Manual of Emergency Psychiatry, from American Psychiatric Publishing.

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Patients Get Opportunity to Safely Dispose of Unwanted Medication

The Sixth National Prescription Drug Take-Back Day, a program of the Drug Enforcement Administration (DEA), will take place this Saturday April 27 across the country, giving people a chance to safely dispose of medication they no longer need. National Take-Back Day was initiated to prevent pill abuse and theft by ridding homes of potentially dangerous expired, unused, or unwanted prescription drugs. Local law enforcement agencies in thousands of American communities have partnered with the DEA to take in more than 2 million pounds—almost 1,018 tons—of expired prescription drugs since September 2010. The DEA says that unused medications in homes create a public-health and safety concern because they are highly susceptible to accidental ingestion, diversion, misuse, and abuse. Rates of prescription drug abuse in the U.S. are alarmingly high—more Americans currently abuse prescription drugs than the number of those using cocaine, hallucinogens, and heroin combined, according to the most recent National Survey on Drug Use and Health. The majority of abused prescription drugs are obtained from family and friends, including from the home medicine cabinet. 

Collection sites will be open from 10 a.m. to 2 p.m. local time. Visit dea.gov and click on the “Got Drugs?” icon for the location of the nearest site.

Monitoring programs that offer real-time information to pharmacies could also curtail prescription drug abuse, said Canadian researchers recently. Read about their study and recommendations in Psychiatric News here.

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Prenatal Valproate Exposure Raises Risk of Autism Spectrum Disorders

Researchers at Aarhus University in Denmark reported April 24 in JAMA that maternal use of valproate during pregnancy is associated with a significantly increased risk of autism spectrum disorder (ASD) and childhood autism, even after adjusting for maternal epilepsy. The population-based study included all children born in Denmark from 1996 to 2006.

"Valproate is generally regarded as a bad drug to take while pregnant," said Gail Robinson, M.D., director of the Women's Mental Health Program of the University Health Network of Toronto and a professor of psychiatry at the University of Toronto, who commented on the study for Psychiatric News. Robinson noted that valproate is also associated with increased risk for atrial septal defect, hypospadias, cleft palate, craniosynostosis, and spina bifida, at rates that far outweigh the risks for ASD. "For all of these reasons, psychiatrists who specialize in peripartum mental health disorders try to avoid its use during pregnancy...whether or not it increases the risk of autism, where possible it should be eliminated during pregnancy and a safer drug substituted."

To read a detailed report of preliminary findings from this study, see Psychiatric News here. 

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Cognitive Remediation, Vocational Rehab Create 'Total Dose Effect' for Schizophrenia

Cognitive remediation therapy (CRT) for schizophrenia is being combined with vocational rehabilitation and other psychosocial interventions to create multimodal interventions aimed at improving “real-world” functioning. That’s what Philip Harvey, Ph.D., the Leonard M. Miller Professor of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine, said at the International Congress of Schizophrenia Research in Orlando, Fla., this week. The title of his talk was “Cognitive Remediation and Cognitive Enhancement: State of the Art.”

Harvey (pictured above at the congress) provided an overview of a field that has garnered increasing interest among schizophrenia researchers: the effort to address cognitive impairments, which have been shown to be more crucial to long-term functional outcome—and more stubbornly resistant to treatment—than positive symptoms of psychosis. Harvey described a trend toward using cognitive remediation in combination with other psychosocial interventions—especially vocational rehabilitation—that can produce robust effects even in a relatively short period, suggesting the importance of a multimodal strategy with a “total dose effect” that may be as important as the duration of treatment. Several researchers at the congress described cognitive remediation efforts that are embedded within vocational rehabilitation programs.

“When I look at these data, what I see is that there seems to be this total dose treatment effect,” Harvey said. “If you give people 100 sessions of CRT and nothing else, or 20 sessions of CRT plus vocational rehabilitation, you get the same outcome…. It’s very encouraging to me to review data on cognitive enhancement therapies that not only make your cognition better, but make it look like you are doing better in the world in a short time period.”

For more about Harvey's research on cognitive remediation, see the American Journal of Psychiatry.

(image: Mark Moran/ Psychiatric News)

Extreme Fatigue in Teens May Be Pathological Condition

“Extreme fatigue that continues even after rest and interferes with adolescents’ ability to participate academically, socially, or at home is a pathological condition," but it is a condition that is often overlooked and untreated because it is not viewed as serious enough to warrant medical attention. That is a key finding of a study by Kathleen Merikangas, Ph.D., of the National Institute of Mental Health and colleagues to be reported in the May American Journal of Psychiatry, which will be available May 1. The researchers surveyed more than 10,000 adolescents across the United States as part of the National Comorbidity Survey Adolescent Supplement and found that 3% said they had been experiencing extreme fatigue for at least three months and that getting rest did not relieve the condition. Of the teens reporting extreme prolonged fatigue, more than 50% also reported "severe" or "very severe" difficulties in school, family, or social situations. Despite these problems, only 14% of the respondents had received any treatment for the condition.

In addition, of those reporting extreme fatigue, about 50% also had a depressive or anxiety disorder, and these teens were more disabled and more likely to receive treatment for their disorders than their peers with fatigue only or with anxiety or depression only. However, since the teens with persistent fatigue but without comorbid depression or anxiety exhibited substantial impairment and "a striking degree of disability," the researchers said, this suggests "that fatigue states are themselves an important clinical entity."

For information about treating psychiatric illness in youngsters, see American Psychiatric Publishing's Concise Guide to Child and Adolescent Psychiatry, Fourth Edition. 

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Insurer Says It Will Change Mental Health Fee Schedule After APA Files Suit

Today, the Insurance Commission of Connecticut issued a press release stating that Anthem had agreed to adjust its fee schedule for mental health care providers to recognize coding changes in Current Procedural Terminology (CPT). The readjustment, which will be retroactive to January 1, 2013, is reported to cover 28,000 claims and $400,000 in payments owed.

APA had initiated a lawsuit against Anthem and Wellpoint alleging that its implementation of the CPT codes violated the Mental Health Parity and Addiction Equity Act (MHPAEA) and state parity, contract, and consumer protection laws. According to APA Medical Director and CEO James H. Scully Jr., M.D., “APA cannot assume that Anthem’s proposed solution complies with federal parity law or that Anthem has ended its discrimination against those in need of mental health care and benefits that we alleged in our complaint.  In our view, the press release is interesting in that there is much that it does not say; leaving many outstanding issues that need to be resolved before we can assure members and their patients that Anthem is not discriminating against mental health patients. I have asked David Fusco, Anthem’s CEO, to provide answers to outstanding questions that appear not to have been addressed in this agreement with the Insurance Commission, which we understand was reached without consideration of the federal [parity] law."

In his communication with Fusco, Scully has requested that Fusco provide additional information about the plans to correct the MHPAEA violations alleged in APA’s complaint. APA says that "Whether Anthem and Wellpoint companies will continue their alleged violations of the MHPAEA and discrimination against mental health patients is unclear."

Read more about APA's suit against Wellpoint and Anthem in Psychiatric News.

Violence Can Change Children's Chromosomes

Children who experienced at least two types of exposure to violence showed significantly more telomere erosion between ages 5 and 10 than did controls subjects, report researchers from Duke University. Shortened telomeres eventually lead to cell death and are associated with aging and degenerative diseases.

The study of 236 children born in 1994 and 1995 took DNA samples at ages 5 and 10 and also looked at their exposure to maternal domestic violence, frequent bullying victimization, and physical maltreatment by adults.

“This finding provides support for a mechanism linking cumulative childhood stress to telomere maintenance, observed already at a young age, with potential impact for life-long health,” said postdoctoral fellow Idan Shalev, Ph.D., and colleagues online today in Molecular Psychiatry.

To learn more about how telomere length affects both mental and physical health, see Psychiatric News here and here.

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Bill Would Clarify Clinicians' Credentials, Stop Misrepresentation

When is a doctor not a doctor? That question is the focus of legislation just introduced in Congress and supported by APA calling for clarification of any practitioner’s qualifications and licensure. The Truth in Healthcare Marketing Act of 2013 (H.R. 1427) refers to surveys conducted in 2008 and 2010 and points out that “patient confusion result[s] from ambiguous health care nomenclature…” because “consumers are often unaware of the differences in, and seek more information about, the qualifications, training, and education of their health care professionals.”

For example, patients are often confused by obscure sets of initials following a practitioner’s name or by titles (like “medical psychologist”) that may not be connected to any actual professional license. The bill requires the Federal Trade Commission (FTC) to identify misleading practices regarding health care practitioners' credentials and detail instances of harm these practices may have caused. It would prohibit any misrepresentation of a person’s licensing, training, or expertise, and be enforced by existing FTC measures. APA, the AMA, and other medical professional organizations have urged Congress to pass this bill.

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Oxytocin May Augment Social-Cognition Training in Schizophrenia Patients

Oxytocin, a hormone known to influence a variety of emotional responses including attachment and social engagement, appears to be helpful as an adjunct to social-cognition training for some patients with schizophrenia, said Stephen Marder, M.D., of the Semel Institute for Neuroscience at UCLA yesterday at the International Congress on Schizophrenia Research in Orlando, Fla. 

Marder (pictured above at the conference) made his remarks during a symposium on “Pharmacological Approaches for Facilitating Non-Pharmacologic Treatments.” He outlined evidence for impairment in social cognition in schizophrenia and its relationship to poorer outcome, as well as studies indicating that training can improve social cognition and evidence for the efficacy of oxytocin in enhancing empathic accuracy and recognition of positive and negative social cues. Marder explained that social cognition consists of “lower level” cognitive skills—such as recognition of facial cues—and “higher order" skills such as the ability to make emotional inferences and recognize sarcasm, for instance. He then described studies at UCLA in which schizophrenia patients were administered oxytocin prior to receiving social-cognition training. The findings were intriguing: while the skills training was primarily useful for lower-level social skills, the oxytocin appeared to enhance the higher-level skills of drawing accurate inferences from social cues and empathic accuracy.

“We think if these findings are confirmed in larger trials they have important significance for pharmacologically augmenting cognitive training and may be useful in the treatment and outcome of some patients,” Marder said.

For more information about oxytocin and about cognitive training in schizophrenia see Psychiatric News here and here.  For detailed information about treatment of patients with schizophrenia, see Clinical Manual for Treatment of Schizophrenia from American Psychiatric Publishing.

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NIDA Researchers Suggest New Direction for Treating Addictions

Using optogenetics, essentially shining a light, on particular cells in the prefrontal cortex can reduce cocaine addiction in rats, according to a study published April 3 in Nature. The senior scientist was Antonello Bonci, M.D., scientific director of the National Institute on Drug Abuse (NIDA). "Our results can be immediately translated to clinical research settings with humans, and we are planning clinical trials to stimulate this brain region using noninvasive methods," Bonci reported in a press statement. "By targeting a specific portion of the prefrontal cortex, our hope is to reduce compulsive cocaine-seeking and craving in patients."

"This exciting study offers a new direction in research for the treatment of cocaine and possibly other addictions," added NIDA Director Nora Volkow, M.D. "We already knew, mainly from human brain imaging studies, that deficits in the prefrontal cortex are involved in drug addiction. Now that we have learned how fundamental these deficits are, we feel more confident than ever about the therapeutic promise of targeting that part of the brain."

Bonci and his colleagues gave cocaine to two groups of rats—those addicted to cocaine and those not addicted to cocaine—then compared the neuron-firing patterns in the prefrontal cortex in both groups. They found less firing in the deep-layer pyramidal neurons of the prefrontal cortex in the addicted rats than in the nonaddicted rats, implying that such sluggish firing might be critical for cocaine addiction. They then used optogenetics to stimulate the underperforming pyramidal neurons in the addicted rats and found that it reduced cocaine-seeking behavior. "Thus, targeted stimulation of the prefrontal cortex could serve as a promising therapy for treating compulsive drug use," the researchers concluded.

More information about advances in treating cocaine can be found in American Psychiatric Publishing's Cocaine and Methamphetamine Dependence: Advances in Treatment.

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APA Medical Director Comments on Gun Control and Mental Health System

While advocates of some form of gun-control legislation, particularly a mandate for more-comprehensive background checks of buyers, recently suffered a major setback when the Senate failed to muster a sufficiently large majority to pass such a bill despite widespread public support, mental health issues raised in the gun-control debate still have a pulse, according to a report in Politico newspaper yesterday.But do mental health experts and advocates think linking mental health care to guns is a winning strategy? “It wasn’t our choice to be tied to guns—it was kind of the evolution of the sentiment of the public as well as the mood of the Senate to focus on mental health as part of this debate,” said Chuck Ingoglia, of the National Council for Community Behavioral Healthcare. There was a lack of agreement among mental health groups about closely linking gun control and gun violence, particularly in the context of unmet treatment needs, said Andrew Sperling, federal legislative director for the National Alliance on Mental Illness. Better strategies for improving an ailing mental health system appear to lie in expanding Medicaid and in having the Department of Health and Human Services publish long-delayed regulations to implement the federal mental health parity law. HHS Secretary Kathleen Sebelius told a congressional committee last week that such final regulations would be out by the end of the year—five years after the parity law passed.

Commenting on the issue for Politico, APA Medical Director James H. Scully Jr., M.D., emphasized that unless serious flaws in the system are fixed, some people will continue to get treatment in the same costly but inadequate setting they are getting it now: our jails and prisons. "It's the same old story you've been dealing with for all these decades," Scully said. As for the lengthy path that legislation to improve the mental health system will have to travel, Scully said, "We knew it would be a hard slog. In our profession, we know it takes a long time to get people to change. Therapy takes a long time. So does politics."

To read more about the issue of gun violence and mental illness, see Psychiatric News here and here. 

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New Study Refutes Common Belief About Effects of Solitary Confinement

It has been commonly believed for some years now that prolonged solitary confinement in prison is psychologically damaging. Now a "carefully performed study calls those beliefs into question," Paul Appelbaum, M.D., the Dollard Professor of Psychiatry, Medicine and Law at Columbia University and a past APA president, told Psychiatric News. "The intuition that many people have that, 'If they ever put me in solitary, I'd go crazy,' just doesn't reflect what actually occurs." The study was conducted by Jeffrey Metzner, M.D., a clinical professor of psychiatry at the University of Colorado, and colleagues. The results were published in the March Journal of the American Academy of Psychiatry and the Law.

The study included 270 Colorado prison inmates who had violated prison rules and who, following a hearing, were placed in one of three different prison environments—solitary confinement for inmates with or without mental illness, a general population maximum-security housing unit for inmates with or without mental illness, or a special housing unit for inmates with mental illness. The subjects were followed for a year. The researchers found that while some of the inmates' psychological health deteriorated over the course of the study, this was generally not the case, even among inmates in solitary confinement. "We were surprised that only a small number of inmates in segregation got clinically worse," Metzner told Psychiatric News.

So what might explain these surprising results? "Administrative segregation may not  be pleasant, but based on these data, it appears that prisoners—even prisoners with mental illness—find ways of adapting that mitigate negative consequences," said Appelbaum, who is also chair of the APA Committee on Judicial Action.

To read more about the controversy over the psychological impact of solitary confinement, see Psychiatric News.

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New Proposal to Eliminate SGR Gaining Traction

APA has responded to the latest iteration of a proposal by Republicans in the House of Representatives to eliminate the Sustainable Growth Rate component of the Medicare payment formula in a letter Tuesday to Rep. Dave Camp (R-Mich.), chair of the House Ways and Means Committee, and Rep. Fred Upton (R-Mich.), chair of the Energy and Commerce Committee. 

The proposal, still evolving and not yet translated into draft legislation, has gained traction as a substantive policy proposal from key House committees after years of congressional inaction on replacing the SGR system. In addition, the Congressional Budget Office recently released estimates that put the overall  costs of eliminating the SGR much lower than previously expected. (The SGR mandates that increases in Medicare volume be offset by decreases in physician pay, without taking into account practice costs and inflation. The new lower CBO estimates of the cost of eliminating SGR are the result of substantially lower increases in Medicare volume).

The new proposal may be the best chance for eliminating the SGR formula, according to APA’s Division of Government Relations. But the proposal is also linked to significant overall reforms of Medicare and physician payment. In the letter to Upton and Camp, APA addresses the complexities of the proposal and raises a number of questions pertinent to psychiatrists. To read the APA letter go here.

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Government Cracks Down on So-Called "Bath Salts" as Public-Safety Hazard

On April 12, the Drug Enforcement Administration (DEA) published a Final Rule to permanently control 3,4-methylenedioxy-N-methylcathinone (methylone) and a Notice of Intent to temporarily schedule three synthetic cannabinoids. Methylone, a psychoactive stimulant drug falsely marketed as “bath salt” products, is permanently placed in Schedule I under the Controlled Substances Act, the most restrictive category, which is reserved for unsafe, highly abused substances with no accepted medical use. The DEA previously temporarily scheduled methylone on October 21, 2011, after finding it posed an imminent hazard to public safety. On October 17, 2012, the DEA proposed making methylone’s Schedule I status permanent, taking steps that concluded with the Final Rule last week.

The FDA’s Notice of Intent to temporarily control three synthetic cannabinoids—UR-144, XLR11, and AKB48—was an action taken after finding that these three substances pose an imminent hazard to public safety. This action will become effective upon publishing a Final Order to temporarily control these substances as Schedule I substances for up to two years, with the possibility of a one-year extension. 

Read about one psychiatrist's battle against the abuse of "bath salts" in Psychiatric News here. 

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People with Mental Illness Define "Community" Their Own Way

That place where everybody knows your name is crucial for persons with serious mental illness. “The experience of having a serious mental illness shapes preferences for and perceptions of community in pervasive ways,” wrote Elizabeth Bromley, M.D., Ph.D., of the Department of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles, in Psychiatric Services in Advance April 1. Bromley and colleagues conducted extensive interviews with 30 people with serious mental illness. Respondents named family, places of worship, neighborhoods, and mental health peers as “communities” to which they belonged.

A deeper analysis identified four “patterns of experience” that made up communities for the respondents. Communities were places where they could receive help, especially in times of vulnerability. Communities were also places to manage risk and minimize the anxiety they feel in public settings. The stigma experienced in the general community or even within their families led many respondents to identify more strongly with their mentally ill peers. Communities are also place where they could “give back” and help others.

“Rather than striving for normalcy per se, participants emphasize most often the need for reliable communities that provide consistent support and a safe haven,” concluded Bromley and colleagues.

To read about one long-standing mental health community, see Psychiatric News here.

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APA Member Finishes Boston Marathon Moments Before Blast

Less than a minute after psychiatrist Brent Forester, M.D., crossed the finish line at Boston’s 117th Marathon—achieving his goal of running the race in under four hours—he heard the sound of what he knew could not be good news. “It sounded just like a loud cannon, but I was close enough to see there was smoke and debris everywhere, and I knew this was not normal,” Forester (shown here before the race) said of the attack that killed at least three people and injured more than 170. “I thought possibly it was an accident, a gas main or a furnace, but it was clearly an explosion. And I knew there would be many people dead or injured.”

Forester, a geriatric psychiatrist at McLean Hospital and chair of the APA Council on Geriatric Psychiatry, was running his fourth Boston Marathon and raising money for the Alzheimer’s Association of Massachusetts and New Hampshire. This year he also raised money—some $3,500—for the Scholar’s Program sponsored by the American Association for Geriatric Psychiatry (AAGP) and the Geriatric Mental Health Foundation, which pairs medical students and psychiatry residents with mentors in the field and brings them to the AAGP annual meeting. Running for charity causes is a common feature of the race that has become emblematic of Boston, especially so among those who are not elite athletes, but who run for a meaningful cause and the thrill of crossing the finish line to the cheers of thousands. And Forester noted an especially chilling aspect of Monday’s attack: the bombs were timed to go off as those countless “regular-folk” runners were crossing the finish line, and when their family and friends were bound to be there to watch.

“I’ve never experienced something like this, and I’m not an expert in disaster psychiatry, but people here need to talk about what they have been through,” Forester said. “I spoke with some of my medical students after the race and they all wanted to do something to help. Boston's citizens were being turned away from hospitals because they didn’t need blood right now, though will in the coming weeks. But I told the students that the injured, their families, and first responders all need a lot of emotional support.”

For more information on psychiatric sequelae of disasters, see Disaster Psychiatry: Readiness, Evaluation, and Treatment published by American Psychiatric Publishing.

(Image: courtesy of Brent Forester, M.D.)

Fitness Program Leads to Better Cardiovascular Health in Those With Serious Mental Illness

Overweight and obese adults with a severe mental illness showed a clinically significant reduction in cardiovascular risk after participation in a physical fitness program called In SHAPE, which involves a free fitness club membership and the active assistance of a health mentor. The program was also associated with weight loss and overall improvement in fitness. In a report to be published ahead of print next month in Psychiatric Services in Advance, Stephen Bartels, M.D., M.S., of the Department of Psychiatry and Department of Community and Family Medicine at Geisel School of Medicine at Dartmouth, and colleagues followed 133 subjects with serious mental illness and a body mass index over 25 for 12 months. They were randomly assigned to either the In SHAPE program or were provided with a one-year fitness club membership and educational materials about the benefits of exercise and a healthy diet. Subjects had been diagnosed with either major depression, bipolar disorder, schizoaffective disorder, or schizophrenia and had persistent impairment in major areas of functioning. The health mentors were taught about the symptoms of the mental illnesses, received instruction in motivational interviewing to help In SHAPE participants change their lifestyles and set goals and objectives, and were trained in nutrition education.

While many believe that individuals with severe mental illnesses are unlikely to be able to take steps to lose weight and improve physical fitness, Bartels and colleagues found that twice as many of the In SHAPE participants showed significant cardiorespiratory improvement after 12 months than did the control subjects, as well as clinically significant weight loss. They said their findings show that "a health mentor intervention may help overcome the motivational challenges and low self-efficacy often experienced by persons with serious mental illness."

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Massachusetts District Branch, APA Respond to Boston Tragedy

APA President Dilip Jeste, M.D., contacted the Massachusetts Psychiatric Society (MPS) today, offering APA’s sympathies and assistance in the wake of the bombing of the Boston Marathon. “We know our colleagues may be called upon to deal with the mental health consequences that may arise from this traumatic event, and we are confident they will meet this challenge,” wrote Jeste to the MPS’s president and executive director. “There is no doubt that, as we have done so many times in the past, we all will emerge from this horrific event with a renewed sense of unity, resilience, and strength.” Jeste said APA's Committee on Psychiatric Dimensions of Disasters, chaired by Robert Ursano, M.D., and the Office of International Activities are involved in the district branch’s response to the tragedy.

Todd Holzman, M.D., MPS’s disaster liaison, told Psychiatric News that the district branch is coordinating support and relief efforts with the Red Cross and has asked MPS members to let the DB know of their availability as volunteers. He said psychiatrists were also being asked to let MPS know whether they had any institutional or practice needs for which the MPS can offer support and expertise. The MPS has been working with APA’s Committee on Psychiatric Dimensions of Disasters and other APA members who are expert in disaster-related issues to gather information for posting on its Web site.

Luckily, the MPS had held a training program last spring on disaster response, and about 60 psychiatrists and mental health professionals were certified by the Red Cross, said Holzman, “Even though the Boston area is known as a rich and sophisticated area—with many outstanding academic and medical institutions—it doesn’t reduce suffering or the need for a strong psychiatric response to help the many people in our city who are affected by yesterday’s events,” said Holzman. "I want everyone to know that we are grateful for the offerings of help and support from APA and our friends and colleagues throughout the country. They have given us an emotional hug.”

One of the sources of information the MPS is using is American Psychiatric Publishing's Disaster Psychiatry: Readiness, Evaluation, and Treatment by Frederick J. Stoddard Jr., M.D., Anand Pandya, M.D., and Craig L. Katz, M.D. Stoddard, a clinical professor of psychiatry at Harvard and on the staff of Massachusetts General Hospital, is among those providing assistance in the Boston area.

(AP Photo/Charles Krupa)

Over-Exercise May Signal Heightened Suicide Risk in Bulimic Individuals

Over-exercise in females with bulimia nervosa is linked to suicidality, April Smith, Ph.D., of Miami University in Ohio and colleagues report in the April 30 Psychiatry Research. In a first study, which included 204 women who met full or partial criteria for a DSM-IV diagnosis of bulimia nervosa, the researchers found that the frequency of over-exercise—defined as "hard exercise as a means of controlling weight or shape"—significantly predicted suicidal gestures and suicide attempts, even when other bulimic behaviors such as vomiting, purging, and fasting were considered.

They then attempted to replicate this finding in a nonclinical sample of 171 college students. The students were evaluated for symptoms of bulimia nervosa, including over-exercise, as well as for "acquired capability of suicide" (that is, fearlessness about lethal self-injury). The researchers found that over-exercise predicted "acquired capability of suicide" even when other bulimia nervosa symptoms were considered.

And in a third study, this one of 467 college students, Smith and colleagues found that over-exercise predicted pain insensitivity over and above other bulimic behaviors. They thus suspect that over-exercise might lead to suicidality by increasing pain and in turn pain tolerance, and the pain tolerance in turn might make a person less fearful of death. "These results may help explain the increased rate of suicidal behavior displayed by people with bulimia nervosa," the researchers said. "And given these findings, an important treatment target for individuals with bulimia nervosa who are engaging in over-exercise may be to teach healthy exercise..."

More information about bulimia nervosa and how to treat it can be found in Psychiatric News and in American Psychiatric Publishing's Clinical Treatment of Eating Disorders.

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APA Answers Insurance-Related Questions About DSM-5

Today, APA posted questions and answers regarding the insurance implications of DSM-5. One frequent question, for example, is: When can DSM-5 be used for insurance purposes? The answer is the following: "Since DSM-5 is completely compatible with the HIPAA-approved ICD-9-CM coding system now in use by insurance companies, the revised  criteria for mental disorders can be used immediately for diagnosing mental disorders when it is released in May 2013. However, the change in format from a multiaxial system in DSM-IV-TR may result in a brief delay while insurance companies update their claim forms and reporting procedures to accommodate DSM-5 changes."

Another common question is: How are DSM-5 and ICD related? Here is the answer: "DSM-5 and the ICD should be thought of as companion publications. DSM-5 contains the most up-to-date criteria for diagnosing mental disorders, along with extensive descriptive text, providing a common language for clinicians to communicate about their patients. The ICD contains the code numbers used in DSM-5 and all of medicine, needed for insurance reimbursement and for monitoring of morbidity and mortality statistics by national and international health agencies..."

Yet a third frequent inquiry is: Can clinicians continue to use the DSM-IV-TR diagnostic criteria? The answer is: "Clinicians may use DSM-5 in their practices starting in May, when the manual is released. However, there may be brief delays while insurance companies update their claim forms and reporting procedures to accommodate DSM-5 changes, and clinicians should use DSM-IV-TR diagnoses and codes when required by a specific company. Transition details are still being developed with CDC-NCHS, CMS, and private insurance agencies. APA is working with these groups with the expectation that a transition to DSM-5 by the insurance industry can be made by December 31, 2013."

To read all the questions and answers that have been posted on the subject, visit this link.

Google Study Shows Searches for Mental Illness Information Are Seasonal

Analysis of an Internet search engine's use can provide useful data about how and when the public seeks information on mental illness, reported researchers in the May American Journal of Preventive Medicine. Lead investigator John Ayers, Ph.D., of the Graduate School of Public Health at San Diego State University and colleagues evaluated all mental health queries through the Google search engine in the U.S. and Australia from 2006 to 2010, using terms such a anxiety, bipolar, depression, and suicide.

They found that queries on all of these psychiatric-illness-related terms followed seasonal patterns, with winter peaks and summer troughs. The group said the challenge of population-level mental health surveillance is limited by resource constraints, long time lags in data collection, and stigma, but the collection of passively generated digital data, like that used in their current study, is a promising approach. "If additional studies can validate the current approach by linking clinical symptoms with patterns of search queries (beyond general information seeking), this method may prove essential in promoting population mental health," they concluded.

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New Technique Brings CLARITY to Brain Research

Imagine replacing the walls of a house with sheets of glass, allowing an onlooker to examine the wiring and plumbing without ripping the building apart. Stanford University researchers have done something like that with the brain. Psychiatrist Karl Deisseroth, M.D., Ph.D., and colleagues report that they have developed a method to replace the fats that hold brain cells in place with a porous, plastic-like, clear gel.

Ordinarily, brain tissue must be sliced into very thin layers for study. But that can distort the cells and their connections. The new method—Clear Lipid-exchanged Anatomically Rigid Imaging/immunostaining-compatible Tissue Hydrogel (CLARITY)—retains support for brain cells and their interconnections, down to the molecular level. More importantly, CLARITY permits the scientists to label antibodies and repeatedly stain and de-stain tissues without disturbing them.

“Using mouse brains, we show intact-tissue imaging of long-range projections, local circuit wiring, cellular relationships, subcellular structures, protein complexes, nucleic acids and neurotransmitters,” wrote Deisseroth, Kwanghun Chung, Ph.D., and colleagues in Nature online April 10. New tools such as this one open new avenues for scientific discovery, said Thomas Insel, M.D., director of the National Institute of Mental Health, which helped fund Deisseroth’s research. “I predict this new tool will revolutionize neuropathology, opening a new era for studying the neural basis of mental disorders,” said Insel in his weekly blog post.

To read more about Deisseroth’s brain research, including his studies of optogenetics, click here.

(image: Kwanghun Chung, Ph.D., and Karl Deisseroth, M.D., Ph.D., Stanford University)

APA, Connecticut Psychiatrists Sue Insurer Over Parity Violations

APA, the Connecticut Psychiatric Society, the Connecticut Council of Child and Adolescent Psychiatry, and two individuals have filed suit against a major insurer charging that it has denied care and taken other actions that are violations of the federal mental health parity law. Their suit says that Anthem Health Plans and its parent company, Wellpoint Inc., have used Current Procedural Terminology (CPT) codes to reduce the fees they pay to the psychiatrists who provide care to the company's beneficiaries, thus forcing the patients to shoulder a larger financial and administrative burden than if they received care for a physical rather than mental illness. APA and the other plaintiffs maintain that these actions discriminate against psychiatric patients and are a violation of the Mental Health Parity and Addiction Equity Act (MHPAEA).

In laying out Anthem's alleged parity-act violations, the plaintiffs state that the company's CPT coding "manipulation" is discriminatory because it "preclude[es] psychiatric patients from receiving psychotherapy from a psychiatrist in the same session as the patient is medically evaluated, thereby increasing the time burden and imposing additional copayment obligations on mental health patients" and that by paying rates to psychiatrists for evaluation and management services that are 20% lower than what it pays other physicians, the company's roster of in-network providers is greatly diminished making it difficult for beneficiaries to access mental health care.

Commenting on the lawsuit's filing, APA President Dilip Jeste, M.D., emphasized that “APA worked hard to ensure passage of the MHPAEA so that mental health patients would not be deprived of treatment or stigmatized for seeking it. Anthem, Wellpoint companies, and others throughout the U.S. need to start respecting the law and our members’ patients and not directly or indirectly inhibit access to the treatment for which the patients and their employers have paid.”

In March, APA and the Connecticut Psychiatric Society wrote a letter to Anthem Blue Cross Blue Shield of Connecticut protesting the discriminatory practices and calling on the insurer to comply with both the federal and Connecticut parity laws. Read more about that in Psychiatric News here.

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Gene Variations in Alzheimer's Show Racial Variations, Study Finds

Many of the same genes associated with increased risk for Alzheimer's disease among people of European ancestry are also present in African Americans, but effect sizes vary between the two groups, according to a study of thousands of individuals published in today's Journal of the American Medical Association.

Researchers led by Richard Mayeux, M.D., M.Sc., a professor of neurology, psychiatry, and epidemiology at Columbia University, studied data from 1,968 African Americans with Alzheimer's disease and 3,928 control subjects. The most significant gene associated with the disorder was APOE, a previously well-known risk factor. However, another gene called ABCA7 produced a greater effect in African Americans than in non-Hispanic whites (odds ratio = 1.79), said Mayeux and colleagues.

Like APOE, ABCA7 is involved in lipid metabolism. It also influences the transport of amyloid precursor protein, another risk factor for late-onset Alzheimer's disease. If replicated, these findings may eventually help direct future research into the causes or management of the illness.

To read more in Psychiatric News about biomarkers for Alzheimer disease and the hunt for new treatments, click here and here. Also see the American Psychiatric Publishing Textbook of Alzheimer Disease and Other Dementias here.

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Obama Includes Mental Health Funding Increase in Budget Proposal

In this era in which fiscal belt-tightening has become a political mantra, President Obama has cited mental health care as a key area in which the government needs to spend more money. In his budget proposal that will be released today, Obama has included $235 million to fund new mental health programs with a focus on providing training to teachers and other school personnel receive to prepare them to recognize students who have a mental health problem, according to a report in today's Washington Post. The paper also quotes an administration official who said that some of the money is also intended for the training of many more nonphysician mental health professionals who will be needed to meet an expected increase in demand for mental health care stemming from requirements of the Affordable Care Act.

Specifically, $50 million of the proposed funding would be earmarked to train master's-level mental health specialists such as psychologists, school counselors, and nurses. Commenting on that part of the proposal, APA President Dilip Jeste, M.D., said that APA "is deeply concerned that the Administration’s efforts to expand the supply of mental health professionals appears to stop at master’s level practitioners. Along with the administration we recognize the growing need for mental health providers; however, providing a small amount of training to lesser-qualified health professionals at the expense of utilizing veteran medical psychiatric providers will only serve to exacerbate the problem we are trying to solve."

"While we applaud President Obama's budget proposal, it doesn't come close to restoring the drastic cuts in funds for mental health services that have been imposed over the last several years," Robert Cabaj, M.D., chair of the APA Council on Advocacy and Government Relations, told Psychiatric News. "In particular, billions of dollars for these services have been cut at the state and local levels, and even if the federal programs proposed in this budget do get funded, it will still leave a huge funding gap, and closing that gap will require extensive advocacy work locally as well as nationally."

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States’ Decision on Expanding Medicaid Will Impact Inpatient Psychiatric Care

States that opt not to expand their Medicaid rolls when that option becomes available next year under the Affordable Care Act may be courting disaster, because at the same time the federal government will begin to reduce—ultimately by 50 percent—the Disproportionate Share Hospital (DSH) payments that general hospitals receive for care of the uninsured. So states that do not expand Medicaid rolls to those earning 133 percent of the federal poverty level will continue to bear the burden of care for the uninsured, but with substantially less federal DSH support. And since a great many of those uninsured are psychiatric patients, the funding shortfall is likely to fall heavily on the care of mentally ill individuals.

Joseph Parks, M.D., medical director of the Missouri Department of Mental Health, is raising alarms about this little-discussed provision in the ACA that he believes could dramatically affect state mental health budgets and patient care. Parks contacted Psychiatric News and began raising red flags with colleagues in other states after a study ordered by Missouri Gov. Jay Nixon (D) looked at the pros and cons of Medicaid expansion on four Missouri hospitals. The results of that study, outlined in a Psychiatric News report now on the APA Web site showed that without the Medicaid expansion the state would be left with millions of uninsured patients and significantly less—some $250 million less—in federal DSH support for indigent care.

“States that do not opt into the expansion are really going to be caught in a very tight payment vise as they try to provide care to the uninsured with psychiatric conditions because they are going to be getting little or no compensation from federal agencies," said Joel Miller, senior director of policy and health care reform for the National Association of State Mental Health Program Directors, commenting on the Missouri study.

Read the Psychiatric News article here. 

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Psychiatrists Must Rely on Data in Advocacy Involving Gun Control, AJP Editorial Says

President Obama was in Newtown, Conn., yesterday calling for legislative action on gun violence. "We have to tell Congress it's time to require a background check for anyone who wants to buy a gun so that people who are dangerous to themselves and others cannot get their hands on a gun,” Obama said, according to news reports. “We have to tell Congress it's time to restore the ban on military-style assault weapons, and a 10-round limit for magazines, to make it harder for a gunman to fire 154 bullets into his victims in less than five minutes. We have to tell Congress it's time to strengthen school safety and help people struggling with mental health problems get the treatment they need before it's too late.”

In a March 20 editorial in AJP in Advance, American Journal of Psychiatry Deputy Editor Robert Michels, M.D., and Richard Friedman, M.D., discussed the complexities surrounding professional psychiatric advocacy for gun control, lowering the threshold for involuntary commitment, and other issues related to gun violence. "Many of us have passionate advocacy positions on socially charged issues like gun control, positions that may or may not be supported by empirical data,” they said. “When we enter public discourse as psychiatric experts, we have to remember to distinguish between our professional knowledge and expertise on the one hand and our personal advocacy positions on the other. Our primary role as psychiatric experts in public discussions about the controversial links between guns, violence, and mental illness should be to educate the public and to provide public officials with the best available data and critical thinking to help inform the dialogue and the decision making that drive public policy."

The editorial, "How Should the Psychiatric Profession Respond to the Recent Mass Killings?" is online here. For more on this subject see Psychiatric News here.

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ADHD Prevalence Lower in Regions With More Sunlight, New Study Suggests

A large study using both American and international databases has found a lower prevalence of attention-deficit/hyperactivity disorder (ADHD) in geographic regions where there is intense sunlight than in regions where there is less sunlight. The study was headed by Martijn Arns, Ph.D., director of the Research Institute Brainclinics at Utrecht University in the Netherlands and is published in Biological Psychiatry.

Arns and colleagues suggest that "the preventative effect of high solar intensity might be related to an improvement in circadian clock disturbances, which have recently been associated with ADHD." This finding "is intriguing and, if replicated, could help further our understanding of the etiology, treatment, and prevention of ADHD," David Fassler, M.D., a child and adolescent psychiatrist and a clinical professor of psychiatry at the University of Vermont, told Psychiatric News.

To read more about recent research on treatment of ADHD, see the American Journal of Psychiatry and Psychiatric News.

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Study Helps Illuminate Link Between Depression, Heart Disease

Depression appears to lead to inflammation, not vice versa, in individuals with coronary heart disease. This is the key finding from large prospective study headed by Mary Whooley, M.D., of the University of California, San Francisco, and reported in the April Psychoneuroendocrinology. The study included 667 subjects evaluated for depression for five consecutive years and for white blood cell count (which indicates systemic inflammation) at baseline and after the five years of follow-up. The researchers found that 66% of the subjects had no depressive symptoms, 13% had depressive symptoms at one annual assessment, and 21% had depressive symptoms at two or more annual assessments. At the end of five years, subjects with recurrent depressive symptoms had significantly higher white blood cell counts than the other two groups did, even after controlling for demographics, cardiac disease severity, health behaviors, and other variables. Baseline white cell count, in contrast, was not significantly associated with subsequent depressive symptoms.

Thus it appears that "depression is a risk factor for inflammation" and that such inflammation in turn might be "a potential mediator in the relationship between depression and adverse cardiac outcomes," Whooley and her colleagues concluded.

And if this is the case, then it might help explain why people who are depressed after having a heart attack are at three to five times the risk of dying than are those who are not depressed after a heart attack. For more on this topic, see Psychiatric News here and here. More information about the interface between depression and heart disease and how depression might lead to negative heart disease outcomes can be found in American Psychiatric Publishing's Text of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition.

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