Comparison of 15 Antipsychotics Finds Small Differences in Efficacy

An analysis of 212 clinical trials of 15 antipsychotic medications found that all were significantly more effective than placebo, and the differences between them in efficacy were "small but robust." The study, which was published online yesterday in Lancet, included data from randomized controlled trials involving more than 43,000 participants. In addition to assessing efficacy, the study also analyzed discontinuation of the medications and their side effects.

The researchers found that clozapine, amisulpride, and olanzapine showed, respectively, the greatest efficacy, while lurasidone and iloperidone showed the least. Assessment of all-cause discontinuation (when compared with placebo) showed that the best drug on this measure was amisulpride, and the worst was haloperidol. For extrapyramidal side effects, clozapine had the best odds ratio, and haloperidol the worst, while for sedation, amisulpride had the highest odds ratio, and clozapine the worst. Weight gain was also evaluated in comparison with placebo, and haloperidol was linked with the least weight gain, and olanzapine with the most. The researchers said as well that their findings "challenge the straightforward classification of antipsychotics into first-generation and second-generation groupings. Rather, hierarchies in the different domains should help clinicians to adapt the choice of antipsychotic drug to the needs of individual patients."

To read about decision making in choosing a psychoactive medication, see the From the Experts column in Psychiatric News here.

(image: avarand/Shutterstock.com)

Challenges Come With Treating Children With Mental Health Problems in Rural Areas, Study Suggests

Children with the highest levels of impairment related to a mental disorder who live in rural areas are just as likely as their urban counterparts to be diagnosed and treated for mental health conditions, but children in rural areas with less-acute impairment are less likely to be diagnosed with a psychiatric disorder—the exception being ADHD, according to a new report from the Maine Rural Health Research Center at the University of Southern Maine.

Once diagnosed, rural children tend to receive prescriptions significantly more often than do urban youngsters, wrote Jennifer Lenardson, M.H.S., Samantha Neuwirth, M.D., and colleagues. About 8 percent of rural children are prescribed psychiatric drugs, compared with 6.4 percent of children in urban areas.

Lower rates of diagnosis among children with subacute mental health problems “may or may not indicate a need for counseling or medication,” said the researchers. “However, the lack of mental health specialty providers in rural areas means there is, in many cases, no provider available to determine whether treatment is indicated.”

Developing tools to help primary care clinicians or school counselors  in rural areas assess children’s needs and suggest referral options might be one way to overcome some of these differences, suggest the authors.

For more information on trying mental illness, including substance abuse, in rural areas, see Psychiatric News here and here.

(image: Oleksandr Lysenko/Shutterstock.com)

What It Means to Be President

Beginning today, APA President Jeffrey Lieberman, M.D., will be using the Psychiatric News Alert as a forum to reach APA members and other readers on a regular basis. Please send your comments to pnupdate@psych.org.

At this year’s annual meeting in San Francisco, I found myself moved by a normally routine ceremony over which the president-elect presides: administering the pledge to the new group of Distinguished Fellows. It’s the one that begins: “I WILL FAITHFULLY DEDICATE MYSELF ABOVE ALL TO THE WELFARE OF MY PATIENTS; TO MAINTAIN THE DIGNITY OF MY PROFESSION AND THE PRACTICE OF MEDICINE....”

These words, which I and many other psychiatrists have spoken perfunctorily in the past, seemed especially resonant. This was partly because of the realization that I was about to actually take on the weighty responsibility of the APA presidency. But, mostly, it was that the words of the pledge reminded me about the current challenges facing the field of psychiatry. We live in a time of undelivered health care reform, continuing stigma, wanton criticism of psychiatry and APA, and an enormous burden of illness caused by mental illness and unmet clinical need for treatment. 

Under these circumstances, it is very hard to remind the public—and even ourselves—that we are living in a moment of unprecedented scientific progress and with an array of therapeutic interventions with extraordinary effectiveness.

Click here to read more....

APA Applauds Court's Same-Sex Marriage Rulings

APA is hailing the two same-sex marriage rulings issued by the Supreme Court earlier today, with President Jeffrey Lieberman, M.D., citing APA's "long history of supporting freedom in sexual orientation and the rights of same-sex couples." He emphasized that, "By withholding benefits or marriage rights from same-sex couples, the government unfairly stigmatizes an important part of the American population." APA had joined most of the country's leading medical and mental health organizations in signing onto amicus briefs in favor of same-sex marriage in both of the cases. The briefs maintained that a substantial body of scientific evidence supports the conclusion that homosexuality is a normal expression of human sexuality, is not a choice people make, and that same-sex couples form stable, committed relationships that are equivalent to heterosexual ones in multiple respects.

In one of the cases decided today, the Court ruled that much of the Defense of Marriage Act (DOMA), which defines marriage as between a man and a woman, and thus denies federal benefits to legally married same-sex couples, is unconstitutional. (Twelve states and the District of Columbia have legalized same-sex marriage.) Justices did not decide, however, whether there is a constitutional right to same-sex marriage. In the other case, they let stand a California ruling legalizing same-sex marriage. A statewide referendum, Proposition 8, had overturned a law allowing same-sex marriage, but a state court declared the results invalid. The Supreme Court said those who filed the legal challenge trying to get the ban reinstated did not have standing to bring the case.

In 2005, APA adopted an official policy statement stating that it "supports the legal recognition of same-sex marriage with all rights, benefits, and responsibilities conferred by civil marriage, and opposes restrictions to those same rights, benefits, and responsibilities.” 

Read the complete APA press release here.

(image: Lisa F. Young/Shutterstock.com)

 

Community Involvement Appears to Boost Depression Care Outcomes

Getting community organizations like churches, substance abuse programs, senior centers, and barber shops involved in planning and carrying out depression care is more effective than just providing technical information to the community groups, according to a study by RAND Corporation psychiatrist Kenneth Wells, M.D. M.P.H., and colleagues. This “Community Engagement and Planning” model was tested against a “Resources for Services” approach in Los Angeles among 1,018 individuals in 90 programs. The community model “improved clients’ mental health, increased physical activity, lowered their risk of becoming homeless, and decreased hospitalizations for behavioral problems,” said Wells in a statement. This approach also reduced medication visits to users of specialty care while increasing depression visits among users of primary care or public health clinicians.

Employment, use of antidepressants, and total health care contacts were not significantly affected, they wrote online in the Journal of General Internal Medicine. The study was funded by the National Institute of Mental Health, the Robert Wood Johnson Foundation, and the California Community Foundation.

For more in Psychiatric News about community-based depression care, click here.

Integrated Care Driven by Health Reform Law, Mounting Evidence of Effectiveness

Integrated care, also known as collaborative care, is poised to transform the U.S. health system, and with it the care of people with mental illness. That’s what psychiatrist Wayne Katon, M.D., says in an interview published online June 19 in the “Medical News and Perspectives Column” of JAMA. Katon, a leader in integrated care, says the movement toward collaborative care models is driven by the Affordable Care Act and a growing body of evidence showing the effectiveness of integrated care models for complex conditions, including psychiatric illness. (Integrated care refers to a model of patient-centered, multidisciplinary care emphasizing population-based care, measurement-based care, and integration of psychiatric expertise into primary care.)

“Extensive evidence from clinical trials shows that the collaborative care model can almost double the rates of exposure to evidence-based depression/anxiety treatments as well as markedly improve clinical outcomes for patients with depression and anxiety,” Katon said. “More recent evidence also suggests that many people with depression have comorbid medical illnesses. In a 2010 trial, we aimed to improve care for depression and poorly controlled diabetes and/or heart disease with a multicondition collaborative care model. It improved not only the patients’ depression-related outcomes, but also improved blood glucose, systolic blood pressure,  and LDL cholesterol and reduced overall medical costs.”

Look for a special series of articles on integrated care to begin in Psychiatric News in July. For other news about collaborative care, see Psychiatric News here. Also see an Open Forum in Psychiatric Services on this topic here.

(Image: OPOLJA/shutterstock.com)

Early Short-Term Use of Estrogen Has No Effect on Cognition, Study Finds

A randomized clinical trial of estrogen therapy in younger postmenopausal women, those aged 50-55, has found no long-term risk or benefit to cognitive function. The study, reported in JAMA Internal Medicine yesterday looked at women taking conjugated equine estrogens, the most common type of postmenopausal hormone therapy in the U.S. The earlier Women's Health Initiative Memory Study (WHIMS) had linked the same type of hormone therapy to cognitive decline and dementia in older postmenopausal women.

The new findings come from the Women's Health Initiative Memory Study of Younger Women (WHIMSY) and were reported by Mark Espeland, Ph.D., of Wake Forest School of Medicine on behalf of the academic research centers involved in the study. The study was funded primarily by the National Institute on Aging (NIA) and the National Heart, Lung, and Blood Institute, components of the National Institutes of Health.

"In contrast to findings in older postmenopausal women, this study tells women that taking these types of estrogen-based hormone therapies for a relatively short period of time in their early postmenopausal years may not put them at increased risk for cognitive decline over the long term," said Susan Resnick, Ph.D., chief of the NIA's Laboratory of Behavioral Neuroscience and a co-author of the study. "Further, it is important to note that we did not find any cognitive benefit after long-term follow-up."

For more on menopause and mental health, see Psychiatric News here

(Image:IdeaStepConceptStock/shutterstock.com)

Study Shows That Depressive Symptoms Follow "U"-Shaped Pattern

Depressive symptoms are highest in young adulthood, decrease in midlife, and then increase in later years, Angelina Sutin, Ph.D., an assistant professor of medical humanities and social sciences at Florida State University, and colleagues report in JAMA Psychiatry. The longitudinal study included more than 10,000 depressive-symptom assessments conducted on some 2,300 subjects. "Symptoms of depression follow a U-shaped pattern across adulthood," Sutin and her team concluded, noting that "Older adults experience an increase in distress that is not due solely to declines in physical health or approaching death."

"This is an interesting study," Dilip Jeste, M.D., immediate past APA president and chair of aging at the University of California, San Diego, told Psychiatric News. "The findings are consistent with an increased prevalence of subsyndromal (but not major) depression in older age. It should be noted, however, that the increase in depressive symptoms...was relatively small. Also, the overall trajectory of symptoms, especially around middle age, is at variance with several other studies...showing a worsening of quality of well-being from age 20 to 50, with improved self-reported mental functioning thereafter. The reasons for the discrepant results are not obvious and need further research."

More information about studies on depression and aging, as well as about Jeste's on views on aging, can be found in Psychiatric News .

(Image: FooTToo/Shutterstock.com)

Brains of Pathological Gamblers Show Greater Response to Money Than Sex, Study Finds

It appears that the brains of pathological gamblers want money more than sex, Jean-Claude Dreher of the Cognitive Neuroscience Center in Lyon, France, and colleagues report in Brain. The researchers used fMRI imaging to compare the brains of 18 pathological gamblers and 20 healthy control subjects while the subjects engaged in a simple task involving either monetary rewards or visual erotic rewards. The ventral striatum of those with pathological gambling reacted less to erotic stimuli than to money-related ones, while the reverse was the case in control subjects. Furthermore, during reward outcome, a posterior orbitofrontal cortex region responding to erotic rewards in both groups was further activated by monetary gains in the pathological gamblers, but not in the control subjects. Thus the brains of pathological gamblers appear to be "biased towards monetary rewards, potentially promoting addictive gambling behavior," the researchers concluded.

Gambling disorder is included among substance-related and addictive disorders in DSM-5. For information on that topic, see Psychiatric News. For more information about pathological gambling, see American Psychiatric Publishing's Pathological Gambling - A Clinical Guide to Treatment.

(Image: martan/Shutterstock.com)

Intra-Family Bullying Bad for Kids' Mental Health

Bullying by brothers or sisters against their siblings is as bad as that from outsiders and is associated with worse children’s and adolescents’ mental health.

A national sample of 3599 youth (or their caregivers) reported greater mental health distress in the prior year if they experienced psychological, property, or mild or severe physical assault by their siblings, wrote Corinna Jenkins Tucker, Ph.D., of the Department of Family Studies, University of New Hampshire in Durham.

Sibling physical aggression was nearly as harmful as that by non-family peers, and combined aggression from within and outside the family caused nearly double the level of distress.

“Sibling aggression is not benign for children and adolescents, regardless of how severe or frequent,” concluded Tucker et al., in the July issue of the journal Pediatrics. “An implication of our work is that parents, pediatricians, and the public should treat sibling aggression as potentially harmful and something not to be dismissed as normal, minor, or even beneficial. The mobilization to prevent and stop peer victimization and bullying should expand to encompass sibling aggression as well.”

For more in Psychiatric News about bullying, click here.

(Image: Keith Publicover/Shutterstock.com)

AMA Approves Policy Recognizing Obesity as Disease

The AMA this week approved a policy that recognizes obesity as a disease requiring a range of medical interventions with the aim of advancing treatment and prevention.

Timothy Walsh, M.D., chair of the DSM-5 Work Group on Eating Disorders, told Psychiatric News that mental disorders do interact with risk factors for obesity; for example, some psychopharmacologic treatments for serious mental illness are known to cause weight gain. “It’s important for psychiatrists to be aware of obesity as a medical problem and to monitor their patients for weight gain.” He noted that the DSM-5 work group early in its deliberations debated whether obesity should be considered a mental disorder. After much discussion and a comprehensive literature review, the group decided unanimously against including it in DSM-5. “Obesity is the result of an interaction of many influences—genes, environment, sometimes with psychological states and sometimes with abnormal behaviors,” Walsh said. “But we did not think it qualified as a mental disorder.” 

AMA Board member and psychiatrist Patrice Harris, M.D., in a statement noted that improving health outcomes is one of AMA’s goals in its strategic initiative. Harris is a past member of the APA Board of Trustees. “Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately 1 in 3 Americans,” said Harris. “The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and type 2 diabetes, which are often linked to obesity.”

For more on this topic, see Psychiatric News here.

(Image: Andrii Kondiuk/shutterstock.com)

Course From Initial Trauma Response to PTSD Shows Considerable Variation, Study Finds

The way from trauma to delayed-onset posttraumatic stress disorder (PTSD)may be long and winding, according to Australian researchers. They evaluated 1,084 patients admitted to four trauma hospital units and then assessed them again at three, 12, and 24 months after their injuries. The course of illness and risk among these patients was complex, wrote Richard Bryant, Ph.D., Alexander MacFarlane, M.D., and colleagues in JAMA Psychiatry online yesterday.

Among those diagnosed with PTSD at 24 months, 44 percent reported no PTSD at three months. Initial PTSD symptom severity in that group predicted PTSD severity at 24 months, as did the presence of mild traumatic brain injury, the length of hospital stay, and experiencing stressful events between three and 24 months. Among the other 56 percent of patients with diagnosed PTSD or symptoms of the disorder at three months, having had a prior psychiatric disorder, severity of initial PTSD symptom, and type of injury predicted PTSD severity at 24 months.

"The present study demonstrates longitudinally that there is not a linear relationship between acute trauma response and long-term PTSD and highlights that PTSD levels fluctuate markedly in the initial years after trauma exposure,” concluded the authors. “This pattern can explain the modest predictive capacity of acute markers to identify subsequent PTSD status.”

For more in Psychiatric News about trauma and PTSD, click here. Also see the Journal of Neuropsychiatry and Clinical Neurosciences here.

 (Image: VILevi/Shutterstock.com)

New Findings Suggest Fibromyalgia Is Neuropathic, Not Depression Variant

Small nerve fibers in subjects with fibromyalgia syndrome are impaired, Nurcan Uceyler, M.D., of the University of Wurzburg in Germany and colleagues report in the June Brain. This is not the case for matched control subjects or for subjects with depression who do not have fibromyalgia syndrome. "This strengthens the notion that fibromyalgia syndrome is not a variant of depression, but rather represents an independent entity that may be associated with depressive symptoms," the researchers said. Furthermore, the findings point "towards a neuropathic nature of pain in fibromyalgia syndrome."

Still other research results point to a similar conclusion. For example, individuals with fibromyalgia are known to have an abnormally low pain threshold. They also have abnormally low levels in their spinal fluid of metabolites of two neurotransmitters—serotonin and norepinephrine—and abnormally high levels of substance P, an amplifier of pain messaging.

For more details about these findings, as well as information about treatments for fibromyalgia patients, see Psychiatric News. Information about fibromyalgia syndrome can also be found in American Psychiatric Publishing's Pain: What Psychiatrists Need to Know.

(Image:decade3d/Shutterstock.com)

FDA Investigating Deaths Following Zyprexa Injections

The Food and Drug Administration (FDA) issued an alert today stating that it is investigating two patient deaths that appear to be linked to the injectable antipsychotic medication Zyprexa Relprevv (olanzapine pamoate). The patients died three to four days after receiving intramuscular injection of the drug in appropriate doses, and the deaths occurred well after the three-hour monitoring period required under the Zyprexa Relprevv Risk Evaluation and Mitigation Strategy (REMS). Both patients were found to have very high olanzapine blood levels after death, the FDA said. Under the REMS, patients must receive their Zyprexa Relprevv injection at a REMS-certified facility, be continuously monitored for at least three hours, and be accompanied home from the facility. These steps are in response to concerns about post-injection delirium sedation syndrome, a serious condition in which the drug enters the blood too fast, leading to elevated blood levels and marked sedation that can include coma, and/or to delirium.

While it investigates the two cases, the FDA is recommending that physicians follow the REMS requirements and drug-label recommendations. The alert, which was issued via the FDA's MedWatch system, also urges patients and caregivers to talk to their physician or other health professional if they have questions about the medication.

The alert can be read here.

(image: arsgera/Shutterstock.com)

AMA Adopts Policy on Dual Eligibles, Opens House to GLBT Physicians, and Works to Lower Student Debt

The AMA House of Delegates yesterday approved a policy on Medicare and Medicaid dually eligible patients—a category that includes many patients with psychiatric illness—that would customize benefits for patients and ensure that care-coordination demonstration programs do not interfere with the patient-physician relationship. “The AMA is working to improve the nation’s health care system through sustainable delivery and payment options that give physicians the flexibility to help lower costs and improve the quality of care for patients,” said AMA Board member Carl Sirio, M.D. “The principles included in this new policy address streamlining care plans while eliminating conflicting payment rules.”

The AMA also announced yesterday that the Gay and Lesbian Medical Association (GLMA) has been admitted to the House of Delegates. Physicians and medical students unanimously voted to accept GLMA’s application for representation in the House of Delegates. "Gay, lesbian, bisexual, and transgender (GLBT) physicians and medical students will now have an important voice within the house of medicine that will enhance AMA policy and programs, especially those that affect GLBT physicians, students, and patients," said incoming AMA President Ardis Dee Hoven, M.D. "The GLMA’s growth and rising profile has been good for both patients and physicians and has opened eyes regarding the diverse needs of GLBT patients. As a result, all our patients are stronger and healthier."

Additionally, the AMA adopted a policy to work with other health profession organizations to advocate for a reduction of the fixed interest rate of the Stafford student loan program. “To help students, residents, and physicians manage their medical student loan debt, the AMA has advocated for numerous policies, including the creation of additional tuition-assistance and loan-forgiveness programs,” said AMA Board member Stephen Permut, M.D. “A reduction in the fixed interest rate of Stafford loans, combined with other advocacy efforts, will help physicians and physicians-in-training better manage their debt burden.”

For more information about the AMA and its priorities, see Psychiatric News here.

(Image:haveseen/shutterstock.com)

Needs of Senior Physicians Focus of New AMA Group

The “golden years” can be a time of opportunity and challenge for physicians. To address key issues in this area, three psychiatrists participated in a special educational session on “The Aging Physician: Opportunities and Challenges” this weekend at the AMA House of Delegates meeting in Chicago. It was sponsored by the AMA’s Senior Physician Section, the newest AMA section. There are 57,000 AMA members over age 65.

Sheila LoboPrabhu M.D., an associate professor of psychiatry at Baylor College of Medicine; Luis Sanchez M.D., director of Physician Health Services Inc., a Massachusetts Medical Society corporation; and Paul Schyve, M.D., senior advisor for health care improvement at the Joint Commission, discussed the physiology of aging with an emphasis on sensory and cognitive changes, maintenance of certification for seniors, and strategies to retain physicians in the workforce while practicing in a safe manner.

Psychiatrist Paul Wick, M.D., (pictured above), chair-elect of the Senior Physician Section, told Psychiatric News that nationally one-third of practicing physicians will turn 65 in the next eight years. “There are more physicians in this age group than there are in the 40 and younger category,” Wick said. And he said a goal of the section is to develop guidelines for assessing competency in senior physicians so they can continue practicing for as long as possible, while maintaining competence and quality care. “Aging physicians will leave the future supply of physicians in a critical condition,” Wick emphasized.

For more information on this topic, see Psychiatric News here.

(photo: Mark Moran)

Psychiatrist Jeremy Lazarus, M.D., Ends Year at Helm of AMA

It was a year of tumult, challenges, and successes that outgoing AMA President Jeremy Lazarus, M.D., recalled in his presidential address this weekend at the AMA’s House of Delegates meeting in Chicago. Lazarus recounted legislative and legal victories by the AMA regarding physician payment, scope of practice, insurance coverage, and access to care issues, as well as the organization’s continued pursuit of the goals of its strategic initiative: enhancing physician professional satisfaction and practice sustainability, changing and improving medical education for the 21st century, and improving health outcomes.

A past speaker of the APA Assembly, and just the third psychiatrist to be president of the AMA, he brought a new focus on mental illness and the importance of psychiatry to the larger medical community. In his address at the House, Lazarus noted that just a month after his inauguration as AMA president last year, the Aurora, Colo., shooting occurred in which 12 people were killed and some 58 wounded. It was followed by the calamitous shooting in Newtown, Conn., in December. “It brought to the forefront problems with our mental health system and our capacity to prevent at least some of these tragic events,” he said. “And as a psychiatrist, I was at the same time all too aware of the potential backlash against mental health patients…. [W]e know that the vast amount of violence has no relation to mental illness. So we went to work on initiatives to remove the stigma still present against those with mental illness and to offer better treatment options for those affected. Shortly after Sandy Hook, we met with [Obama] administration officials in Washington to discuss a strategy to address gun regulation, mental illness, and public education,” Lazarus said. “We also believe strongly that physicians must be able to have to frank discussion with their patients and families about firearm safety issues and risks.”

To view a video interview with Lazarus at last month's APA annual meeting, click here.

(Image: Ted Grudzinski/AMA)

Privacy Rule Should Not Be Changed for Firearm Background Checks, Says APA

The National Association of State Mental Health Program Directors is the latest medical organization to oppose the incorporation of mental health records into the national gun background-check database, reports the Wall Street Journal. APA went on record with similar opposition in a letter last month to the Department of Health and Human Services (HHS). APA emphasized that the justice system—not a mental health service provider—is the best source of information on mental health concerns regarding individuals wishing to purchase firearms.

The letter was in response to an HHS proposal that the federal privacy rule be changed so that state mental health authorities could transmit information about individuals declared mentally unfit to the National Instant Criminal Background Check System (NICS). The NICS was created by the Brady Act and ensures that guns are not sold to those prohibited by law from buying them, including felons, those convicted of domestic violence, and individuals involuntarily committed to a mental institution or found to be a danger or unable to manage their affairs due to a mental health condition.

The debate involves a plan by the Department of Health and Human Services to amend a federal privacy rule. The amendment would expressly allow state mental-health authorities to transmit records of anyone who has been declared mentally unfit by a court or other authority to the National Instant Criminal Background Check System, or NICS, maintained by the Federal Bureau of Investigation.

“APA thinks responsibility for transmitting the identities of individuals subject to the mental health prohibitor to NICS should rest with the justice system,” wrote APA Medical Director and CEO James H. Scully, Jr., M.D., in the May 28 letter addressed to the HHS Office for Civil Rights (OCR). “As non-HIPAA-covered entities, the courts are in the best position to transmit the identities of individuals subject to the mental health prohibitor to NICS.”

Scully cautioned OCR not to construe support of NICS reporting by the justice system as support for eroding existing HIPAA privacy protections afforded to patients who are not subject to the federal mental health prohibitor. “An individual’s confidence in the privacy he or she will be afforded when seeking medical care, particularly mental health care, often singularly determines whether or not that individual will agree to receive health care treatment,” he wrote. Read APA's letter to OCR here.

(Image: Dino Osmic/Shutterstock.com)

Government Issues FAQ Concerning DSM-5

In light of last month's publication of DSM-5, the federal government's Centers for Medicare and Medicaid Services (CMS) has clarified in the "Frequently Asked Questions" section of its Web site that it is appropriate for clinicians to use DSM-IV and DSM-5 to cross-walk to official HIPAA ICD-CM diagnostic code sets for Medicare and Medicaid claims, and to define these disorders for quality assessment, medical review, consultation, and patient communication. The following specific language in the FAQ makes the point that ICD-9-CM is the official HIPAA diagnostic code set for claims, although it does not have detailed information to define disorders for the additional functions described.

"The introductory material to the DSM-IV and DSM-5 code set indicates that the DSM-IV and DSM-5 are 'compatible' with the ICD-9-CM diagnosis codes. The updated DSM-5 codes are crosswalked to both ICD-9-CM and ICD-10-CM. As of October 1, 2014, the ICD-10-CM code set [will be] the HIPAA-adopted standard and required for reporting diagnosis for dates of service on and after October 1, 2014.

"Neither the DSM-IV nor DSM-5 is a HIPAA-adopted code set and may not be used in HIPAA standard transactions. It is expected that clinicians may continue to base their diagnostic decisions on the DSM-IV/DSM-5 criteria, and, if so, to crosswalk those decisions to the appropriate ICD-9-CM and, as of October 1, 2014, ICD-10 CM codes. In addition, it is still perfectly permissible for providers and others to use the DSM-IV and DSM-5 codes, descriptors, and diagnostic criteria for other purposes, including medical records, quality assessment, medical review, consultation, and patient communications."

APA has yet to determine the dates at which time it will recommend that government agencies and private insurers officially transition from using DSM-IV diagnoses to those in the new DSM-5. The CMS FAQ ends by referring readers to APA's DSM-5 Web site http://www.dsm5.org for additional information.

Information about purchasing DSM-5 and its companion guides is posted at http://www.appi.org/Pages/DSM.aspx.

Addiction's 'Dark Side' Rises as Important Treatment Target

Do addicts take drugs to make them feel good or less bad? That’s a current debate taking place within the addiction research community. The old view was that addiction provided pleasure to the user, but more recent attention has focused on negative motivational brain circuitry, which causes addicts to take drugs to alleviate the misery of withdrawal. This “dark side” of addiction is characterized by overactivity of various receptors in the central amygdala of the brain, including dynorphin/kappa-opioid receptors.

Now scientists at the Scripps Research Institute in La Jolla, Calif., report that a kappa-opioid receptor antagonist infused into the central amygdala of cocaine-addicted rats lessened hyperactive and anxiety-like behavior usuaslly seen in withdrawal, wrote Marisa Roberto, Ph.D., and colleagues online June 10 in Biological Psychiatry.

Blocking kappa-opioid and other pathways to the “dark side” of addiction might prove “a viable therapeutic strategy for cocaine addiction” while keeping positive motivational pathways open to the ordinary pleasures of life, they said.

To read more about research at Scripps on the “dark side” of addiction, see Psychiatric News here.

(Image: Sebastian Kauliztki/Shutterstock.com)

Symptom Recovery Found to Take Much Longer After Certain Concussions

If there’s one thing worse than having a concussion, it’s having a previous one. Young people who had a prior concussion took twice as long (median: 24 days vs. 12 days) to get over their symptoms compared with peers who had not had a previous concussion, noted Matthew Eisenberg, M.D., of Boston Children’s Hospital, and colleagues, online June 10 in Pediatrics. The researchers studied 280 children and adolescents with an acute concussion, aged 11 to 22, seen in the emergency department.

For those with more than one previous concussion, it took 28 days to resolve symptoms, and 35 days for those who experienced another concussion within the prior year. Children with only a single prior concussion that occurred more than a year before the study had the same risk as those who had not experienced a concussion. They also found that symptoms lasted longer in children aged 13 and older, which they thought might reflect either differences in neurobiology or more severe injuries from contact sports played by older children.

The results, said the authors, suggest that “. . . sufficient time to recover from a concussion may improve long-term outcomes.”

Read more about concussion and its relationship to traumatic brain injury in Psychiatric News here. Also see the Journal of Neuropsychiatry here.

(Image: Auremar/Shutterstock.com)

Multifamily Group Intervention Helps Vets with TBI and Their Caregivers

A multifamily group intervention for veterans with traumatic brain injury (TBI) improves interpersonal functioning and symptomatic distress among veterans, while helping to decrease the burden on caregivers. That was the finding from an initial evaluation published online today in Psychiatric Services.

Veterans at two VA 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.

Researchers at the VA Mental Illness Research, Education and Clinical Center in New York and other institutions found that treatment was associated with statistically significant decreased veteran anger expression and increased social support and occupational activity. Additionally, caregivers reported decreased burden and increased empowerment. “The results supported implementation of a randomized controlled trial, building in education at the provider and family level,” the researchers stated.

The Psychiatric Services study is here. More information on TBI is found in American Psychiatric Publishing's Management of Adults With Traumatic Brain Injury. Also see Psychiatric News here.

(Image:Linda Bucklin/shutterstock.com)

Hypoglycemia, Dementia Appear to Compound Each Other in Diabetes

Among older adults with diabetes there appears to be a bidirectional association between hypoglycemia and dementia, according to a report published online yesterday in JAMA Internal Medicine. Researchers at the University of California, San Francisco, and other institutions studied 783 older adults with diabetes (mean age 74) who were participating in the prospective Health, Aging, and Body Composition Study beginning in 1997 and who had baseline Modified Mini-Mental State Examination scores of 80 or higher. Dementia diagnosis was determined during the follow-up period from hospital records indicating an admission associated with dementia or the use of prescribed dementia medications. Hypoglycemic events were determined by hospital records.

They found that during the 12-year follow-up, 61 participants (7.8%) had a reported hypoglycemic event, and 148 (18.9%) developed dementia. Those who experienced a hypoglycemic event had a two-fold increased risk for developing dementia compared with those who did not have such an event. Similarly, older adults with diabetes who developed dementia had a greater risk for having a subsequent hypoglycemic event compared with participants who did not develop dementia.

“Hypoglycemia may impair cognitive health, and reduced cognitive function may increase the risk for a hypoglycemic event that could further compromise cognition, resulting in a detrimental cycle,” the researchers said, urging that “Cognitive function should be considered in the clinical management of older individuals with diabetes.”

The new study is posted here. For more information on the link between dementia and diabetes, see Psychiatric News here.

(Image:Lightspring/shutterstock.com)

Negative Expectations During Pregnancy Associated With Later Child Abuse, Study Finds

How pregnant women visualize their forthcoming infants' behavior may predict whether they are at risk of abusing them after they are born, suggests research reported in the June JAMA Pediatrics by Lisa Berlin, Ph.D., an associate professor at the University of Maryland School of Social Work, and colleagues. They evaluated some 300 pregnant women from various socioeconomic backgrounds as to whether they expected their future infants to behave intentionally in a negative way—for instance, to ignore their mothers to be annoying, to dirty their diapers to be difficult, or to throw things on the floor to make a mess. After the women's babies were born, the women were evaluated to see whether they engaged in harsh parenting. Women who had expected their babies to behave with negative intent were significantly more likely to do so than were women who had not expected their babies to behave with negative intent.

"We believe that this study highlights the value of practitioners (including psychiatrists) attending to mothers' and expectant mothers' attributions about infants' intentions," Berlin told Psychiatric News, adding she believes that changing misperceptions about infant behavior would then reduce child abuse.

Indeed, there is evidence that educating pregnant women and new mothers from lower socioeconomic backgrounds on how to care for their infants and perceive their behavior can reduce child abuse. See Psychiatric News here. More information on the topic of child abuse can be found in American Psychiatric Publishing's Family Violence: A Clinical and Legal Guide.

(Image: Velazquez77/Shutterstock.com)

Reason Suggested for GHRH's Beneficial Impact on the Senior Brain

During the past several years, Michael Vitiello, Ph.D., a professor of psychiatry at the University of Washington, and colleagues have found that injections of growth-hormone-releasing hormone (GHRH) improve executive function in both healthy older subjects and in subjects with mild cognitive impairment. The results are "highly promising," Dilip Jeste, M.D., chair in aging at the University of California, San Diego, and immediate past APA President, told Psychiatric News, particularly as there are currently no Food and Drug Administration-approved treatments for aging-associated cognitive impairment or mild cognitive impairment.

Now Vitiello and his team report in JAMA Neurology that GHRH injections in both healthy older subjects and in subjects with mild cognitive impairment increase brain levels of the neurotransmitter GABA, which is a major inhibitory neurotransmitter and to also plays a role in successful cognition. Thus GHRH may enhance executive function in both healthy older adults and in adults with mild cognitive impairment by increasing GABA activity, the researchers suggest.

To learn more about GHRH's beneficial impact on healthy older individuals as well as on those with mild cognitive impairment, see Psychiatric News here. Memory training is also proving to be beneficial for people with mild cognitive impairment, and more about studies on that topic can be found in Psychiatric News here.

(Image: Junial Enterprises/Shutterstock.com)

Researchers LInk Atrial Fibrillation to Cognitive Impairment

Reporting online in the June 5 Neurology, researchers at the University of Washington’s Cardiovascular Health Research Unit have determined that people with atrial fibrillation are likely to develop cognitive impairment or dementia at earlier ages than people without atrial fibrillation. They made that determination through a longitudinal analysis in the Cardiovascular Health Study, a community-based study of 5,888 men and women aged 65 and older, enrolled in 1989/90 or 1992/93. None of the participants had atrial fibrillation or a history of stroke at baseline.

Atrial fibrillation was identified by hospital discharge diagnosis codes and annual study ECGs. The main outcome was rate of decline in mean scores on the 100-point Modified Mini-Mental State Examination administered annually up to nine times. Of 5,150 participants who qualified for the analysis, 552 (10.7 percent) developed atrial fibrillation during seven years of follow-up. The authors hypothesized that embolic infarcts might be the cause of their findings, even though they excluded participants who experienced a stroke during the study. Cerebral hypoperfusion was also considered a possible etiology.

Read more about the causes of cognitive decline in elderly patients in Essentials of Geriatric Psychiatry, Second Edition, available from American Psychiatric Publishing here. 

(Image: sfam_photo/Shutterstock.com)

"Miswired" Brain Circuits May Lead to Development of Brain Disorders

Researchers at Weill Cornell Medical School say they have uncovered a mechanism that guides the exquisite wiring of neural circuits in a developing brain and gained unprecedented insight into the faulty circuits that may lead to brain disorders such as autism. Reporting in the June 6 Cell, the study’s senior author Samie Jaffrey, M.D., Ph.D., an associate professor of pharmacology at Weill Cornell, and colleagues described the process by which faulty wiring occurs when RNA molecules embedded in a growing axon are not degraded after they give instructions that help steer the nerve cell. The researchers say their description is of a process of brain wiring that is much more dynamic than was previously known, and thus more prone to error. And they believe that understanding the basis of brain “miswiring” can help scientists devise new therapies to correct problems.

“The idea that control of brain wiring is located in the RNA molecules that are constantly being dynamically turned over is something that we didn’t anticipate,” said Jaffrey. “This tells us that regulating these RNA degradation pathways could have a tremendous impact on brain development. Now we know where to look to tease apart this process when it goes awry and to think about how we can repair it.”

Several experts say the future looks promising for approaches—perhaps like this one—that will lead to the prevention of mental illnesses. Read more about that in Psychiatric News here.

(Image: traffico/Shutterstock.com)

Long-Term Follow-Up Appears to Confirm Validity of Ultra-High-Risk Criteria for Psychosis

Patients deemed to be at “ultra high risk” (UHR) for psychosis are at substantial risk for developing a psychotic disorder over the long term, with the highest risk in the first two years, according to a report online in JAMA-Psychiatry. Barnaby Nelson, Ph.D., of the Orygen Youth Health Research Centre in Melbourne, Australia, and colleagues assessed the rate and baseline predictors of transition to psychotic disorder in 416 UHR patients seen between 1993 and 2006 at a clinic with a specialized service for UHR patients. They were followed for two to 15 years after presentation.

Transition to psychosis was measured with the Comprehensive Assessment of At-Risk Mental States, Brief Psychiatric Rating Scale/Comprehensive Assessment of Symptoms and History, or state public mental health records. During the time to follow-up, 114 of the 416 participants were known to have developed a psychotic disorder. The highest risk for transition was within the first two years of entry into the service, but individuals continued to be at risk up to 10 years after initial referral. The overall rate of transition was estimated to be 34.9 percent over a 10-year period.

“Long duration of symptoms, low functioning, negative symptoms, and disorders of thought content predicted psychosis," the researchers said. "Ongoing research is needed to identify additional robust predictors. Services should aim to follow up patients for at least two years. Individuals with a long duration of symptoms and poor functioning may need closer monitoring.”

The study is posted here. For more information on psychosis risk, see Psychiatric News here.

(Image: Gunnar Pippel/shutterstock.com)

Anxiety More Common Than Depression in Cancer Survivors and Their Spouses

Anxiety, rather than depression, is more likely to be a problem in long-term cancer survivors and spouses, and the prevalence of both disorders did not differ significantly between survivors and their spouses. That was the finding of a meta-analysis of studies looking at depression and/or anxiety among cancer survivors and spouses compared with healthy controls published online yesterday in The Lancet-Oncology. Alex Mitchell, M.D., of the University of Leicester and colleagues searched several databases for reports on the prevalence of mood disorders in patients with cancer.

In 43 studies analyzed, the researchers found that the prevalence of depression was 11.6 percent in cancer survivors and 10.2 percent in healthy controls, while the prevalence of anxiety was 17.9 percent in cancer survivors and 13.9 percent in healthy controls. Neither the prevalence of depression nor of anxiety differed significantly between cancer patients and their spouses.

“Cancer is a family illness,” Michelle Riba, M.D., a past APA president and director of the PsychOncology Program at the University of Michigan Comprehensive Cancer Center, told Psychiatric News. “It affects children and spouses, and everyone in the family worries about recurrences, worries every time a scan is ordered or there is recurring pain or even a doctor’s appointment. So it’s not surprising that the prevalence of depression and anxiety wouldn’t differ significantly between survivors and spouses.” Riba said that as more people survive cancer, the psychosocial aspects of survivorship have become an important focus of research. And she noted that further research should investigate the nature and severity of anxiety in survivors and spouses, as well as the influence of other chronic medical conditions—such as cardiovascular disease—on mood disorders.

An abstract of the study is here. To read more on this topic see Psychiatric News here.

(Image: Christopher Parypa/shutterstock.com)

IOM Issues Guidelines for Research on Gun Violence

The Institute of Medicine today released a report identifying research priorities for studies of ways to reduce the threat of firearm-related violence. The report came in response to President Obama’s executive orders to federal agencies following a number of mass-shooting incidents to better understand the causes of firearm violence, possible preventive measures, and ways to reduce the public health burden of such violence.

The Centers for Disease Control and Prevention (CDC) requested the report, which suggested several areas for investigation:

• Characterizing gun ownership and use in the U.S.
• Identifying risk and protective factors concerning gun possession and use, especially as they apply to young people;
• Investigating interventions that might reduce access to firearms by high-risk individuals and thus prevent violence;
• Looking at technological approaches to gun safety; and
• Examining the possible association between media violence and real-life violence.

The report raises questions about individuals with mental illness twice in the context of preventive measures, calling for research into the public-health effects of banning firearm sales to people with “specific psychiatric illnesses” and of removing guns from those “who develop a disqualifying characteristic, for example, mental illness, with a potential for violence.”

To read more about issues surrounding firearms and mental illness, see Psychiatric News and the American Journal of Psychiatry.

(Image: Vladimir Koletic/Shutterstock.com)

VA Researchers Question FDA Antidepressant Warning

The U.S. Food and Drug Administration (FDA)
in 2011 and 2012 issued warnings that higher doses of the antidepressant citalopram hydrobromide increased the risk of two adverse cardiac outcomes—prolonged QT interval and torsade de pointes. Now, after studying records of nearly 1 million patients with depression, a group of Department of Veterans Affairs (VA) researchers “question[s] the continued merit of the warning.”

They compared low, medium, and high doses of citalopram with those another antidepressant, sertraline, that does not have an FDA cardiac-related warning. Adjusted results revealed that higher doses (40 mg/day) of citalopram were actually associated with lower risks of ventricular arrhythmia, all-cause mortality, and noncardiac mortality, compared with doses of 1 mg/day to 20 mg/day, they wrote in the June American Journal of Psychiatry. There was no increase in risk of cardiac mortality with the higher dose.

Patients prescribed sertraline recorded similar results, although without any associations with all-cause or noncardiac mortality.

“These findings raise questions regarding the continued merit of the FDA warning and provide support for the questions of whether the warning itself will cause more harm than good,” said Kara Zivin, Ph.D., of the VA’s National Serious Mental Illness Treatment and Evaluation Center and an assistant professor of psychiatry at the University of Michigan Medical School and colleagues.

For more in Psychiatric News about the FDA’s warning on citalopram, click here.

(Image: infocus/Shutterstock.com)

Job Hunting? Have a Job to Fill? Don't Miss APA's Virtual Career Fair!

APA JobCentral will soon make it easier than ever for psychiatrists seeking a job and employers with positions to fill to connect with each other. The venue for this activity, however, won't be across a desk but in cyberspace. On June 18 JobCentral will host its first Virtual Career Fair in which employers and job seekers will be able to connect directly with each other in a live one-on-one chat setting.

Job seekers can register for free whether or not they are APA members, and during the fair will be able to interact with recruiters, share their resume, discuss their professional experience, and schedule second-round interviews.

The Virtual Career Fair will take place from noon to 3 p.m. Eastern time on Tuesday, June 18. To register, visit APA JobCentral at http://jobs.psychiatry.org/home/index.cfm?site_id=13622. The event is filling up fast, so complete your registration as soon as possible!

APA Representatives Hold Press Conference in Wake of White House Meeting

Yesterday, President Obama and Vice President Biden held a White House conference on mental health. In attendance were Jeffrey Lieberman, M.D., president of APA; Paul Summergrad, M.D., APA president-elect; Jeffrey Borenstein, M.D., editor-in-chief of Psychiatric News and president and CEO of the Brain & Behavior Research Foundation; and former member of Congress Patrick Kennedy, a senior strategic advisor for APA (pictured above with APA President Jeffrey Lieberman, M.D.). After the conference, these participants, as well as APA Medical Director James H. Scully Jr., M.D., hosted a press conference to discuss some of the pressing issues in mental health care.

One such issue concerns the federal parity law that was passed five years ago, but which still does not have a final rule to ensure that insurance companies follow the law. "We want a rule to be released by the White House" that says that the brain as well as the body should be covered, Kennedy declared, and there should also be disclosure of those insurance companies that do not comply with the parity law. Sommergrad concurred: "It has been five years since the parity act was passed. A final rule is critical."

Another key issue addressed is how to dissuade the American public from thinking that people with mental illness are likely to be violent. "Gun control and violence have been conflated with mental illness," observed Lieberman. Yet only 4 percent of violent crimes are committed by mentally ill individuals, he emphasized.

And yet a third crucial issue is how to combat stigma. The speakers agreed that the best way is to change how the media portray mental illness. A good example of how reporters propagate stigma is when they write, for example, "A politician has a schizophrenic attitude," Borenstein noted. Reporters would certainly never write, "A politician has a diabetic attitude," he emphasized.

(Image: David Hathcox)