Emergency Room Diagnosis May Reduce Incidence of Self-Injury

Emergency room recognition of mental disorders can reduce the number of repeat cases of deliberate self-harm, according to a report in yesterday’s AJP In Advance. Researchers in the Department of Psychiatry at Columbia University lead a study that assessed the effectiveness of emergency department (ED)diagnosis of psychiatric disorders among patients treated for intentional self-injury. Data came from the files of 5,567 Medicaid recipients aged 21 to 64, who visited the ED for deliberate violent or nonviolent self-harm. Patients’ medical records were evaluated for repeated self-harm events and psychiatric hospital admission 30 days after index ED visit.

The results showed that nearly 10% of the patients returned to the ED for deliberate self-harm within 30 days after initial hospital visits for the same issue. Incidence of repeat self-harm visits was inversely proportional to the ED's recognition of mental disorders—mainly bipolar and anxiety disorders—regardless of the precedent psychiatric diagnosis. Approximately 13.6% of the self-injury visits were followed by psychiatric hospitalization within the 30-day period. Diagnosis of mental disorders by the ED decreased the likelihood of psychiatric hospitalization by 4.4%, compared with that of undiagnosed patients.

Lead author Mark Olfson, M.D., M.P.H., told Psychiatric News that "many emergency departments do not have access to mental health professionals...they focus on treating medical injury rather than underlying psychiatric disorders." He is confident that including a mental health focus on ED treatment for intentional self-harm may prevent repeated self-injury and hospitalization and reduce suicide risk.

Read more about deliberate self-harm in Psychiatric News here and in The American Psychiatric Publishing Textbook of Suicide Assessment and Management, Second Edition here.

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Firearm Suicides Decline After Size of Army Reduced

A study published yesterday in AJP in Advance (the online-ahead of-print website of the American Journal of Psychiatry) sheds light on the debate over whether reducing the availability of guns might contribute to a reduction in the suicide rate. Researchers found that after Switzerland's government cut the size of the country's army in half a decade ago, there was a significant drop in the number of suicides among Swiss men aged 18 to 43, while the number of suicides among two comparison groups—women in the same age group and men aged 44 to 53—did not change significantly. Switzerland has a militia army in which soldiers keep their government-issued guns in their homes, so with a substantial reduction in the number of military members, there was a corresponding reduction in the number of guns available to young men. While there was a small uptick in the number of railroad-related suicides in the years after the reform, no significant increase was found to indicate people were turning to other methods of suicide.

"The army reform wasn't intended to be a suicide prevention measure," said lead researcher Thomas Reisch, M.D., of University Hospital of Psychiatry in Bern, Switzerland, "but suicide by shooting is often done impulsively, and reducing the availability of firearms may have decreased impulsive suicides."

The APA Board of Trustees addressed the link between guns and suicide in passing the following position at its meeting earlier this month: "Although concern is understandably heightened when mass tragedies occur, the daily occurrence of murders and suicides due to the use of guns accounts for a far greater proportion of gun deaths. Although people with mental disorders, when treated, are not at increased risk of committing violence toward others, only a small minority of people with mental disorders, even without treatment are violent." 

Read more about the issue of guns, suicide, and violence in Psychiatric News here. Also see Psychiatric Services here.

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New Study Examines Relationship Between Homicide, Psychiatric Illness

Agreeing to a guilty plea was positively associated with a history of mental illness but inversely related to a history of violent crime, according to a report appearing online today in AJP in Advance. Researchers at the University of Pittsburgh School of Medicine and other institutions analyzed demographic, historical, and psychiatric variables as well as offense characteristics and legal outcomes for defendants charged with homicide in a U.S. urban county between 2001 and 2005.

Fifty-eight percent of the sample had at least one DSM-IV Axis I or II diagnosis, most often a substance use disorder. Although 37 percent had prior psychiatric treatment, only 8 percent of the defendants with diagnosed  Axis I disorders had outpatient treatment during the three months preceding the homicide; African Americans were less likely than non-African Americans to be in treatment.

Of particular interest is that psychiatric factors did not predict multiple victims, firearm use, or a guilty verdict. But agreeing to a guilty plea was positively associated with a history of mental illness while being inversely related to a history of violent crime. Sentences for defendants with an Axis I diagnosis, particularly a substance use disorder, tended to be longer. “These findings raise questions regarding potential biases toward mentally ill individuals in plea offers and sentencing practices,” the authors said.

The study can be read here. For more information on gun violence and mental illness, see Psychiatric News here and here.

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FDA Approves Medication for Major Depressive Disorder

Forest Laboratories Inc. and Pierre Fabre Laboratories announced July 26 that the FDA has approved their once-daily serotonin and norepinephrine reuptake inhibitor (SNRI) Fetzima (levomilnacipran extended release capsules) for treatment of major depressive disorder in adults.

The double-blind phase 3 studies used a daily dose of either Fetzima, ranging from 40mg to 120mg, or placebo for 8 weeks. Subjects were diagnosed with moderate to severe depression indicated by an average score of 34 on the Montgomery–Åsberg Depression Rating Scale (MADRS) at baseline. The results showed a significant improvement in MADRS scores in Fetzima patients, with a 3.1 point difference between drug and placebo. A 2-point difference between drug effect and placebo general indicates a meaningful improvement in depressive symptoms.

“I’m in favor of having more drugs available for patients,” said Alan Schatzberg, M.D., a professor in the Department of Psychiatry and Behavioral Sciences at Stanford University and a past APA President. “One drug does not have the same efficacy in every patient,” he told Psychiatric News. Schatzberg mentioned that more studies should be conducted to compare Fetzima with other available SNRIs.

Read more about treatment for depressive disorders in Psychiatric News here and in the American Psychiatric Publishing Textbook of Mood Disorders here. Schatzberg is a coeditor of that volume.

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Homelessness Appears to Increase Death Risk Among Veterans With Mental Illness

Homelessness in conjunction with severe mental illness increases early mortality risk in veterans, according to a new study published in the July Psychiatric Services. The Department of Veterans Affairs conducted a study to assess the impact of both homelessness and psychiatric disorders on premature death in veterans. Using the VA National Patient Care Database, researchers at the VA Center for Clinical Management Research in Ann Arbor, Mich., evaluated mental health status of 575,194 homeless and nonhomeless patients who died from 2000 to 2009. The deceased veterans were divided into four groups: homeless with severe mental illness (SMI), homeless without SMI, nonhomeless with SMI, and nonhomeless without SMI.

The study showed that psychiatric disorders increased early mortality likelihood among veterans by 2.4 years regardless of homelessness status when compared with those without disorders—however, these numbers were amplified by homelessness. Homeless veterans diagnosed with mental illness had the highest risk for premature death among all groups studied and were more likely to die 10.3 years earlier than their nonhomeless mentally ill counterparts.

Ending homelessness among veterans is a top priority for the VA, which recently implemented a broad array of programs addressing mental health and homelessness. The programs may prove helpful with these issues among the civilian population, according to VA senior consultant and psychiatrist, Ira  Katz, M.D., Ph.D. “World War II led to the development of antibiotics as treatments…we hope that we will be able to tell a similar story about improvements in mental health care coming out of the wars in Afghanistan and Iraq,” Katz told Psychiatric News.

For information about mental health issues of returning veterans, see Psychiatric News here and here.

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Child Maltreatment Can Have Surprising Consequences, Studies Find

Child maltreatment can have some unexpected pernicious effects, Andrea Danese, M.D., Ph.D., a senior lecturer at the Institute of Psychiatry, King's College, London, reported at a July 23 media briefing sponsored by the Brain and Behavior Research Foundation (BBRF) in New York City. Danese is a BBRF grantee and awardee. In one meta-analysis, for example, published in Molecular Psychiatry, Danese and a colleague found that childhood maltreatment was associated with an elevated risk of developing obesity over the life course, especially in women and whites. Thus, interventions targeting childhood maltreatment might improve outcomes of obesity in individuals who had been maltreated, Danese believes.

In another meta-analysis, published in the American Journal of Psychiatry, he and colleagues found that childhood maltreatment was associated with an elevated risk of developing recurrent and persistent depressive episodes as well as a lack of response or remission during treatment for depression. Consequently, he suggested that clinicians might consider more intense and alternative treatment options for depressed individuals with a history of childhood maltreatment.

Child maltreatment can have still other unexpected consequences later in life. Recent research has found, for example, an association with heightened immune vulnerability to cancer. For more on that, see Psychiatric News. More information about the mental health sequelae of child physical and sexual abuse can be found in American Psychiatric Publishing's Family Violence: A Clinical and Legal Guide.

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Prazosin Appears Effective for PTSD-Related Nightmares in Soldiers, Study Finds

Prazosin, an alpha-adrenergic blocker, appears to be effective for combat-related posttraumatic stress disorder (PTSD) with trauma nightmares in active-duty soldiers, according to an online report in AJP in Advance. Researchers at the VISN 20 Northwest Network Mental Illness Research, Education, and Clinical Center (MIRECC) in Seattle and at three other institutions randomly assigned soldiers to treatment with prazosin or placebo for 15 weeks. The drug was titrated based on nightmare response over six weeks. Primary outcome measures were the nightmare item of the Clinician-Administered PTSD Scale (CAPS), the Pittsburgh Sleep Quality Index, and the change item of the Clinical Global Impressions Scale anchored to functioning.

Results showed that prazosin was effective in improving trauma nightmares, sleep quality, global function, CAPS score, and the CAPS hyperarousal symptom cluster. However, there were substantial residual symptoms, according to the secondary measures, suggesting that studies combining prazosin with effective psychotherapies might demonstrate further benefit.

The report is posted here. For additional information on this subject, see Psychiatric News here.

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New York to Move Many With Mental Illness to Community Housing

Yesterday, the state of New York agreed to settle a decade-long lawsuit allowing 4,000 people with mental illness the opportunity to move out of adult group homes and into their own apartments “in the most integrated setting appropriate to their needs.” The consent decree requires that New York set up at least 2,000 supported-housing units and hire staff to advise the residents. The state will also provide coordination of psychiatric and general medical care, employment services, assertive community treatment, and crisis services, among other services.

Seriously ill patients, those considered dangerous, or those requiring nursing care are not covered by the settlement.


“We are happy to see that the state will devote more resources to the housing needs of severely mentally ill people and allow them the opportunity to leave adult homes in cases where it is desired and clinically appropriate,” Glenn Martin, M.D., president of the New York State Psychiatric Association and recorder of the APA Assembly, told Psychiatric News. “We strongly support the goal of reintegration into the community to maximize each person’s potential and believe it is fundamental to good care and outcome.”

The lawsuit was filed after the New York Times reported that operators of the for-profit group homes provided poor care or needless medical treatment to the residents. An independent reviewer will monitor the implementation of the agreement.

For more in Psychiatric News about community care of individuals with mental illness, click here. Also see Psychiatric Services here.

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Diabetes Drug May Help Control Weight Gain in Schizophrenia Patients

Metformin, a drug used for diabetes, may have an important role in diminishing the adverse consequences of obesity and metabolic impairments in patients with schizophrenia. That was the finding from a study by researchers at the University of North Carolina, Columbia University, and New York State Psychiatric Institute published online July 12 in the American Journal of Psychiatry. In a double-blind study, 148 overweight patients with chronic schizophrenia or schizoaffective disorder were randomly assigned to receive 16 weeks of metformin or placebo. Metformin was titrated up to 1,000 mg twice daily, as tolerated. All patients continued to receive their pre-study medications, and all received weekly diet and exercise counseling. The primary outcome measure was change in body weight from baseline to week 16.

Fifty-eight patients who received metformin and 58 who received placebo completed 16 weeks of treatment. Mean change in body weight was −3.0 kg for the metformin group and −1.0 kg for the placebo group. Metformin also demonstrated a significant between-group advantage for body mass index, triglyceride level, and hemoglobin A1c level. Metformin-associated side effects were mostly gastrointestinal and generally transient.

“Metformin was modestly effective in reducing weight and other risk factors for cardiovascular disease in clinically stable, overweight outpatients with chronic schizophrenia or schizoaffective disorder over 16 weeks,” the researchers concluded. “A significant time-by-treatment interaction suggests that benefits of metformin may continue to accrue with longer treatment.”

For more on the subject of psychosis and weight gain, see Psychiatric News here.

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Antidepressants May Help Avert Depression in Head and Neck Cancer Patients

Antidepressant use appears to prevent depression in patients with head and neck cancer, a large double-blind, placebo-controlled clinical trial has found. The study was headed by William Lydiatt, M.D., of the Department of Otolaryngology-Head and Neck Surgery at the University of Nebraska. The results appear in JAMA Otolaryngology-Head and Neck Surgery.

"This study is important in many ways," Michelle Riba, M.D., a former APA president, a professor of psychiatry at the University of Michigan, and a psycho-oncologist, told Psychiatric News. "It looked at a population of patients—those with head and neck cancer—in whom depression is a very prominent and serious condition. It studied a way to help patients in a preventive paradigm, using [the SSRI antidepressant] escitalopram. Furthermore, even though the  study wasn't designed to study quality of life, patients in the escitalopram arm had an overall improved quality of life during the study and three months consecutively after the cessation of drug therapy."

More information about how psychiatrists can help cancer patients can be found in Psychiatric News. Information about the mental health challenges that cancer patients and survivors face is presented in the new American Psychiatric Publishing book, Psycho-Oncology.

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Psychiatrist Named to Head N.Y. State Office of Mental Health

Psychiatrist Ann Marie Sullivan, M.D., who has long been a leader in APA, has been named Acting Commissioner of the New York State Office of Mental Health, according to a Friday announcement by New York Governor Andrew Cuomo. Sullivan is the senior vice president for the Queens Health Network of the New York City Health and Hospitals Corporation, where she is responsible for two large public hospitals, and is also a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai.

In announcing his choice of Sullivan to head that key department, Cuomo said, "Dr. Sullivan's experience at Elmhurst and Queens Hospital Centers, which serve 2 million New Yorkers, will allow the OMH to excel under her leadership and guidance." Sullivan said that she looks forward to spearheading the office's increased emphasis on integrated care and on recovery from mental illness.

Sullivan is a past speaker of the APA Assembly, has served on the Board of Trustees, and is a member of the Psychiatric News Editorial Advisory Board.

Scientific Advances Bring Major Changes to Forensic Psychiatry

As it ends its second decade as an official subspecialty, the field of forensic psychiatry is digesting dramatic changes that are making it more science based and expanding the areas in which it contributes expertise. For example, there has been "the steady introduction of a more systematic means of assessment," Paul Appelbaum, M.D., chair of the APA Committee on Judicial Action and a former APA President, told Psychiatric News. "Clinical evaluations have in many settings been supplemented by more systematic data-gathering tools, such as scales for the assessment of symptoms and mental states." In addition, "forensic psychiatry has become much more important in child custody, disability evaluations, and perhaps more significantly for the public, in sickness-for-duty evaluations," said Patricia Recupero, M.D., J.D., a professor of psychiatry at Brown University.

Perhaps the greatest recent change in this field is its rapidly growing science base, characterized by the introduction of "structural and functional neuroimaging, electrophysiolgical studies, and genetic information in court....," said Appelbaum, who is the Dollard Professor of Psychiatry, Medicine, and Law at Columbia University. "With the human-genome project, there is a lot of interest in genetic testing in forensic situations," noted William Bernet, M.D., a professor of psychiatry emeritus at Vanderbilt University.

To read much more about how forensic psychiatry is changing and the challenges and rewards that its practitioners say come with working in this field, see today's issue of Psychiatric News here and here. For a comprehensive review of the field, see the American Psychiatric Publishing Textbook of Forensic Psychiatry, Second Edition here.

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Some Cancers Linked With Reduced Alzheimer's Risk, Study Finds

There is an inverse relationship between many types of cancers and the risk of Alzheimer's disease (AD), Jane Driver, M.D., an assistant professor of aging/geriatrics at Harvard Medical School, and colleagues reported this week at the Alzheimer's Association International Conference in Boston. They analyzed health records of some 3,500,000 veterans aged 65 and older who were seen in the Veterans Administration health care system between 1996 and 2011 and who were free of dementia at baseline. The objective was to evaluate the relationship between a history of 19 different cancers, cancer treatment, and subsequent AD.

Over a median follow-up of six years, about 82,000 veterans were diagnosed with AD, and 24% of those veterans had a history of cancer. The researchers found that most types of cancer assessed were associated with a reduced Alzheimer's risk ranging from 9% percent to 51%. Reduced risk was greatest among survivors of liver cancer (51% lower risk), pancreatic cancer (44%), esophageal cancer (33%), myeloma (26%), lung cancer (25%), and leukemia (23%). Cancers that did not appear to offer a reduced AD risk, or were associated with increased risk, included prostate, melanoma, and colorectal cancers.

The researchers also found that among veterans with a cancer history, treatment with chemotherapy—but not with radiation—conferred a reduced Alzheimer's risk of 20% to 45%, depending on cancer type, with the exception of prostate cancer. So might certain types of cancer, as well as chemotherapy, help protect people from AD? It's a possibility that needs to be further explored, Driver said.

Researchers have been studying other less-traumatic factors that might confer some degree of protection from developing AD such as exercise, diet, or memory training. See Psychiatric News for details.

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Psychiatry Has Nothing to Be Defensive About

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. Please send your comments to pnupdate@psych.org.

The integrity of our profession and the science of psychiatry are being questioned—again by articles in the media. Two recent missives, which I found particularly disturbing, are by the noted columnist David Brooks ("Heroes of Uncertainty," New York Times, May 28) who calls psychiatry a “semi-science,” and by Leonard Sax, a British psychologist (Wall Street Journal, June 26), who accused DSM-5 of having “broadened the definition of mental illness to absurdity.” Although the most recent media criticisms have been focused on the process and finished product of DSM-5, such invective is really nothing new. But it may be time to respond in a new way.

I recently wrote an article for the Scientific American blog that explores how stigma and antipsychiatry sentiments fuel prejudice against our field and our patients. But I think it’s also important to note how the unwillingness of the public and pundits to accept psychiatry as a scientific discipline and full-fledged medical specialty perpetuates the false dualism of the mind and the brain—attempting to transport psychiatry back to the Cartesian philosophy of the 17th century. It also undermines the progress that has been made to deconstruct the almost unfathomable complexity of the brain into its constituent neurobiological mechanisms that mediate emotion, perception, and cognition.

The intellectual thrust of psychiatry, throughout its entire history, has been to understand the maladies of the mind in terms of the brain. Prior to the 18th century, mental illness was considered a spiritual or moral affliction. When enlightenment thinking inspired the view of mental illnesses as medical conditions, psychiatrists proceeded to examine the brain but found no visible pathology. Even Freud, a neurologist, appreciated the need to invoke the brain to understand behavior and psychopathology. His “Project for a Scientific Psychology” anticipated a neurobiological explanation for mental processes and unconscious psychic phenomena.

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Debate on Gun Policy and Mental Illness Needs Better Evidence Base

Arguments for or against keeping guns out of the hands of people with mental illness rest on a slender base of evidence, according to a study published online July 15 in Psychiatric Services in Advance. “Firearms injury research comes from the public-health community, while studies of mental illness and violence derive from the psychiatry and law sectors, and they haven’t been talking to each other,” said Emma McGinty, Ph.D., M.S., an assistant professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.

Psychiatrists and others often suggest that if stricter standards for background checks are required to purchase firearms, it will deter those with mental illness from seeking treatment. However, McGinty has turned up no research supporting that position. “That’s a bit of a surprise,” she told Psychiatric News. But measuring treatment avoidance is difficult, because it is hard to identify people who do not seek care.

“Policies [on gun restrictions] targeting people with mental illness have simply sprung up, but we have little information about them or if they work,” said McGinty. “We need a comprehensive approach that looks at a broad range of risk factors.”

To read more about mental illness and firearms policies, see Psychiatric News here and here.

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New Studies Show Reduction in Dementia Rates Among Elderly

Rates of dementia among older populations in Britain and Denmark appear to have declined, according to two studies published in The Lancet. The British study surveyed two cohorts of people over age 65 in the same geographic areas in the period 1984-1994 and again in 2008-2011. About 8.3 percent of the first group was expected to have dementia in 2011, but the actual rate was 6.2 percent, wrote Carol Brayne, M.D., of Cambridge University, and colleagues, online July 17.

The Danish study tested cognitive and physical functioning among 2,262 people born in 1905 and among 1,584 born in 1915. "Despite being two years older at assessment, the 1915 cohort scored significantly better than the 1905 cohort on both the cognitive tests and the activities of daily living score, which suggests that more people are living to older ages with better overall functioning,” concluded Kaare Christensen, M.D., of the University of Southern Denmark, and colleagues.

Both studies suggest that cohorts born later have lower rates of dementia. Many factors might cause that difference, ranging from better health care or education among the younger groups to improved diets, less smoking, and reduced cardiovascular risk factors, although the studies did not speculate on reasons for the changes. Some commentators say the two studies are a hopeful sign the dire predictions of a coming onslaught of dementia may not be so dire. Others are not so sure. Replication of the studies in the U.S. and Canada may help answer that question.

For more in Psychiatric News about dementia, click here and here. Also see American Psychiatric Publishing's Clinical Manual of Alzheimer Disease and Other Dementias.

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New Research Suggests Retiring Later May Reduce Alzheimer's Risk

Retiring later may diminish the risk of Alzheimer’s disease, according to  research presented at the Alzheimer’s Association International Conference this week in Boston. According to a report by CBS News, a study of nearly 500,000 people in France found that the risk of Alzheimer’s dropped with each additional year an individual worked.Researchers analyzed health records of more than 429,000 workers, most of whom were shopkeepers or craftsmen such as bakers and woodworkers. They were age 74 on average and had been retired for an average of 12 years.

Nearly 3 percent had developed dementia but the risk of this was lower for each year of age at retirement. Someone who retired at 65 had about a 15 percent lower risk of developing dementia than someone retiring at 60, after other factors that affect those odds were taken into account. "For each additional year of work, the risk of getting dementia is reduced by 3.2 percent," said Carole Dufouil, a scientist at INSERM, the French government's health research agency.


It's by far the largest study to look at this issue, and researchers say the conclusion makes sense. Working tends to keep people physically active, socially connected and mentally challenged — all things known to help prevent mental decline, according to the CBS News report.

The CBS news report is here. For more on Alzheimer’s disease, see Psychiatric News here. The "Clinical Manual of Alzheimer’s and other Dementias" is available from American Psychiatric Publishing here.

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FDA Approves Device to Help Diagnose ADHD in Children

The Food and Drug Administration (FDA) approved marketing of the first medical device based on brain function to help assess attention-deficit/hyperactivity disorder (ADHD) in youth aged 6 to 17. In a statement, the FDA said that when used as part of a complete medical and psychological examination, the device can help confirm an ADHD diagnosis or a clinician’s decision that further diagnostic testing is necessary to assess symptoms similar to ADHD.

The device, the Neuropsychiatric EEG-Based Assessment Aid (NEBA) System, is based on electroencephalogram technology, which records different kinds of electrical impulses given off by neurons in the brain and the number of times the impulses are given off each second. The NEBA System is a 15- to 20-minute noninvasive test that calculates the ratio of two standard brain-wave frequencies, known as theta and beta waves; the ratio has been shown to be higher in children and adolescents with ADHD than in those without it, according to FDA.

“Diagnosing ADHD is a multistep process based on a complete medical and psychiatric exam,” said Christy Foreman, director of the Office of Device Evaluation at the FDA’s Center for Devices and Radiological Health, in a statement. “The NEBA System along with other clinical information may help health care providers more accurately determine if ADHD is the cause of a behavioral problem.”

Child psychiatrist Louis Kraus, M.D., cautioned, however, that the device should never be considered a substitute for a clinical assessment by a physician. "ADHD is a clinical diagnosis and is very clearly defined that way in DSM-5," he told Psychiatric News. "There is no one specific test that can make the diagnosis of ADHD." He said other neuroimaging tools have been proposed as diagnostic of ADHD and have been found to be problematic. "No one should ever look at these tools as overriding the clinical diagnosis," Kraus said. "On the positive side, [the newly approved device] is noninvasive and could be used to support a clinical diagnosis. But ADHD is a disorder involving particular behaviors in the area of attention, hyperactivity, and impulsivity that must occur in more than one environment—at home, at school, or elsewhere. So parents' observations, for instance, will be an important part of an overall clinical assessment."

For more information about recent research on children and ADHD, see Psychiatric News here.

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Measuring Mental Illness Recovery Will Require More Precise Instruments

While the ultimate goal in mental health treatment may be a patient's recovery, no available measure seems to be an ideal method for assessing that recovery, though two show considerable efficacy in measuring several key factors, a new study finds.

"No recovery measure can currently be unequivocally recommended....," Mike Slade, Psych.D., Ph.D., a professor at the Institute of Psychiatry, King's College, London, and colleagues report in Psychiatric Services in Advance. They came to this conclusion after systematically searching for and evaluating research papers on the subject. However, the best recovery yardstick appears to be the Questionnaire About the Process of Recovery, which was developed in the United Kingdom and  measures recovery processes such as connectedness, hope, identity, meaning, and empowerment, the researchers report. The most-published instrument is the Recovery Assessment Scale, developed in the United States, which measures recovery processes such as self-confidence, hope, success orientation, and willingness to ask for help.

Information about individuals who have recovered from serious mental illness can be found in Psychiatric News here and here. For more on the topic, see American Psychiatric Publishing's Recovery From Disability: Manual of Psychiatric Rehabilitation.

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Clinicians Say DSM-5 Criteria Easy to Understand and Use

Just published field-trial research on DSM-5 shows that in routine clinical practice the diagnostic criteria are viewed as easy to understand and use by both clinicians and patients. This follows field trials in high-volume academic centers that found high reliability of the criteria in the revised manual.

As part of the process that tested the more-dimensional approach that characterizes DSM-5, APA’s Division of Research conducted a series of field trials in settings of routine clinical practice. Researchers recruited a sample of 621 psychiatrists, clinical psychologists, social workers, counselors, and other licensed mental health professionals. Each participant was then asked to report on at least one randomly selected active patient. Data were provided on 1,269 patients, who also answered study questions.

The clinicians reported that the revised criteria were generally easy to use and were useful in patient assessment, said principal investigator Eve Mościcki, Sc.D., M.P.H., and colleagues today in Psychiatric Services in Advance. “The clinicians put in a lot of effort collecting data on their patients,” she told Psychiatric News. Large majorities favored the overall feasibility of the DSM-5 approach, the clinical utility of the DSM-5 criteria, and the value of its cross-cutting measures.

“These trials indicate that the DSM-5 approach works in a wide range of practice settings and a wide range of clinical settings,” said Mościcki.

For more about DSM-5, see Psychiatric News here. Information about ordering DSM-5 and its companion volumes is posted here.

Will the Government Do the Right Thing?

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. Please send your comments to pnupdate@psych.org.

The way that psychiatric medicine is practiced in this country—as well as the way mental health care is delivered and financed—is about to change dramatically. The president and Congress are the key drivers in this process, and the critical question everyone’s asking is this: “Will the government do the right thing?”

This is a broad question that many have asked about health care issues for years—as we struggle to improve health care and make it more accessible and cost-effective. But it’s especially important now, as we await the final rule on the Mental Health Parity and Addiction Equity Act, which was passed in 2008 but has yet to be fully implemented. The detailed final rule—which nobody has yet seen but is due out soon—will determine precisely how the law’s provisions will be implemented. Until then, we continue to have symbolic but not actual parity.

As if this were not enough, we also are in the early stages of health care reform via the Patient Protection and Affordable Care Act.

Because so much currently hangs in the political balance for psychiatrists and APA, when I was invited to a special White House Conference on Mental Health last month, I immediately cleared my schedule, as did my invited APA colleagues Paul Summergrad (president-elect) and Jeff Borenstein (chair of the Council on Communications and editor in chief of Psychiatric News).

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AJP Ranked Among Most Influential Journals

A recently released study of the influence of medical and scientific journals finds the American Journal of Psychiatry (AJP) at or near the top of the rankings. Journal Citation Reports, a publication of Thomson Reuters, evaluated journals' "impact factor"—a quality measure indicating how often a journal's research articles are cited in other publications. AJP's impact factor put it within the top 1 percent of the more than 8,000 journals that were assessed. AJP also retained its long-standing position as the leader among the 135 psychiatric journals when the total number of citations was calculated, with its articles being cited 42,370 times, nearly 5,000 more than the next-ranked psychiatric journal.

Commenting on the new data, AJP Editor-in-Chief Robert Freedman, M.D., said, “The editors strive to publish papers that our readers will find important for guiding clinical practice and advancing the broad scientific basis of psychiatry. Impact factor is one measure of the high value of the Journal’s papers."

Web Intervention Plus Intense Therapy Shows Promise in Eating Disorders

Dutch researchers are testing an intervention for eating disorders that combines Web-based activities with intensive therapeutic support. Their findings are published in the July Psychiatric Services. In the first part of a trial of 165 patients testing the program, patients analyzed their attitudes and behaviors about eating; part two focused on behavioral change.

Patients in the program receive messages, assignments, exercises, and psychoeducation from their therapists. They complete four assignments and have at least seven contacts in the first part and six assignments and at least 14 contacts in the second part. Contact is usually over the Internet, but patients can request a telephone or in-person session, if desired.

“Results showed that the Web-based intervention successfully changed eating-disorder psychopathology, with most of the improvements sustained at the six-month follow-up,” wrote Elke ter Huurne, M.Sc., of Tactus Addiction Treatment in Enschede, the Netherlands. “Physical and mental health also improved, and patients were much more satisfied with their body image.” A randomized, controlled trial of the approach is underway and will be completed in 2014.

For more information about treatment for eating disorders, see Psychiatric News here.

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Brain Imaging May Identify Depression in Very Young Children

Functional magnetic brain imaging (fMRI) of preschool-age children appears to be useful in identifying early childhood depression, according to a study in the July Journal of Child and Adolescent Psychiatry. Researchers at Washington University in St. Louis School of Medicine used fMRI to compare blood-flow activity in the amygdalae of 23 nonmedicated preschoolers with depression and 31 nondepressed peers. The children were shown pictures of peoples’ faces with happy, sad, fearful, and neutral expressions. Mock sessions were held with the children to help them get used to the fMRI.

The scans of preschoolers with depression showed much more blood flow in the amygdala no matter what facial expression the child viewed. This was in contrast to findings in the nondepressed preschoolers and provides the earliest evidence yet of changes in brain function in young children with depression. In addition, relationships between increased amygdala activity during face processing and disruptions in parent-reported emotion regulation and negative affect were found.

The researchers say the findings could lead to ways to identify and treat depressed children earlier, potentially preventing problems later in life. “The findings really hammer home that these kids are suffering from a very real disorder that requires treatment,” said lead author Michael Gaffrey, Ph.D., in a statement. “We believe this study demonstrates that there are differences in the brains of these very young children and that they may mark the beginnings of a lifelong problem.”

"This is a small but intriguing study," child psychiatrist and APA Treasurer David Fassler, M.D., told Psychiatric News. "The authors demonstrate significant alterations in functional brain activity in young children with depression.  More research will be needed before we can fully understand the implications of the findings.  However, if replicated, the results of this study may eventually enhance our ability to diagnose depression in very young children as early and accurately as possible."

An abstract of the study is online here. For more information about mental illness in children, see Psychiatric News here.

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CMS Says More Evidence Needed Before Medicare Will Cover Amyloid-Beta Imaging

The Centers for Medicare and Medicaid Services says that evidence is insufficient to approve the use of positron emission tomography (PET) amyloid-beta (Aβ) imaging for Medicare beneficiaries with dementia or neurodegenerative disease. However, CMS did say that there is sufficient evidence that the use of PET Aβ imaging could be promising in two scenarios: (1) to exclude Alzheimer’s disease (AD) in narrowly defined and clinically difficult differential diagnoses, such as AD versus frontotemporal dementia (FTD); and (2) to enrich clinical trials seeking better treatments or prevention strategies for AD, by allowing for selection of patients on the basis of biological as well as clinical and epidemiological factors.

CMS in its decision said it will thus cover one PET Aβ scan per patient who is enrolled in a clinical trial that is designed to develop better treatments or prevention strategies for AD or to resolve clinically difficult differential diagnoses where use of PET Aβ imaging appears to improve health outcomes.

Eli Lilly, which manufactures the Amyvid (florbetapir F18 injection) beta-amyloid scan, in a statement on its Web site expressed disappointment in the decision. “CMS appears to be challenging the value of an adjunctive tool that can assist physicians in making a more-informed diagnosis for patients with cognitive impairment,” said Daniel Skovronsky, M.D., Ph.D., president and CEO, Avid Radiopharmaceuticals, Inc., a subsidiary of Eli Lilly. Restricting coverage could hinder a timely and accurate diagnosis.... In addition, it may stifle future innovation aimed at improving diagnosis."

The CMS decision is posted here. For more on this subject see Psychiatric News here.

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Musical Hallucinations Can Occur in a Variety of Conditions

Visual hallucinations of musical notation can occur in a variety of conditions, Oliver Sacks, M.D., a professor of neurology at New York University and a well-known author, reports in the July Brain.

The conditions include Parkinson's disease, fever, intoxication, and visual loss. For example, a surgeon and amateur pianist who was losing vision from macular degeneration started seeing musical notations, "just like a sheet of real music." A man with Parkinson's disease and a gifted pianist started seeing staves and lines of music on the pages of books he was reading.

Although the brain mechanisms that create visual hallucinations of musical notation are not known, they may involve the left inferotemporal cortex, which is crucial for the act of reading, and perhaps also the parietal lobes, which are known to be involved in reading musical scores, Sacks speculates.

Visual hallucinations are, of course, not limited to music. For instance, when seniors suddenly start seeing images of adults or children whose identity is not known and who do not speak, it should arouse suspicion of the presence of Lewy body disease, according to Myron Weiner, M.D., a clinical professor of psychiatry and neurology at the University of Texas Southwestern Medical Center. For more information about this subject, see Psychiatric News.

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Computer Memory Exercises Can "Bulk Up" Senior Memories

Seniors can improve their memories with a computer memory-training program, Karen Milller, Ph.D., an associate clinical professor of neuroscience and human behavior at the University of California, Los Angeles, and colleagues reported in the July American Journal of Geriatric Psychiatry.

The study included 69 cognitively normal older individuals. Their memory and language skills were tested, and they were then randomized to engage in an eight-week computer memory-training program or to be wait-listed for it. Their memory and language skills were also tested two months and six months after the start of the study. Use of the program led to improved delayed memory scores after two months and six months. Also, anyone who used the program for more than 40 sessions improved in terms of not just delayed memory, but immediate memory and language abilities.

"These results suggest that this form of computerized cognitive training may have its greatest benefit when used consistently for at least two months (or the equivalent of 40 sessions) or more," the researchers concluded.

The findings also dovetail with the passionate conviction of Dilip Jeste, M.D., former APA president and chair in aging at the University of California, San Diego, that seniors can continue to function at a high level. "Studies across species have shown that brain growth and development are not restricted to childhood, but continue into old age," he said. "Blood vessels, synapses, even neurons can grow in certain parts of the brain--provided there is optimal psychosocial and physical stimulation."

For more information on this subject, see Psychiatric News.

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Escitalopram and CBT Found to Prevent Relapse in Elderly with GAD

Cognitive-behavioral therapy (CBT) has been found to enhance antidepressant treatment in older adults by reducing worrying in the short term and sustaining remission without long-term pharmacotherapy. Thus, adding CBT may be a useful treatment option for some patients as standard first-line treatment, researchers concluded in a study reported in the July American Journal of Psychiatry.

The study subjects were 60 years or older with generalized anxiety disorder who had been recruited from three outpatient sites. Subjects received 12 weeks of open-label escitalopram and were then randomly assigned to one of four conditions: 16 weeks of escitalopram (10–20 mg/day) plus modular CBT, followed by 28 weeks of maintenance escitalopram; escitalopram alone, followed by maintenance escitalopram; escitalopram plus CBT, followed by pill placebo; and escitalopram alone, followed by placebo. The four groups did not differ on demographic variables or anxiety or worry level at pretreatment.
The researchers found that escitalopram augmented with CBT increased response rates on the Penn State Worry Questionnaire but not on the Hamilton Anxiety Rating Scale compared with escitalopram alone. Both escitalopram and CBT prevented relapse compared with placebo.

“Continued medication prevents relapse, but for many individuals, CBT would allow sustained remission without requiring long-term pharmacotherapy.” the researchers wrote.


To access the study, click here.

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Lurasidone Gains New Indication for Bipolar Depression

The U.S. Food and Drug Administration (FDA) has approved new indications for the atypical antipsychotic drug lurasidone (Latuda; Sunovion) in treatment of patients with depressive episodes associated with bipolar I disorder. The approval covers use alone and as adjunctive therapy with lithium or valproate.

“Its utility as monotherapy and adjunctive therapy places the drug in a select position in an area with few other medication choices,” said Roger McIntyre, M.D., a professor of psychiatry and pharmacology at the University of Toronto, in an interview. Lurasidone was already approved for use in patients with schizophrenia.

With the new indications, the drug appeared to cause fewer metabolic problems or weight gain than other drugs in its class, said McIntyre, who formerly consulted with Sunovion’s Canadian affiliate, but does not do so now.

In two clinical trials submitted to the FDA, lurasidone was tested over its complete dosing range of 20mg to 120 mg day, and average weight gain was 0.3 kg with monotherapy and 0.1 kg with adjunctive use, said psychiatrist Antony Loebel, M.D., chief medical officer at Sunovion. Trial results were presented as posters at APA's 2012 annual meeting and have been submitted for publication.

The new indication should help fill the unmet need for more treatment options for clinicians and their patients with bipolar depression, said Loebel.

For more in Psychiatric News about medications used to treat bipolar depression, click here.

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Mobile App for DSM-5 Now Available

The DSM-5 Diagnostic Criteria Mobile App is designed to help mental health practitioners, researchers, and students fully integrate the new DSM criteria and codes into their practice and study. Users have full offline access to all of the criteria sets as well as online access to supporting videos, commentary, and resources. Powerful search and customization tools aid and enhance assessment of symptom presentations in a variety of clinical and administrative settings.

The app features access to the complete DSM-5 diagnostic criteria sets on your phone and tablet, up-to-date access to ICD-9-CM and ICD-10-CM codes for clinical and administrative use, video commentary from the DSM-5 task force members highlighting changes from DSM-IV to DSM-5, streamlined navigation of the classification hierarchy, and robust disorder, acronym, code, and symptom search functionality. Bookmarking allows customization of the criteria sets most commonly referenced for individual practice with easy access to recently viewed content.

The mobile app can be bought through the iTunes store for Apple mobile devices, and through Google Play for Android.

To obtain more information or access links to purchase the app, click here.

FDA Says New Insomnia Drug Must be Available at Lower Doses Before Approval

The Food and Drug Administration has advised Merck Pharmaceuticals that suvorexant, the company’s investigational medication for the treatment of insomnia, is not approved at doses of 30 mg and 40 mg.

In a response to the company's drug approval request, the FDA advised the company in a "Complete Response Letter" that 10 mg should be the starting dose for most patients and must be available before suvorexant can be approved; 15 mg and 20 mg doses would be appropriate in patients in whom the 10 mg dose is well-tolerated but not effective, the agency said. (And for patients taking concomitant moderate CYP3A4 inhibitors, a 5 mg dose would be necessary.)

“We will evaluate the requests outlined in the Complete Response Letter, and expect thereafter to work expeditiously with the FDA to make suvorexant available as a new treatment option for patients suffering from insomnia,” said Roger M. Perlmutter, M.D., Ph.D., president, Merck Research Laboratories, in a statement on the company’s Web site.

An article in the New York Times yestreday about the FDA decision notes that the agency’s decision is similar to the findings in May of a federal advisory panel, which concluded that lower doses of the drug were safe and effective, but expressed concern that higher doses led to daytime drowsiness and other side effects. It is also in keeping with a recent decision by the FDA that women who take the sleep drug Ambien reduce their dosage by half, because of similar concerns about drowsiness.

For more on insomnia, see Psychiatric News here.

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High-Fat Diet Increases Levels of Beta Amyloid

A diet high in fat, cholesterol, and sugar has been implicated in Alzheimer's. But how might it contribute? By increasing the level of beta-amyloid—a hallmark of Alzheimer's—in the brain and cerebrospinal fluid, a new pilot study suggests. It was headed by Suzanne Craft, Ph.D., of Wake Forest University and reported in JAMA Neurology.

The study included 20 older adults with normal cognition and 27 with mild cognitive impairment, which is often a precursor to Alzheimer's. Levels of beta amyloid in subjects' cerebrospinal fluid were compared. The subjects with mild cognitive impairment had more beta amyloid in their cerebrospinal fluid than did the cognitively normal subjects. The subjects were then randomized to a high-fat or low-fat diet for four weeks. The researchers assessed whether the diets affected the levels of beta amyloid in cerebrospinal fluid. The high-fat diet increased such levels; the low-fat diet lowered them. The results not only suggest how an unhealthy diet may contribute to Alzheimer's, but imply that changing one's diet might be one way to lower Alzheimer's risk.

Among potentially effective factors that might reduce Alzheimer's risk are increased physical activity and memory training, but more and larger controlled trials are needed to confirm preliminary findings on these factors. See Psychiatric News here. More information about Alzheimer's drugs in clinical trials can be found in Psychiatric News here.

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