Reasons Cited for Optimism About Outcomes of Children With Bipolar Disorder

What does the future hold for children with bipolar disorder? Boris Birmaher, M.D., a professor of psychiatry at the University of Pittsburgh, and colleagues at UCLA and Brown University, followed up 367 of children with the disorder for an average of eight years to find out. They found that about 45% of the subjects were doing "relatively well" by the end of this time, which they defined as having had a stable mood for most of the follow-up period.

Birmaher reported the findings at a Brain and Behavior Research Foundation symposium in New York, where he was honored for outstanding achievements in childhood-onset bipolar disorder research.

The research by Birmaher and colleagues also showed that youth whose bipolar illness developed later in adolescence; who at intake had less-severe depressive and manic symptoms, less suicidality, and less substance abuse; and who lived in families with a higher socioeconomic status were more likely to do well. These findings suggest that treatments that could delay the onset of the disorder or that target other factors related to illness course might increase the likelihood that youth with bipolar disorder will be able to maintain a long-term stable mood, the researchers concluded.

More information about this topic can be found in the Psychiatric News articles "DSM-5 Fine-Tunes Diagnostic Criteria for Psychosis, Bipolar Disorders" and "Severe Childhood Mood Disorder May Be Unique Syndrome." Also see the Clinical Manual for Management of Bipolar Disorder in Children and Adolescents from American Psychiatric Publishing.

(photo: Boris Birmaher)

Law That Changed Mental Health Care Celebrates 50th Anniversary Today

Fifty years ago today, President John F. Kennedy signed  a law that became a major milestone on the long road to improving the state of mental health care in the U.S. The primary goal of the Community Mental Health Act of 1963, signed just three weeks before Kennedy was assassinated, was to greatly reduce the number of patients with serious mental illness who were routinely treated in huge state hospitals and ensure instead that they would receive treatment in their communities. He envisioned that 1,500 community mental health centers (CMHCs) would be built under funding provided through the act, which would result in a cut of 50% in the 500,000 or so patients who were in state psychiatric hospitals in 1963. The act also signaled a shift to giving the federal government a greatly expanded role in mental health care.

Part of the act's promise was fulfilled in that deinstitutionalization did, in fact, occur on a massive scale, but an adequate number of community-treatment alternatives did not follow. Only half of the proposed CMHCs were built, and none received the full amount of funding indicated in the act or funds to function over the long term. In addition, many CMHCs did not want to treat patients with severe illnesses. During the Reagan administration, the funding was converted into mental health block grants that went to the states to distribute.

To read more about the legacy of the 1963 mental health act, see the essay "The Next 50 Years: A New Vision of 'Community Mental Health' ” by former member of Congress Patrick Kennedy and psychiatrists John Greden, M.D, and Michelle Riba, M.D., in the October American Journal of Psychiatry.

Early Detection Poised to Limit Devastating Effects of Psychosis, Says Lieberman

It has taken a century, but researchers are finally close to altering the outcomes of the most severe psychiatric illnesses, points out APA President Jeffrey Lieberman, M.D., in a video presentation posted this afternoon on the APA website. "New care models developed for early detection and intervention in psychoses, also known as EDIP, provide us with the potential to limit the devastating effects of these disorders," he says. "Through research we have learned that the earlier patients are diagnosed and treated for psychosis, the better they respond to treatment and the greater their potential for recovery. We also know that resilience, coping skills, and peer and family support are important contributors to recovery. The EDIP model is based on this research and focuses on early detection, multi-element team-based interventions, and sustained engagement with patients. The goals of EDIP are to enhance symptomatic remission, functional recovery, and prevent relapse and disability."

Lieberman notes that while the EDIP model is influencing psychosis treatment in Canada, Australia, and several European countries, the U.S. has seen little progress on this front due to "the complicated and inefficient U.S. health care financing system, which often does not cover psychosocial and rehabilitative services."

To enhance the quality of care in this country, Lieberman emphasizes, "We must challenge the configurations of the current mental health care services and reimbursement schemes and emphasize the importance of care at the earliest stages of psychotic disorders."  

To watch the complete video and others in this series, click here.

Company Releases Data on FDA-Approved Treatment for Bipolar I Depression

In July, lurasidone—a dopamine receptor 2 (D2) blocker originally approved to treat schizophrenia—was approved by the Food and Drug Administration (FDA) to treat depression associated with bipolar I disorder. Today in AJP In Advance, lurasidone's developers showed in their study titled "Lurasidone Monotherapy in the Treatment of Bipolar I Depression: A Randomized, Double-Blind, Placebo-Controlled Study" how the drug received FDA approval to remedy this difficult-to-treat condition.

Researchers from Sunovion Pharmaceuticals recruited approximately 500 participants with bipolar I depression in their assessment of the drug's efficacy and safety. Participants were given 20mg to 120mg per day of lurasidone or placebo for six weeks. Changes in depression were measured by the Montgomery Asberg Depression Rating Scale (MADRS), and depression severity was measured by the Clinical Global Impression scale for bipolar illness (CGI-BP).

Results showed that lurasidone reduced MADRS scores 31% more than placebo did and decreased CGI-BP scores by more than 38% compared with placebo. In addition, those given lurasidone showed improvements in anxiety symptoms and patient-reported quality of life and functional impairment. The most frequent adverse events reported by participants were nausea, headache, restlessness, and drowsiness. Discontinuation rates due to adverse events were similar among both active and placebo groups.

R.H. Belmaker, M.D., a faculty member in the Bipolar Clinic at Hadassah Medical Center in Israel, commented in an accompanying editorial that "sometimes incremental progress in psychopharmacology can gradually add up after much preclinical work, [and] many clinical trials... The discovery of a D2 blocker with a concomitant receptor profile that…avoids cardiovascular side effects and is also effective in bipolar disorder could be a serious advance of the field. Together with the large number of overlapping genetic linkages between schizophrenia and bipolar disorder, one might envision an impact on the battle over unitary psychosis theory that could even affect DSM-6."

To read more about lurasidone and its FDA approval, see the Psychiatric News article "FDA Approves Antipsychotic to Treat Bipolar Depression.” Also see Belmaker's book review of "The Bipolar Brain: Integrating Neuroimaging and Genetics" in the American Journal of Psychiatry.

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Parity for Substance Use Treatment Has Positive Effect on Treatment Rates, Study Finds

State laws requiring parity treatment for substance use disorder (SUD) that were enacted prior to the passage of the federal parity law in 2008 appear to have had a positive effect on treatment rates. Moreover, the more comprehensive the parity law, the higher the rates of treatment for SUD in that state.

Those were the findings of an analysis in JAMA Psychiatry of the effect of state-level parity legislation on access to specialty SUD treatment from 2000 to 2008 by psychiatrist Benjamin Druss, M.D., and colleagues at Emory University. They examined treatment rates at all known specialty SUD treatment facilities in the United States. Their main data source was the federal National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment.

Druss and colleagues found that the implementation of any SUD parity law increased the treatment rate by 9% in all specialty SUD treatment facilities and by 15% in facilities accepting private insurance. Full parity and parity only if SUD coverage was offered increased the SUD treatment rate by 13% and 8%, respectively, in all facilities, and by 21% and 10%, respectively, in facilities accepting private insurance.

The researchers said that the findings bode well regarding the impact of the federal parity law. “Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment,” they concluded.

To read about issues involved in the 2008 mental health parity law, see the Psychiatric News articles ”Court to Hear Case Alleging Parity-Law Violation,” "Parity Law Celebrates Anniversary," and "APA Wants Parity Rules Clearer in Health Exchanges." Also see the Psychiatric Services study, "Effect of Insurance Parity on Substance Abuse Treatment."

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FDA Approves Long-Acting Extended-Release Hydrocodone Formulation

The Food and Drug Administration  (FDA) yesterday approved Zohydro ER (hydrocodone bitartrate extended-release capsules) for management of pain severe enough to require daily, around-the-clock, long-term treatment and for which alternative treatment options are inadequate.

Zohydro ER, a Schedule II controlled substance, is the first FDA-approved single-entity (not combined with an analgesic such as acetaminophen) and extended-release hydrocodone product. Due to the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, Zohydro ER should be reserved for use in patients for whom alternative treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain, according to the FDA.

Schedule II drugs can only be dispensed through a physician’s written prescription, and no refills are allowed. There are also stringent recordkeeping, reporting, and physical security requirements for Schedule II controlled substances.

For more information about how the government sets schedules for classifying opioid medications, see the Psychiatric News article, “AMA Delegates Debate Opioid Rescheduling.” To read about the role of psychiatrists in treating patients with chronic pain, see the article "Psychiatrists' Expertise Useful in Managing Chronic Pain."

Also see the book Clinical Manual of Pain Management in Psychiatry from American Psychiatric Publishing.

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FDA Approves Imaging Drug to Evaluate Alzheimer’s and Dementia

On Friday, the Food and Drug Administration (FDA) approved Vizamyl (flutemetamol) for use with positron emission tomography (PET) brain imaging in adults being evaluated for Alzheimer's disease (AD) and dementia. The approval was the FDA's second approval for a radioactive diagnostic drug used to detect images of beta-amyloid—a major mechanism in progression of AD. Amyvid was the first such drug approved. 

The effectiveness of Vizamyl was measured by two clinical trials with a total of 384 participants with varying degrees of cognitive function. All patients were injected with the drug and underwent PET imaging. Results showed that Vizamyl accurately detected beta-amyloid in the brain. In addition, the study confirmed that the scans were reproducible and could be interpreted accurately by trained readers. 

The safety of the radioactive drug was further established in 761 participants. Safety risk included hypersensitivity reactions and radiation exposure. Common side effects included flushing, headache, increased blood pressure, nausea, and dizziness.

Sandra Jacobson, M.D., an associate research professor at the University of Arizona College of Medicine, told Psychiatric News that "Flutemetamol is like florbetapir [Amyvid] and other compounds in the pipeline. The question now comes down to whether flutemetamol is superior to florbetapir. CMS asked for more evidence regarding florbetapir’s utility before further consideration of Medicare coverage. Will the same hold true for flutemetamol? At this point, it is too early to tell." Jacobson concluded that this FDA approval is an advancement for AD research and clinical work.

To read about other techniques used to evaluate AD and dementia, see the Psychiatric News article, "Lab Testing in Diagnosis of Alzheimer’s Disease: An Update."

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APA President Calls Research Funding Cuts 'Devastating'

In today's edition of his video series addressing key issues in mental health and its treatment, APA President Jeffrey Lieberman, M.D., discusses important scientific advances in understanding mental illness over the last several decades and how cuts in research funding are likely to stall future advances. At a time when talented researchers are devoting their careers to uncovering more of the brain's mysteries and should be attracting increased funding, "Federal investment in research through the National Institutes of Health is currently $4 billion lower than the peak year of 2003 and at the lowest level since 2001. These deep cuts have forced hard choices," Lieberman emphasized, "destructive choices amounting to wide-scale de-emphasis of clinically oriented, disease-relevant research."

He called the funding cuts "devastating" since their effect could be to delay crucial discoveries and erode the cadre of researchers working in this field. "It's time that our government aligns its policies with our national interests and scientific opportunities. We need to prioritize the health of the nation to protect and to support biomedical research," he said.

View the entire video, as well as other videos in the series, here.

Issues Cited by President Kennedy in 1963 Said to Still Affect Mental Health Policy

President John F. Kennedy’s 1963 Community Mental Health Act was signed 50 years ago, but it resonates with contemporary federal policy on mental health. Kennedy’s messages to Congress included references to financing mental health care in the same way as other medical services, the need to overcome mental health care disparities, a nod towards what would be called “recovery” today, and references to social determinants of health, said Substance Abuse and Mental Health Services Administrator Pamela Hyde, J.D., at the Kennedy Forum Inaugural Conference in Boston yesterday.

Thursday’s conference coincided with other current policy developments in the care of people with mental illness, added APA President Jeffrey Lieberman, M.D. “We have the Affordable Care Act being rolled out, the final rule on the mental health parity act being issued soon, and the symbolic inspirational power of the 1963 act, which was the first legislation to truly envision how mental health care could be provided in a much more humane and much more effective way in our society,” said Lieberman. (Lieberman is shown in the photo above with former U.S. Surgeon General David Satcher, M.D., at yesterday's forum.)

The Kennedy Forum's event on the 50th anniversary of the Community Mental Health Act was a major step, but not the last, said former member of Congress Patrick Kennedy, the late president's nephew, who convened the conference and who has spent his post-congressional career leading efforts to improve mental health and substance use research and services. To follow up, scientific, advocacy, and professional organizations are likely to unite to refine and clarify future directions for the public and Congress. “We need to determine what the policy priorities are, so we spend our time working on the things that have the greatest leverage to improve the whole world of mental health,” Kennedy stated.

To read more in about the work of Patrick Kennedy, see the Psychiatric News article "Kennedy Makes Suicide Concerns Focus of National Media Tour."

 (Photo: Aaron Levin, Psychiatric News)

Expert Discusses Problems of Comorbid ADHD, Substance Use Disorder in Adolescents

At the 60th annual meeting of the American Academy of Child and Adolescent Psychiatry this week in Orlando, Timothy Wilens, M.D., director of Substance Abuse Services in Pediatric Psychopharmacology at Massachusetts General Hospital, addressed issues at the intersection of attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs).

“Overall, [data show that] 23 percent of adults with substance abuse have ADHD,” said Wilens, but ADHD frequently goes undiagnosed in those who abuse substances. He presented research data indicating that the onset of SUD is 50 percent higher in individuals with untreated ADHD than in those without ADHD. Cigarette smoking and alcohol use were the most prevalent SUDs among this population, he said, and in some cases, use of stimulant drugs that treat ADHD symptoms resulted in reduced cigarette smoking, but did not affect level of alcohol use.

Wilens also discussed the misuse and diversion among adolescents of stimulant drugs that were prescribed to treat ADHD. According to a 2012 national survey, 13% of teenagers reported using stimulants nonmedically. Wilens said that adolescents with ADHD were five times more likely to misuse stimulant medications and 10 times more likely to sell their medication than were their peers without ADHD. In addition, he cited data showing that adolescents who were prescribed extended-release stimulants were less likely to report misuse.

When treating adolescents with comorbid ADHD and SUD, Wilens suggested that “it is best to sequence treatment, and treat the substance abuse first.” He also emphasized the importance of prescribing extended-release stimulants to avoid drug misuse among this population.

To read more about research concerning treatment for adolescents with comorbid ADHD and substance use disorders, see the Psychiatric News article “ADHD Meds May Not Cut Risk For Drug Abuse in Teens.” Also see the Textbook of Substance Abuse Treatment from American Psychiatric Publishing for more information on this topic.

(Image: Vabren Watts/ Psychiatric News)

Pioneer of Cognitive-Behavior Therapy Honored With New Award

Edward Kennedy Jr., son of the late Massachusetts senator who fought so long for mental health parity, presented Aaron Beck, M.D., with the first Kennedy Forum Community Mental Health Award for his work in developing cognitive-behavior therapy. Beck (shown in the center of the photo between APA President Jeffrey Lieberman, M.D., and APA CEO and Medical Director Saul Levin, M.D., M.P.A.) was honored Wednesday evening at a gala dinner held at the John F. Kennedy Presidential Library in Boston. Beck first became interested in mental illness in the years before passage of the Community Mental Health Act in 1963, he recalled. “Those were the ‘snakepit’ days, when they used insulin therapy and lobotomies."

The modern recovery movement, by contrast, seeks to reintegrate people with mental illness into the community, which not only can make them happier, more productive citizens, he said, but also often lessens the severity of their symptoms. “We don’t have to be so symptom oriented when we realize the patient is a real person,” Beck concluded.

With a nod to the World Series beginning across town as he spoke, Beck said that he originally became interested in depression because he was a Boston Red Sox fan in the years when the team was in the doldrums. Now that the team was in the World Series again, Beck thought he might have to switch to studying mania instead.

(image: Aaron Levin/Psychiatric News)

HHS Secretary Praises Parity Law, Says Final Rule to Be Issued Soon

The United States is approaching a long-sought mental health milestone, said Secretary of Health and Human Services (HHS) Kathleen Sebelius in Boston last night. “HHS will be getting the final parity rule out shortly,” she said, speaking to a packed audience at a Kennedy Forum gala held at the John F. Kennedy Presidential Library and Museum. The event commemorated the 50th anniversary of President Kennedy’s signing of the Community Mental Health Act of 1963. “The parity rule, in conjunction with implementation of the Affordable Care Act, will result in the largest expansion of behavioral health care in a generation,” Sebelius stated.

APA was represented at the event by President Jeffrey Lieberman, M.D., President-elect Paul Summergrad, M.D., and CEO and Medical Director Saul Levin, M.D.

Vice President Joe Biden also spoke at the event and lauded advances in brain research, but he noted that the persistence of stigma toward mental illness and its treatment keep people who need care from seeking it. “There are treatments for mental illness and substance abuse that go unused, and so many people still suffer silently,” Biden emphasized. “Too many young people never get connected with mental health care. And it’s not only the individual that suffers but the entire family.”

Former member of Congress and long-time mental health care advocate Patrick Kennedy also addressed the forum. “In 1963, the mentally ill were relegated to the shadows, and Americans with disabilities were institutionalized and told they’d never recover," he said. "President Kennedy said this was outright discrimination and wanted to return mental health care to the mainstream of American medicine. Together we must ensure not only the quality of mental health care but also the equality of that treatment."

To view a video of APA President Jeffrey Lieberman, M.D., discussing the Community Mental Health Act, as well as the recent parity law and the Affordable Care Act, click here.

(Image: Aaron Levin)

Expert Discusses Treatment of Adolescents, Young Adults With Treatment-Resistant Depression

At a popular session yesterday at the 60th annual meeting of the American Academy of Child and Adolescent Psychiatry in Orlando, Fla., Karen Wagner, M.D., Ph.D., director of child and adolescent psychiatry at the University of Texas Medical Branch at Galveston, provided insights into the management of treatment-resistant depression in children based on her extensive research in this field.

Giving an overview of her work and that of other researchers, Wagner presented data involving the incorporation of cognitive-behavior therapy (CBT) with pharmacological agents in young adults with treatment-resistant depression. The data show that combining CBT with certain selective serotonin reuptake inhibitors can increase response rates by 10 percent or more, higher than medication therapy or CBT alone. Wagner also emphasized that the addition of CBT was twice as effective in depressed children who have been abused, compared with their counterparts who did not receiving CBT.

In addition, Wagner highlighted therapies that have recently been shown to be effective in treating young adults with treatment-resistant depression, including exercise, bright light treatment therapy, and video gaming.

Wagner urged using caution when prescribing medications that have not been thoroughly studied in children and adolescents, including vilazadone and ketamine. She advised clinicians to allow their patients, and parents of patients, to research the drugs that have been recommended prior to beginning treatment with them. “I do not give medication on the first day…I want them to read about the medication," said Wagner. She emphasized as well that it is “important to increase the knowledge about the role psychotherapy to improve the outcome in patients.”

For more information about adolescent depression, see the Psychiatric News article "Most Young Girls With Depression Fail to Receive Treatment". Also see the book Cognitive-Behavior Therapy for Children and Adolescents from American Psychiatric Publishing.

(image: Vabren Watts/Psychiatric News)

APA Leaders Join National Leaders at Kennedy Forum Mental Health Summit

APA President Jeffrey Lieberman, M.D. (left), President-elect Paul Summergrad, M.D., CEO and Medical Director Saul Levin, M.D., M.P.A., and Assembly Speaker Melinda L. Young, M.D., are joining Vice President Joe Biden and Health and Human Services Secretary Kathleen Sebelius at the Kennedy Forum's inaugural events today and tomorrow to celebrate the 50th anniversary of President John F. Kennedy's Community Mental Health Act.

The goal of the forum, which is headed by former member of Congress Patrick Kennedy, "is to unite the mental health community to engage in a national dialogue and to advocate for future breakthroughs in policies affecting those with mental illness, disabilities, and addictions."

Tonight's gala will be followed by several panel discussions tomorrow, including one on public health and community approaches to mental illness that will be moderated by Chelsea Clinton, vice chair of the Clinton Foundation. Summergrad will moderate a session on securing policy and measuring progress, and Lieberman will lead the conference's closing session on the future of mental health care and the prospects for fulfilling the goals of the 1963 Community Mental Health Act. Lieberman commented that "APA looks forward to future collaboration with Congressman Patrick Kennedy in working to secure a final parity rule and ensuring that our patients receive the quality mental health care that they need and deserve." Kennedy is a senior strategic advisor to APA.

Tonight's gala will be live streamed at 7:30 Eastern time, and a recording of the conference will be made available at www.thekennedyforum.org. Also see a commentary by Kennedy, John Greden, M.D., and Michelle Riba, M.D., in American Journal of Psychiatry titled "The Next 50 Years: A New Vision of 'Community Mental Health.' "

Sleep Duration May Be Associated With Brain Deposits Linked to Alzheimer's

Shorter sleep duration among community-dwelling older adults appears to be associated with greater build-up in the brain of beta-amyloid (Aβ), the protein that has been shown to be strongly associated with development of Alzheimer’s disease.

That’s the finding from a study of 70 adults (average age 76) from the neuroimaging substudy of the Baltimore Longitudinal Study of Aging, published online yesterday in JAMA Neurology. The study was conducted by researchers from Johns Hopkins University School of Medicine and Bloomberg School of Public Health. In the study, the respondents self-reported their nightly sleep duration. β-amyloid burden was assessed using positron emission tomography. After adjusting for potential confounders, the researchers found that reports of shorter sleep duration were associated with greater Aβ burden.

“Additional studies with objective sleep measures are needed to determine whether sleep disturbance causes or accelerates Alzheimer disease,” the researchers pointed out.

For more on research into Alzheimer's disease causes and prevention, see the Psychiatric News article, “For Now, Preventive Efforts Are Best Alzheimer’s Weapon.” Also see The American Psychiatric Publishing Textbook of Alzheimer Disease and Other Dementias.

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APA Journal Launches "Assessing the Evidence Base" Series for Mental Health, Substance Abuse Services

The APA journal Psychiatric Services yesterday launched the “Assessing the Evidence Base for Behavioral Health Services” Series to provide science-supported information about selected mental health and substance abuse services for health care leaders as they implement new benefit packages as part of health care reform.

The series reviews research on 14 behavioral health services: behavioral management for children and adolescents, trauma-focused cognitive-behavioral therapy for children and adolescents, recovery housing, residential treatment for individuals with substance use disorders, peer-support services for individuals with serious mental illness, peer-recovery support for individuals with substance use disorders, permanent supportive housing, supported employment, substance abuse intensive outpatient programs, skill building, intensive case management, consumer and family psychoeducation, medication-assisted treatment with methadone, and medication-assisted treatment with buprenorphine.

The reviews are commissioned by the Substance Abuse and Mental Health Services Administration through a contract with Truven Health Analytics and conducted and written by experts in each topic area. Each article was peer reviewed by a special panel of Psychiatric Services reviewers.

Accompanying an introduction to the series is the first review: "recovery housing." That review, by Sharon Reif, Ph.D., of the Institute for Behavioral Health at the Heller School for Social Policy and Management at Brandeis University, and colleagues, found that the level of evidence for recovery housing was moderate. "Studies consistently showed positive outcomes, but the results were tempered by research design limitations, such as lack of consistency in defining the program elements and outcome measures, small samples, and single-site evaluations, and by the limited number of studies," they found. "Results on the effectiveness of recovery housing suggested positive substance use outcomes and improvements in functioning, including employment and criminal activity."

See the first article, "Recovery Housing: Assessing the Evidence." Also see the book “How to Practice Evidence-Based Psychiatry: Basic Principle and Case Studies,” from American Psychiatric Publishing.

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Antisocial Behavior Prior to Psychosis Points to Later Risk for Violence, Study Suggests

Individuals who engage in antisocial behavior before showing symptoms of schizophrenia are more likely to be violent after a first schizophrenia episode occurs, a new prospective study reported in JAMA Psychiatry has found. The study was conducted by Catherine Winsper, Ph.D., and psychiatrist Swaran Singh, M.D., of the University of Warwick in England and colleagues.

The study included 670 young adults being treated for a first episode of psychosis. The subjects were divided into four groups depending on whether they had engaged in antisocial behavior before their first psychotic episode or not, and if so, to what degree. The researchers then followed up to see which subjects committed violence and  compared the four groups regarding their antisocial behavior histories. Subjects who had engaged in moderate or high levels of antisocial behavior on a regular basis before their first psychotic episode were four times as likely to engage in violence as were subjects who had engaged in little or no antisocial behavior before experiencing their first psychotic episode.

 "These data have implications for violence prediction and treatment in patients with schizophrenia," Paul Appelbaum, M.D., told Psychiatric News. "[They] suggest that treatment targeting psychotic symptoms in higher-risk patients may not be enough to prevent violent behavior—interventions aimed specifically at propensities for violence may be needed as well." Appelbaum is a former APA president and is the Dollard Professor of Psychiatry, Medicine, and Law at Columbia University. He is chair of the APA Committee on Judicial Action.

"Simply put, these data point out that youth with a history of delinquent behaviors and a vulnerability for psychosis are clearly at risk for behaving violently once that vulnerability becomes expressed as a first episode of schizophrenia," Thomas McGlashan, M.D., observed. McGlashan is a professor of psychiatry at Yale University and an expert on the prodromal phase of schizophrenia. "For this subsample of young people, early detection and intervention at the pre-onset of prodromal phase of the disorder may be doubly protective by preventing not only the onset of psychosis, but also the perpetration of any associated...antisocial behaviors."

More information about the link between antisocial behavior, violence, and psychosis can be found in the Psychiatric News articles "High Rates of Mental Illness Associated With Gang Membership" and "Threat Delusions Linked to Violence in First Episode Psychosis."

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Study Finds Antiseizure Drug Promising in Treating Cocaine Addiction

New data suggest that the antiseizure medication topiramate could be a future option in treating cocaine addiction, a study headed by Bankole Johnson, M.D., Ph.D., chair of psychiatry at the University of Maryland and published in JAMA Psychiatry suggests. Johnson led a randomized, double-blind, placebo-controlled trial that included 142 cocaine-dependent subjects and lasted 12 weeks. The results showed that topiramate was significantly more effective than placebo in decreasing craving, reducing cocaine use, and improving global functioning. In short, "We have some great news on a treatment for cocaine dependence," Johnson told Psychiatric News.

"Finding a safe  and effective medication (or vaccine) for the treatment of cocaine-use disorder has been the holy grail of our field for decades," Petros Levounis, M.D., chair of psychiatry at Rutgers New Jersey Medical School and an addiction psychiatrist, said in an interview. "Every few years, an exciting possibility appears on the pharmacotherapy scene, only to fizzle out a little later. For a long time, topiramate has been thought of as one of the more promising medications for the treatment of cocaine addiction, and the present study supports this notion. We hope that our current optimism for the success of topiramate is not once again short-lived. Had the study been longer than 12 weeks, our confidence in the reported encouraging results would be considerably higher."

More information about treating addiction can be found in the American Psychiatric Publishing book Cocaine and Methamphetamine Dependence Advances in Treatment. For recent research in this area, also see the Psychiatric News article, "Scientists Closer to Finding Drugs to Treat Addiction."

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Playing Video Games May Increases Cognitive Control in Seniors, Study Finds

While studies have pointed to negative consequences of children’s excessive video-game playing, when adults try their hand at these games, it may increase their cognitive control, according to a Nature study featured in "Journal Digest" in today's  Psychiatric News.

Researchers at the University of California, San Francisco, created a 3-D racecar video game that measured cognitive control in adults who were instructed to notice specific road signs while driving full speed—virtually. After one month of video-game participation, adults aged 60 to 85 were evaluated for alterations in multitasking, working memory, and attention sustainment. Results showed that multitasking capabilities, working memory, and attention sustainment were dramatically increased and sustained six months after the video-game training. In addition, multitasking capabilities of seniors surpassed that of young adults who played the game for the first time.

The authors noted that this is the first study to show how custom-designed video games can be used to assess cognitive abilities across the lifespan. If the research is replicated, this could be a beneficial application to other brain-related disorders such as attention-deficit/hyperactivity disorder, depression, and dementia, which are also associated with deficits in cognitive control, the authors concluded.

To read more about emerging therapies for cognitive disorders and factors that may contribute to cognitive disorders, see the Psychiatric News articles "New Target Emerges in Search for Alzheimer’s Treatment" "Hearing Loss in Seniors Linked to Cognitive Decline."

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Change, Challenge, and Opportunity: Psychiatry Through the Looking Glass of Research

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. This column was written by Steven Hyman, M.D., and Dr. Lieberman.

The first two articles in this series addressed the prospect of change in psychiatric medicine and mental health care and the anticipated effects, in this regard, of health care reform. In this article we discuss the current status of biomedical research and how it will impact our field and practice.

The research enterprise has brought clinical psychiatry to an exciting but treacherous juncture. Based on remarkable new tools and technologies in genetics and neuroscience, there has been an explosion of new knowledge about the etiology and neural underpinnings of schizophrenia, bipolar disorder, Alzheimer’s disease, autism, addictions, and other serious conditions. Indeed, the fields of psychiatric medicine and mental health care are poised on the brink of transformative advances in diagnostic methods and therapeutic modalities. However, just at the time when biomedical research is gaining significant traction and momentum in understanding the brain and mental disorders, support for all research, and most importantly biomedical research funded by the National Institutes of Health, is painfully contracting, the result of congressionally driven budget cuts. Just as scientific opportunity in our field is waxing, the ability to exploit it is waning.

The recent budget sequestration has had a huge negative effect, but is part of a larger pattern of what has been eroding the support for research in the United States. The decline in research funding affects all of medicine, but psychiatry faces a special problem. Since 2010, the pharmaceutical industry has substantially retreated from research on psychiatric disorders despite years of commercial success with antidepressants and antipsychotic drugs.

To read more, including advances in genetics and stem-cell research, click here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman. To do so, go to https://twitter.com/DrJlieberman, log in or register, and click on “Follow.”

Study Finds Link Between Schizophrenia and Autoimmune Diseases

New data show that individuals with schizophrenia are at increased risk of developing autoimmune diseases, according to a study reported yesterday in AJP in Advance. The study, "A Nationwide Study on the Risk of Autoimmune Diseases in Individuals With a Personal or Family History of Schizophrenia and Related Psychosis," led by Michael Benros, M.D., Ph.D., of Denmark's Aarhus University and the Mental Health Center Copenhagen, suggests that "The increased risk of subsequent autoimmune diseases in individuals with schizophrenia may involve neuropsychiatric manifestations from the undiagnosed autoimmune disease, medical treatment or lifestyle associated with schizophrenia, or common etiological mechanisms, such as infections and shared genetic factors."

Benros and colleagues noted that prior research has shown an increased risk of schizophrenia in those with autoimmune diseases, but that theirs is the first study to investigate the link between schizophrenia and subsequent development of an autoimmune disease "and to consider the effect of infections, a possible risk factor for both schizophrenia and autoimmune diseases." They analyzed data from Danish nationwide registers that included 3.8 million people from which they identified 39,364 with "schizophrenia-like psychosis" and 142,328 with autoimmune disease. They found that "individuals with schizophrenia had an elevated risk of subsequent autoimmune diseases, with an incidence rate ratio of 1.53." Their analysis also found that "For individuals with schizophrenia as well as hospital contacts for infections, the combined risk of autoimmune diseases was 2.70."

To read more about research on links between schizophrenia and infections, see the Psychiatric News articles "Immune System Protein Could Give Clue to Late-Onset Schizophrenia" and "Psychiatrist Hunts for Evidence of Infection Theory of Schizophrenia."

(image: Kheng Guan Toh/Shutterstock.com)

APA Issues Updated Guide to Help Psychiatrists Manage HIPAA Rules

APA this week released an updated version of its publication “Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule Manual: A Guide for Psychiatric Practices.”

HIPAA compliance can be a complicated and confusing venture, which is why the manual was revised, said Matthew Sturm, an associate director in APA’s Department Of Government Relations. In addition to a thorough explanation of HIPAA regulations, the manual includes step-by-step instructions, checklists, template forms, patient notices, and a list of frequently asked questions. The manual also cross-references useful APA-developed materials on HIPAA issues such as treatment of psychotherapy notes and “minimum necessary” disclosure standards. It also reflects new requirements related to issues such as patient notification after breaches of security and accounting for disclosures by electronic systems.

The revised manual includes a reminder to physicians from the Department of Health and Human Services (HHS) that the HIPAA privacy rule is not an iron-clad barrier to sharing health information appropriately. “[The] Rule does not prevent your ability to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when you believe the patient presents a serious danger to himself or other people,” wrote Leon Rodriguez, director of the HHS Office for Civil Rights, in January following the Newtown school shooting.

The manual is available at no cost to APA members.

The manual and other APA-provided HIPAA resources are posted at http://www.psychiatry.org/hipaa/.

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Social Support Does Little to Buffer Effects of Poverty on Depressive Symptoms, Study Finds

Poverty remains a factor linked to depression for mothers, even for those who have established good social and personal supports. A study of nearly 2,000 mothers of young children in Chicago found that depressive symptoms were strongly associated with lower household income, higher degree of financial strain (difficulty obtaining and paying for food, rent, or medical care), and lower neighborhood socioeconomic status, wrote Sharon Kingston, Ph.D., an assistant professor of psychology at Dickinson College in the October American Journal of Community Psychology.

Married women had fewer depressive symptoms than single mothers, but being married did not affect the link between economic adversity and depression.

“Perceived social support decreased depressive symptoms for residents living in all neighborhoods, but the effects of social support were weakest in neighborhoods characterized by low socioeconomic status,” said Kingston. “[T]he results suggest that directly addressing economic conditions may be more effective than efforts to change parents’ interpersonal context.”

For more information about the relationship between mental health and poverty and other social determinants, see the Psychiatric News articles, "Psychiatrist Exposes How Public Policies Have Devastated Health of Communities" and "Antipoverty Experiment Boosts Subjective Well-Being." Also see the reports "The Hotel Study: Multimorbidity in a Community Sample Living in Marginal Housing" in the American Journal of Psychiatry and "Comparing Neighborhoods of Adults With Serious Mental Illness and of the General Population: Research Implications" in Psychiatric Services.

 

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Psychiatrists, Judges Discuss Mental Health Treatment in the Judicial System

Fifty leading judges and psychiatrists from across the country met in Philadelphia at the APA Institute on Psychiatric Services this past weekend to begin developing strategies to improve outcomes for individuals with mental health needs in the criminal justice system.

As part of an ongoing collaboration, the Judicial-Psychiatric Leadership Forum was convened by the Judges’ Leadership Initiative for Criminal Justice and Behavioral Health and the Psychiatric Leadership Group for Criminal Justice and was coordinated by the American Psychiatric Foundation and the Council of State Governments Justice Center.

“The progress made at this forum is an important step forward in addressing the needs of people with mental illnesses who become entangled in the criminal justice system. The cost of incarcerating rather than treating people with mental illness both in financial and human terms is exorbitant and unnecessary,” said Miami-Dade County Judge Steve Leifman, cochair of the Judges Leadership Initiative.

Psychiatrist Fred Osher, M.D., director of the Center for Health Systems and Services Policy for the Council of State Governments Justice Center, added, “It is critical that psychiatrists engage judges in a dialogue to identify effective strategies that result in improved public health and safety outcomes. It is a shared set of concerns that require a shared vision and collaboration to have the largest impact.” (Pictured above speaking at the institute are, from left, Leifman, Osher, and former Ohio Supreme Court Justice Evelyn Stratton, J.D.)

An estimated 17% of people admitted to jail have serious mental disorders—more than three times the rate in the general population, and nearly 70% of adults in jails and prisons have a substance use disorder. For more information on this topic, see the Psychiatric News articles "Combined Effort Needed to Prevent Incarceration of Mentally Ill People" and “Judges Get Help Handling Mentally Ill Defendants.”

(Image: Aaron Levin)

Racial Disparities in Mental Health Services Persist, Study Shows

Disparities in receipt of outpatient mental health services between white and nonwhite individuals have continued to be large and have not shown improvement over a 15-year period.

That’s the finding from the report "Racial-Ethnic Disparities in Outpatient Mental Health Visits to U.S. Physicians, 1993–2008" based on data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey and published online today in Psychiatric Services in Advance. Researchers from Columbia University and Brown University estimated annual visit prevalence for three racial-ethnic groups—non-Hispanic whites, non-Hispanic blacks, and Hispanics—as the number of visits divided by the group’s U.S. population size. Analyses were stratified by diagnosis, physician type, patient characteristics, and year.

Total annual prevalence rates for mental-health-related physician visits were 197 visits per 1,000 population for non-Hispanic whites, 118 for non-Hispanic blacks, 114 for Hispanics, and 90 for non-Hispanic others. Non-Hispanic blacks were treated markedly less frequently than whites for obsessive-compulsive, generalized anxiety, attention-deficit/hyperactivity, personality, panic, and nicotine use disorders but more frequently for psychotic disorders. Hispanics were treated far less frequently than whites for bipolar I, impulse control, autism spectrum, personality, obsessive-compulsive, and nicotine use disorders but more frequently for drug use disorders.

For more information about mental health and minority groups, see the Psychiatric News article, "To Understand Mental Health Disparities, Look to R.I.C.E. not Race."

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Children With Autism Need to Be Taught Skills for Adult Life, Expert Says

In the past, autism was seen as a disorder of very young children. But children grow up, and far too little is known about autism in adults, said Fred Volkmar, M.D., a professor of psychiatry and director of the Yale Child Study Center, speaking Saturday at the APA Institute on Psychiatric Services in Philadelphia. Autism is a disorder characterized by considerable variability, he noted, "and it has a tremendous range within the person, across populations, and across time."

Preparing adolescents to transition to an adult world calls for more than using interventions originally tailored for children, Volkmar said. “Adaptive skills must be taught explicitly,” he said, recounting one patient who could do complex mathematics in his head but could not order a hamburger and count the change.

The educational transition takes work, too. College students are not covered by the same laws as elementary and high school students. If college students self-identify as having autism under the Americans with Disability Act, they can receive certain services and accommodations. But many don’t do that and may behave in ways that get them dismissed from school, Volkmar noted.

People with autism may also develop both physical and psychiatric problems as they age. They appear to have increased mortality from accidents. A sedentary lifestyle (and some medications) may increase risk of obesity. Anxiety and depression are increasingly prevalent as well. “Much more research focused specifically on this cohort is needed in order to provide the evidence base for their lifelong care,” Volkmar emphasized.

Watch a video interview with Fred Volkmar, M.D., here. 

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U.S. at Decisive Moment in History of Mental Health Treatment, Kennedy Says

Parity for treatment of mental illness and substance abuse is a human- and civil-rights issue, said former congressman Patrick Kennedy last night during a “Conversations” event with APA President Jeffrey Lieberman, M.D., at the APA Institute on Psychiatric Services. “Conversations” is an annual event at APA meetings sponsored by the American Psychiatric Foundation.

Kennedy and Lieberman spoke for over an hour before a packed hall, and the former congressman, who was instrumental in helping to pass the landmark 2008 parity bill, discussed his own journey toward understanding the importance of equal treatment for mental illness and substance abuse. He recounted his mother’s struggle with alcoholism and his problems with addiction, as well as his Aunt Rosemary’s intellectual disability, saying that within his own family mental illness and substance abuse were “the elephant in the living room that no one talked about.” And he recalled how during his political career he parked his car three blocks away from his psychiatrist’s office to avoid being recognized. And yet, ironically, he found himself, along with his late father, Sen. Edward Kennedy, being a champion of the 2008 federal parity law.

Kennedy emphasized that now—with a “final rule” from the government that will provide a regulatory framework for implementing the 2008 law expected very soon—is a decisive moment. He said transparency in the way insurance companies make medical-necessity decisions will be crucial to ensuring the full implementation of parity. “The exciting thing for all of you is that with health care reform, we are rewriting the rules,” Kennedy emphasized. “Organizations like APA need to be even more aggressive than ever before, because we are at a formative point….This is the moment in history when we really have the opportunity to change the landscape.”

(Image: Ellen Dallager)

Building Alliances Key to Recovery Model in Philadelphia

Philadelphia’s template for transforming its public mental health system has used a recovery model that has upended the traditional approach to care.

“Our first goal is to optimize treatment based on strong empirical evidence but also to individualize treatment with regard to co-occurring conditions and cultural issues,” said Arthur Evans, Ph.D., commissioner of the city’s Department of Behavioral Health and Intellectual disAbility Services.

However, other areas of a patient’s life, such as housing, education, or community, also play a significant role in the recovery process, said Evans today at APA's Institute on Psychiatric Services in Philadelphia. His department has consistently built alliances with community groups throughout the city, tying behavioral health providers together with religious organizations and other local groups. Those nonclinical entities provide a sense of community, critical social support, and a way to connect people to services when needed.

Another key element of Philadelphia’s recovery approach is the heavy involvement of peers in the department’s operations at every level, said Evans. Peers in recovery from mental illness or substance abuse welcome newcomers to community drop-in sites or clinics, but also follow up with clients to keep them engaged in treatment and provide role models.

Evans has also instituted important fiscal and administrative changes for the $1 billion system to maintain standards and keep staff and providers focused on the broader recovery model.

“We developed a set of practice guidelines to drive any kind of services and then base our credentialing process on an understanding of those policies and procedures,” he said. It’s been a long, but cooperative process, since Evans took on the job in 2004.

“All the work we’ve done, we’ve done together as providers, consumers, and administrators,” he said.

For more information, see a study published in Psychiatric Services that was conducted in Philadelphia and shows that people trying to recover from serious mental illness face numerous obstacles in their poor neighborhoods.

(Image: Ellen Dallager)

Psychiatrist-Patient Relationship Becomes More Meaningful When Mental Illness Persists, Author Says

For patients with severe and mental illness that has persisted over many years, a psychiatrist may be the patient’s only stable and lasting relationship as friends and family drop away. 
 
That’s what author Jay Neugeboren told psychiatrists today at APA's 65th Institute on Psychiatric Services in Philadelphia at the session on “What Families Need from Psychiatrists.”

Neugeboren is the author of Imagining Robert, which describes his relationship with his brother Robert, who has been in and out of psychiatric treatment facilities and institutions for decades. In another of his books, Transforming Madness, he recounted interviewing men and women who had once been institutionalized but had gone on to lead productive lives. While many factors may have contributed to recovery, what he said was common to all stories of recovery was a lasting and important relationship.

But Neugeborn said that for some patients who have had severe mental illness for years and years, resulting in multiple hospitalizations, family and friends sometimes drop away. He described his many visits to his brother at treatment facilities, including a residential treatment facility when Robert was living with other people with mental illness, and said that he was often the only family member visiting.

“When the condition goes on and on, family and friends drop away,” he said. “That means the responsibility of the psychiatrist is greater—but you should see it as an opportunity. Generally, people with very severe mental illness that has lasted for years don’t have people to rely on. You as the psychiatrist become the constant when family members drop away.” 

For more information, see "Personal Accounts: Mental Disorders: Pathways to Hope . . . ?" by Neugeboren in Psychiatric Services.

(Image: Mark Moran)