Cognitive Deficits Precede First Episode of Schizophrenia, Study Shows

Further evidence that cognitive deficits appear in individuals at risk for psychosis well before the first episode of acute psychosis appears comes from a study published online in Schizophrenia Research. Researchers in the Department of Psychiatry at the Istanbul Faculty of Medicine in Turkey compared cognitive functions of 52 individuals at ultra high risk (UHR) for psychosis, 53 patients who had a first episode of psychosis (FES), their 30 healthy siblings (who were considered to be at familial high risk, FHR), and 35 healthy controls with no familial risk.

The researchers found that the FES group had worse neuropsychological performance than did controls on all of the cognitive domains measured, and the UHR group had worse performance on three of them—verbal learning, attention, and working memory—than did controls. They also found that individuals with familial risk had worse performance on executive functions and measures of attention than did the control group. In addition, the FES group had lower global composite scores than did the UHR group and scored worse on a measure of sustained attention than did their siblings in the FHR group.

The researchers concluded that their findings "suggest that cognitive deficits in schizophrenia may start before the first episode, since cognitive functions were similar among FHR, UHR, and FES groups. Our aim as a next step is to detect cognitive predictors of transition to psychosis in both groups in a study with a longitudinal design and with larger sample size."

For research on improving cognitive function in patients with schizophrenia, see the Psychiatric News article, "Optimism Grows About Potential to Aid Schizophrenia Cognition." For a review of assessment and treatment issues in schizophrenia, see American Psychiatric Publishing's Clinical Manual for Treatment of Schizophrenia. And for a recent study on this topic, see the American Journal of Psychiatry report "Anatomical and Functional Brain Abnormalities in Drug-Naïve First-Episode Schizophrenia."

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Autistic Traits Are Stable Across Childhood and Largely Influenced by Genetics, Study Shows

Autistic traits appear to be highly stable across middle childhood, and this stability is attributable primarily to genetic factors, according to a report published online in the Journal of the American Academy of Child and Adolescent Psychiatry.

In the study, more than 6,000 twin pairs were rated on a scale of autistic traits by their parents at ages 8, 9, and 12 and by their teachers at ages 9 and 12. Participants came from the Twins Early Development Study, a population-based longitudinal study of all twins born in England and Wales from 1994 to 1996. Included in the study population were 238 children who had suspected or confirmed autism spectrum disorder (ASD) based on the Development and Well-Being Assessment.

Study results indicated that, consistently across raters, not only were autistic traits stable and moderately to highly heritable at individual ages, but there was also a high degree of overlap in genetic influences across age. Furthermore, autistic trait stability could largely be accounted for by genetic factors, with the environment unique to each twin playing a minor role.

“The findings of the present study have important implications for understanding ASD,” the researchers said. “They suggest that autistic traits are not just highly stable across middle childhood, but that this stability is caused largely by genetic influences in both boys and girls. This implies that…stability is a biological characteristic of autistic symptoms, as opposed to, for example, being due to shared environmental factors."

For comprehensive information about ASD, see American Psychiatric Publishing's Textbook of Autism Spectrum Disorders and Autism and Other Neurodevelopmental Disorders. For more on this subject, see the Psychiatric News article “Some Children Eventually Lose ASD Diagnosis.”

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APA Journal Focuses on Psychotherapies for Organ-Transplant Candidates

The fall issue of Focus—APA's journal of lifelong learning—is devoted to expanding psychiatrists' medical knowledge and thus easing their transition into the world of integrated care. One of the articles is devoted to the psychiatric aspects of organ transplantation. The lead author is Andrea DiMartini, M.D., an associate professor of psychiatry at the University of Pittsburgh and an expert on this subject.

Several psychotherapies have been developed or adapted for organ-transplant candidates, especially while they are waiting for a transplant, DiMartini and her colleagues noted. Some of these interventions have also been tested and found effective. For example, quality of life therapy is a form of cognitive-behavioral therapy that has been found, in individuals waiting for a kidney or lung transplant, to reduce psychological stress, lead to more social intimacy, and improve the quality of patients' lives.

If patients experience neuropsychiatric symptoms following transplantation, the symptoms might be due to immunosuppressive medications, DiMartini and her colleagues pointed out. For example, corticosteroids that are used soon after transplant surgery to augment immunosuppression and treat episodes of acute rejection may produce mood lability, insomnia, or cognitive disturbances. However, contrary to common belief, such symptoms are not more common in patients with preexisting psychiatric disorders.

More information about the psychiatric aspects of organ transplantation, such as the psychosocial evaluation of prospective donors or which patients should receive a transplant, can be found in the Focus article "Psychiatric Aspects of Organ Transplantation" or in the Psychiatric News article, "How Critical Is Mental Health in Transplant Decisions?"

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Study Describes Factors That Differentiate OCD From OCPD

Although obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) share some characteristics and genetics, they are distinct disorders, a new study indicates. Both are impairing disorders marked by compulsive behaviors, but they can be differentiated by the presence of obsessions in OCD and by the capacity to delay reward in OCPD. The study's senior researcher was H. Blair Simpson, M.D., Ph.D., a professor of psychiatry at Columbia University. The results appear in Biological Psychiatry.

The findings come with clinical implications, Simpson told Psychiatric News. For example, there are no evidence-based treatments for individuals with OCPD. But given that the ability to delay reward has been linked by other researchers with a heightened activation of the dorsolateral prefrontal  cortex, "our findings suggest potential brain-behavior relationships in OCPD, providing support for future imaging studies and the development of novel pharmacologic and psychosocial strategies to modulate excessive self-control."

Information about OCD's description and classification in DSM-5 can be found in the American Psychiatric Publishing book Obsessive-Compulsive Spectrum Disorders: Refining the Research Agenda for DSM-5.

Although individuals with OCPD are often impaired in psychosocial functioning and quality of life, they sometimes also achieve remarkable successes. A prime example is Noah Webster who was  driven by a need for order and who, for 30 years, worked at creating a dictionary of the English language. Read more about him in the Psychiatric News article "Biographer Explores Character, Pathology, and Achievement."

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American Heart Association Discusses Dementia Risk Factors at Annual Meeting

Though elevated levels of apolipoprotein E (APOE) was initially recognized as a protective factor against cardiovascular disease, accumulating evidence suggest that APOE abundance may have the same protective role in warding off neurocognitive disorders. This week at the 2013 American Heart Association’s Scientific Sessions held in Dallas, Danish researchers from the Copenhagen University Hospital presented data showing that low plasma levels of APOE were associated with increased risk for Alzheimer’s disease (AD) and dementia, regardless of the presence or absence of the APOE epsilon 4 (e4) allele—a trait that is suggested to heighten risk for AD and dementia. 

The study included nearly 80,000 participants that were placed into tertiles based on APOE plasma concentrations. Individuals with the lowest plasma levels of APOE had a risk for dementia three times greater than those who had the highest levels of plasma APOE. This remained significant after adjustment for the APOE e4 genotype. Participants with low plasma APOE also had increased risk for cardiovascular disease.

Ruth Frikke-Schmidt, M.D., Ph.D., the study’s lead investigator and a professor in the Department of Clinical Biochemistry, speculated that low levels of plasma APOE reflect low APOE activity in the brain, which will result in less beta-amyloid being cleared—similar to fatty acid clearance in the cardiovascular system.

Frikke-Schmidt said that this is the strongest evidence, to date, showing that APOE levels can affect dementia independent of genotype. “[Currently] we do not have any biomarkers for dementia....This suggest that plasma levels of APOE may be a new preclinical plasma biomarker for dementia,” she concluded. 

To read more about APOE, see the Psychiatric News articles "Exercise Found to Reduce Amyloid Plaques in Brain" and "Research Shows Importance of Studying Different Ethnic Groups." More information about dementia and AD can be found in Clinical Manual of Geriatric Psychopharmacology, Second Edition, by American Psychiatric Publishing.

(Image courtesy of the American Heart Association)

Former APA President Reflects on the Day of President Kennedy’s Assassination

“Nothing in my training or life experience prepared me adequately for such a moment—having to give the sister of the president such a report,” said Joseph T. English, M.D., a former APA president who shares his detailed account of the day when President John F. Kennedy was killed, in Psychiatric News. English, who was serving as the first chief psychiatrist of the United States Peace Corps at the time, was in the presence of Sargent Shriver, director of the Peace Corps, and Shiver’s wife, Eunice, the president’s sister.

“The three of us gathered in Mr. Shriver’s office, where wire service reports were given to us.…The first one reported a head wound, and a few minutes later …the one that said the president had expired....”

English also discusses his role in the organization of President Kennedy’s funeral, was personally asked by First Lady Jacqueline Kennedy to view the body of her late husband, and was asked to join world leaders in walking behind the president’s casket from the White House to St. Mathew’s Cathedral.

Since that time, English went on to become one of the most influential leaders in psychiatry. Among many other positions, he was the first psychiatrist to serve as a board member on the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), first president and CEO of the New York Health and Hospital Corporation, and a leading light for psychiatry at the AMA. English currently serves as the Sidney E. Frank Professor and Chair of the Department of Psychiatry and Behavioral Sciences at New York Medical College.

To read the Psychiatric News article of English’s reflection of the day President Kennedy was assassinated, click here. Also see "Joseph T. English, M.D., one hundred twenty-first president, 1992-1993" in the American Journal of Psychiatry.

Study Finds Gabapentin May Be Effective in Treating Alcohol Dependence

Researchers at the Scripps Research Institute report data suggesting that the anticonvulsant drug gabapentin may be effective in the treatment of some patients with alcohol dependence and the relapse-related symptoms of insomnia, dysphoria, and craving, with a favorable safety profile. The study was headed by Barbara Jason, Ph.D., and the findings, published in JAMA Internal Medicine, are based on data from a 12-week randomized, double-blind, placebo-controlled study of 150 subjects with alcohol dependence.

"This is an impressive and revealing study," Marc Galanter, M.D., a professor of psychiatry and director of the Division of Alcoholism and Drug Abuse at New York University, told Psychiatric News. "The authors, however, point out that approved medications are prescribed for only 9% of American alcoholics. Why is this? One reason is that for addiction, a chronic disease, clinicians are most likely to use medications with a demonstrated long-term impact, like buprenorphine for opioid dependence. The impact of gabapentin on alcoholism (like that of naltrexone) is a meaningful, but still limited step toward this goal."

On the other hand, as the researchers point out in their report, "Unlike other approved treatments for alcohol dependence that are prescribed by a small number of specialists, gabapentin may be more readily utilized by primary care physicians."

Information about how the outcome of alcoholism treatment may be determined by a person's genetics can be found in the Psychiatric News article "Genes May Determine Drugs' Alcohol-Treatment Success." Extensive information about alcohol dependence and medications to treat it can be found in the new American Psychiatric Publishing book, Clinical Manual of Addiction Psychopharmacology, Second Edition. Also see the report
"Gabapentin Combined With Naltrexone forthe Treatment of Alcohol Dependence" in the American Journal of Psychiatry.

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Collaborative Care: An Integral Part of Psychiatry's Future

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. This column was written by Dr. Lieberman and Jurgen Unutzer, M.D. Please send your comments to pnupdate@psych.org.

In 1974, music critic Jonathan Landau penned a classic article in which he stated, “I have seen the future of rock and roll and its name is Bruce Springsteen.” Landau was commenting on his impression of the debut album of the then-fledgling rock star. If you will permit my imaginative analogy, I believe that the same can be said about the collaborative care model with respect to the future of psychiatry. For this reason I invited Jürgen Unützer to co-author this column for Psychiatric News. 

With the enactment of the Affordable Care Act, the rise of accountable care organizations and patient-centered medical homes, and the increased national attention on mental health, psychiatrists and primary care providers have an unprecedented opportunity to join together and work collaboratively on increasing the overall health of millions of Americans. APA recognizes this opportunity and has been actively involved in efforts to improve integration and collaboration with our primary care colleagues.

As one of the largest medical specialties, psychiatry is an important component of the physician workforce in the United States, but psychiatrists are distributed unequally around the country. More than half of the counties in the United States don’t have a single practicing psychiatrist. Only about 1 in 10 adults with a diagnosable mental disorder receives care from a psychiatrist in any given year and patients are much more likely to receive mental health treatment from their primary care provider than from a psychiatrist. It is well known and often said that 40 percent of primary care (adult and pediatric) involves dealing with psychiatric problems. Our colleagues in primary care are well aware of the substantial challenges related to treating the millions of patients who present with mental health problems in their offices every year and report serious limitations in the support they receive from psychiatrists and other mental health specialists.

To read more, 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.”

Post-Trauma PTSD Symptoms Raise Risk of Obesity, Study Finds

Women who develop symptoms of posttraumatic stress disorder (PTSD) tend to demonstrate an increase in their body mass index (BMI) compared with women without such symptoms, said researchers in a report published online today in JAMA Psychiatry.

The study was based on 54,224 female participants in the Nurses’ Health Study II who provided data on trauma and PTSD symptoms beginning in 1989. Women who experienced trauma or PTSD before 1989 had a higher BMI during follow-up (through 2005), and their BMI increased at faster rates than in those without PTSD symptoms. For women exposed to trauma in 1989 or later, BMI increased at a faster rate after onset of PTSD symptoms, wrote Laura Kubzansky, Ph.D., a professor of social and behavioral sciences at the Harvard School of Public Health, and colleagues.

Some combination of behavioral mechanisms (such as physical inactivity or unhealthy food choices) or biological  mechanisms (dysregulated neuroendocrine function) may account for these outcomes, they suggested.

“PTSD symptoms should raise clinician concerns about the potential development of physical health problems,” the researchers concluded. “[O]ur work highlights the importance of expanding PTSD treatments to attend to behavioral alterations—such as changes in diet or exercise—that lead to obesity.”

To read more about research on PTSD and descriptions of PTSD diagnostic criteria in DSM-5, see the Psychiatric News article "Trauma Disorder Criteria Reflect Variability of Response to Events."
 

(Image: Christine Langer-Pueschel/Shutterstock.com)

Ketamine Findings Open New Doors to Antidepressant Research

Research suggesting that the anesthetic drug ketamine acts quickly to reduce depressive symptoms is now being supplemented by studies into other substances that operate on similar pathways, according to two reports in the current issue of Biological Psychiatry.

One study of depressed patients by scientists from Taiwan’s China Medical University and from UCLA found that sarcosine improved mood scores and reduced depressive symptoms, when compared with patients taking the antidepressant citalopram. Sarcosine’s effects, however, are the opposite of ketamine’s. Sarcosine enhances activity of the NMDA glutamate receptor, while ketamine blocks it. Further research is needed to clarify these paradoxical outcomes, said John Krystal, M.D., the journal’s editor.

The second study noted that prior research identified the mammalian target of rapamycin (mTOR) as a key mediator of the antidepressant effects of ketamine. Researchers led by Ronald Duman, Ph.D., a professor of psychiatry, neurobiology, and pharmacology at Yale University School of Medicine, found that scopolamine, a muscarinic acetylcholine receptor antagonist, caused rapid activation of mTOR signaling and increased the number of synaptic connections in the prefrontal cortex.

"These effects are similar to the actions of ketamine, showing that two drugs with completely different receptor blocking profiles have common downstream actions linked to rapid antidepressant responses," said Duman in a statement. "Moreover, the increase in synaptic connections reverses the deficit caused by stress and depression and thereby reinstates the normal control of mood and emotion."

To read more about recent research on ketamine, see the Psychiatric News article “Ketamine Shows Rapid Action In Treatment-Resistant Depression.” Also see the study
"Antidepressant Efficacy of Ketamine in Treatment-Resistant Major Depression: A Two-Site Randomized Controlled Trial" in the American Journal of Psychiatry.

 

 

 

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Treating Insomnia With CBT May Curb Depressive Symptoms, Study Finds

Clinicians have long known that insomnia is commonly comorbid among individuals with depression. An article in today’s New York Times highlights a study that investigates how a new cognitive-behavioral therapy to treat insomnia (CBT-I) may also prove beneficial for those with comorbid depression. The study, led by researchers at the Ryerson University in Toronto, is the first of four studies on sleep and depression nearing completion. It included 66 patients with a diagnosis of insomnia and depression. Patients underwent CBT-I sessions for eight weeks, during which they were educated on how to adhere to a regular sleep schedule and avoid stimulating activities such as reading, eating, and watching television in bed.

The results showed that 87 percent of patients whose insomnia was resolved with CBT-I also exhibited a reduction in depressive symptoms after eight weeks of treatment with either an antidepressant or placebo—twice the rate of those whose insomnia could not be resolved.

Nada Stotland, M.D., a past APA president and professor of psychiatry at Rush Medical College, stated that the results were plausible and could lead to major changes in treatment for insomnia and depression—once confirmed by other studies. “It would be an absolute boon to the field,” she told the Times.

The remaining studies—which may be used to confirm these findings from the Ryerson's group—are being conducted at Stanford, Duke, and the University of Pittsburgh. All four studies are funded by the National Institute of Mental Health.

For information on the sleep and depression studies being conducted at Stanford and Duke, see the Psychiatric News article, “Combining Insomnia, Depression Treatment May Improve Outcome.”

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AMA House Approves Several Public-Health Measures, Including on Cannabis Use

The AMA House of Delegates this morning approved a report by the AMA's Council on Science and Public Health (CSPH) urging the formation of a comprehensive national policy on drug abuse and specifically advising that the federal government and the public should acknowledge that federal efforts to address illicit drug use via supply reduction and enforcement have been ineffective. The report calls for research to determine the consequences of long-term cannabis use, especially among youth and adolescents, and supports the modification of state and federal laws to emphasize public-health strategies to reduce cannabis use. (Pictured at left is psychiatrist Kenneth Certa, M.D., who chaired the reference committee that heard testimony on the CSPH report and helped refine it.)

The CSPH report was one of several public-health-related actions taken by the House of Delegates on the last day of its Interim Meeting. Other subjects addressed were gun-safety counseling in undergraduate medical education, athlete concussion management and chronic traumatic encephalopathy prevention, promoting health awareness and preventive screenings for individuals with disabilities, and providing culturally competent mental health care for at-risk communities. Look for further coverage of these subjects in upcoming Psychiatric News issues.

New APA CEO and Medical Director Saul Levin, M.D., M.P.A., also took advantage of the occasion to meet with other specialty society leaders to plan strategy around common goals. To hear a brief audio conversation with Levin click here.

(photo: Mark Moran/Psychiatric News)

AMA House Approves Resolution on SGR

The AMA House of Delegates today approved a resolution that calls on the AMA to continue advocating for the repeal of the sustainable growth rate (SGR) component of the Medicare payment formula for physicians, while upholding the AMA’s principles of pay-for-performance, which were adopted  in 2005. The resolution further asks that the AMA advocate with the Centers for Medicare and Medicaid Services and Congress for “alternative payment models, developed in concert with specialty and state medical organizations, including private contracting as an option.”

An amendment was added that asks the AMA to continue to advocate for "positive updates"—that is, increases, in Medicare payment. The resolution was drafted by a coalition of state delegations in response to news from Capitol Hill that a legislative proposal was in play to end the SGR—but with significant cost offsets to help pay for the accumulated debt from postponing cuts to physician payment. Said one physician on the House floor, “We are at an uncommon time when we have a chance to do something really important, to speak with a unified voice and see the SGR ended. What this tells our constituents is that the SGR fix will not end our advocacy efforts.” 

AMA Debates Medicare Payment Reform as Congress Considers Ending the SGR

There was widespread support in the AMA House of Delegates for a resolution to call on the AMA to continue advocating for the repeal of the Sustainable Growth Rate (SGR) component of the Medicare formula for physician payment, while upholding the AMA’s principles of pay-for-performance, which were adopted in 2005. The resolution further urges that the AMA advocate with the Centers for Medicare and Medicaid Services (CMS) and Congress for “alternative payment models, developed in concert with specialty and state medical organizations, including private contracting as an option.”

The resolution, which was debated in reference committee hearings yesterday at the AMA Interim Meeting, will be voted on by the House of Delegates today. Repeal of the SGR has been one of APA's and the AMA’s top legislative priorities. For close to a decade the formula has required increasingly severe cuts in physician pay, which have been averted by Congress usually at the end of each year; but each year the Medicare program’s debts have accumulated because of the congressional postponement. The resolution was drafted by a coalition of state delegations in response to news from Capitol Hill that a legislative proposal was in play to end the SGR—but with significant cost offsets to help pay for the accumulated debt, including a possible 10-year freeze on physician pay. In her opening address, AMA President Ardis Hoven, M.D., urged delegates not to reject the legislative proposal while it was still in draft form. “[W]alking away [from negotiations] now would be a colossal mistake….To walk away now before we know what modifications may be made would be ill advised.“

Look for further coverage of this issue in upcoming editions of Psychiatric News. For more information about AMA’s pay for performance principles see the Psychiatric News article, “Pay for Performance Must Be Quality Issue, AMA Says.”

Report Calls for AMA to Advocate Public-Health Approach to Cannabis Use

Child psychiatrist and member of the AMA Council on Science and Public Health (CSPH) Louis Kraus, M.D., testified yesterday at the Interim Meeting of the AMA House of Delegates in support of a CSPH report on individual, societal, and public-health issues concerning federal drug control policies, the so-called “war on drugs,” state-based cannabis activities, drug decriminalization/legalization, and the intersection of illicit and prescription drug abuse.

The report would put AMA on record as supporting the modification of state and federal laws to emphasize public-health strategies to address and reduce cannabis use. Kraus is chief of child and adolescent psychiatry at Rush University Medical Center. Specifically, the report urges development of a comprehensive national policy acknowledging that federal efforts to address illicit drug use via supply reduction and law enforcement have been ineffective and should be accompanied by increased efforts to reduce demand for illicit drugs. Kraus emphasized that the report does not support legalization or reclassification of cannabis and does not address potential medicinal effects of cannabis, for which he said insufficient evidence exists.

The report will be voted on by the full House of Delegates today.

To read more about research on cannabis use, see the Psychiatric News articles, "Cannabis Users Have Earlier Age of Psychosis Onset" and "Medication Coupled With Rewards Found to Reduce Cannabis Use."

(Image: Erin Connors)

Eating Disorders Advocate Testifies at AMA

Laura Collins, the founder of F.E.A.S.T. (Families Empowered and Supporting Treatment of Eating Disorders), testified this morning at the AMA’s Interim Meeting in Washington, D.C., in support of a resolution calling on the AMA to advocate for federal legislation requiring full insurance coverage of medically appropriate treatments for eating disorders (ED), including inpatient, outpatient, and maintenance care. At left is David Fassler, M.D., the American Academy of Child and Adolescent Psychiatry's alternate delegate, who also spoke in support of the resolution.

Collins and Fassler explained that despite the parity law and the Affordable Care Act, not all insurance policies cover comprehensive treatment for eating disorders.

“Why do we need a full spectrum of ED treatment covered by insurance? Because EDs are treatable, but we’re not doing it," Collins said. "Yes, eating disorders are treatable brain disorders. They are not a ‘problem with food’ or a weight issue. They are not a choice by the patient nor are they caused by bad parenting or size 0 models. They are a treatable problem with the brain. Untreated, or treated inadequately, eating disorders maim and kill. When my daughter became ill, I learned for the first time that my dear 14-year-old girl had a 1-in-10 chance of dying of her anorexia—1 in 10.

"What I didn’t know then was that newer treatments can have far higher rates of recovery in a much shorter timeframe. Others need more. But few were getting any. We need insurance coverage to save lives: early intervention and access to care across settings works....The current situation for American families facing a newly diagnosed eating disorder is grim. We face a revolving door of emergency care instead of access to the care needed early on. We second-mortgage homes, drain retirement, but more often simply don’t pursue care due to financial constraints—for a treatable problem. These patients are not dying of their disorder; they are dying from lack of access and lack of coordination."

For more information, see the Psychiatric News article "Eating Disorders May Pose Greater Risk in Type 1 Diabetes" and Developing an Evidence-Based Classification of Eating Disorders: Scientific Findings for DSM-5, published by American Psychiatric Publishing.

 (Image: Mark Moran)

Scully Honored at AMA Meeting

Immediate past APA Medical Director and CEO James H. Scully, M.D., was feted last night at a reception during the AMA’s Interim Meeting in Washington, D.C., where APA and AMA leaders hailed Scully’s contributions to organized medicine. From left to right are Patrice Harris, M.D., past APA Board member and current member of the AMA Board of Trustees; new APA CEO and Medical Director Saul Levin, M.D., M.P.A.; Carolyn Robinowitz, M.D., chair of the Section Council on Psychiatry and former senior deputy medical director of  APA; Scully; and immediate past AMA President and former APA Assembly Speaker Jeremy Lazarus, M.D.

Scully has a long history with the AMA, serving as a delegate to the House of Delegates and chair of the Section Council on Psychiatry. Robinowitz and Lazarus especially emphasized his leadership in AMA’s Scope of Practice Partnership, which has spearheaded the AMA’s efforts around psychologist prescribing and other scope-of-practice issues. “Jay has been a trusted and respected CEO among the specialty societies," commented Lazarus. "Not everyone has the kind stature he has.”

For more about Scully's career and retirement, see Psychiatric News by clicking here.

(Image: Mark Moran)

Kennedy Speech to APA Assembly Available Now for Listening

To standing ovations, former Congressman Patrick Kennedy presented an impassioned speech to the APA Assembly on November 9, the day after the government issued the long-awaited final parity rule. Kennedy is a senior advisor to APA. 

“What you're fighting for at APA,” he declared, “is giving a connection to human beings who feel marginalized because their illness is so shamed and stigmatized, much like Americans who are marginalized because of the color of their skin, their gender, their sexual orientation, or their religious ethnicity.” 

Click here to listen to Kennedy’s speech.

(Image: Mark Moran)

Psychiatrist Serves on New AMA Integrated Care Section

The Affordable Care Act and other factors are accelerating change in health care delivery and creating a strong impetus to foster and expand integrated modes of practice in the near term, according to Jerry Halverson, M.D., a delegate to the Section Council on Psychiatry and an affiliate member of the Integrated Physician Practice Section (IPPS), the newest addition to the AMA’s sections and special groups within the House of Delegates.

In an interview with Psychiatric News, Halverson said that the IPPS enables physicians in or actively working toward multispecialty, physician-led, integrated health care delivery groups or systems to have an official vote in the AMA policymaking process.

To listen to an interview of Halverson about the new section,click here.To read a list of FAQs about integrated care and how to get involved, click here.

(Image: Mark Moran)

Forensic Psychiatrist Honored for Years of Service at AMA

Howard Zonana, M.D. (center), was honored at a reception last night at the AMA's Interim Meeting in Washington, D.C. Zonana is retiring as medical director of the American Academy of Psychiatry and the Law (AAPL) and will no longer be serving on the Section Council on Psychiatry. Pictured with Zonana in the front row (from left) are Carolyn Robinowitz, M.D., chair of the section council; Robert Phillips, M.D., Ph.D., AAPL's delegate; and Jacquelyn Coleman, executive director of AAPL; in the back row are Barry Wall, M.D., AAPL's alternate delegate; and Ryan Hall, M.D., and Jennifer Piel, M.D., AAPL's young physician delegates.

Zonana, a professor of psychiatry at Yale University and clinical professor (adjunct) of law at Yale Law School, has helped bring the expertise of AAPL to issues of psychiatry and the law addressed by the AMA. He also has been a passionate voice for the rights of people with mental illness. At the 2007 AMA Annual Meeting, the House of Delegates approved a resolution brought by the Section Council on Psychiatry that reaffirmed the organization's prohibition on physician involvement in the execution of defendants convicted of capital offenses. At that meeting, Zonana also spoke on behalf of a resolution calling for a national moratorium on executions generally. "The politics of the death penalty has shifted dramatically in favor of death," he said at the meeting. "Legislators have consistently strengthened the number of crimes [punishable by death] and cut back the funding for defense of capital defendants. This has resulted in a process whereby you get death not for having committed the worst crime, but for having been assigned the worst lawyer."

Zonana has also been a prominent speaker at APA meetings, talking about psychiatry, ethics, and the law. For more information, see the Psychiatric News articles http://dsm.psychiatryonline.org/newsarticle.aspx?articleid=113546 and http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=113670.

 (Image: Mark Moran)

Psychiatry Fellow Offers Resolution on Sunshine Act Exemption

Simon Faynboym, M.D., a PGY-2 psychiatry resident at Indiana University School of Medicine and an APA delegate to the AMA's Resident and Fellow Section (RFS), testified today before the RFS on a resolution calling on the AMA to "clarify the status of fellows and prevent inappropriate or unanticipated reporting under the requirements" of the Physician Payment Sunshine Act. The law was passed by Congress as part of the Affordable Care Act and seeks to enhance transparency of financial interactions between certain manufacturers and physicians and teaching hospitals. Residents are already exempted, but fellows are not, and the resolution—if accepted by the AMA House of Delegates this weekend at the AMA’s interim meeting—will add a powerful voice on behalf of America’s youngest physicians.  

Faynboym is one of the new, young faces of the AMA and an important member of psychiatry's delegation. The Section Council on Psychiatry, composed of representatives from APA, the American Academy of Child and Adolescent Psychiatry, the American Academy of Psychiatry and the Law, and the American Association for Geriatric Psychiatry, is one of the most successful in the House of Delegates; psychiatrists sit on many of the AMA’s decision-making councils. Additionally, there are more than 50 psychiatrists in the House of Delegates from around the nation. 

In an interview with Psychiatric News, Faynboym explained that many aspects of medical fellowship may be funded by industry and would subject fellows to reporting requirements that could be onerous; at the same time, the AMA’s own definition of “residency” includes physicians who are in fellowship programs. “If the AMA House supports this resolution, it would mean that the AMA could work with other organizations and the government to clarify the definition of a 'resident' under the law and the status of fellows,” he said.

For more on the sunshine act, click here.

 (Image: Mark Moran)

Former Surgeon General Discusses Health Disparities, Mental Health of African Americans

On Tuesday, APA's Office of Minority and National Affairs (OMNA) partnered with the American Association of Community Psychiatrists and the Alabama Psychiatric Physicians Association to discuss “Transcendence and Resilience Following Trauma.” The discussion, at the University of Alabama, Birmingham, was in celebration of the triumph of African Americans after the 16th Street Baptist Church bombing, an act of racial hatred that killed four young girls 50 years ago.

The event's keynote speaker was former U.S. Surgeon General David Satcher, M.D., Ph.D., who spoke about growing up in Alabama during an era when racism was supported by harsh states laws that restricted the freedoms of African Americans. He said that because of racism's many manifestations—which included inadequate health care for minorities—and because of his personal life experiences, he was prompted to join forces with those committed to eliminating health disparities in this country.

“I grew up during a time when black children died at home because they could not be admitted to a hospital…. In order to eliminate the disparities in mental health and other areas of health, we needed—and still need—people who care about other people, regardless of race and ethnicity,” said Satcher.

In response to the Birmingham church bombing, Satcher—who in 1999 became the first surgeon general to release a report on mental health—said that mental health can be defined as “the ability to deal with adversity... I can’t think of any greater adversity than that of a church bombing that killed four little girls.” Satcher said that having discussions about the emotions associated with that tragic event is what has allowed, and will allow, people to heal. 

To read about other OMNA-sponsored initiatives, see the Psychiatric News articles, "Knowledge of Military Life Facilitates Vets' MH Care," and "Philadelphia Artists, Doctors Ease Immigrants’ Access to Care." Also see the brochure "Let's Talk Facts About Mental Health in African Americans," which is available from American Psychiatric Publishing.

(Photo: University of Alabama at Birmingham/ Brad Daniel)

Research Findings Providing Tools to Make Early Psychosis Intervention a Reality

Early identification of schizophrenia and other psychoses should not just be a priority for clinicians—it should be a national priority, says psychiatrist Raquel Gur, M.D., a leading schizophrenia researcher. Speaking at the APA Institute on Psychiatric Services, Gur pointed out that despite the illness's complexity, early psychosis identification is becoming more likely thanks to a growing research base linking genetic, neurodevelopmental, and behavioral findings about how psychosis progresses over time. Such early identification must follow the pattern that made it routine for diabetes, cardiovascular disease, and other disorders. "It is no different for psychosis," she said. "When someone presents with a risk, we cannot send them away until they meet DSM criteria for schizophrenia."

Pursuing the path of other illnesses, however, will not be simple, she added, in large part because of the stubborn stigma that attaches to mental illness and the complexity of the brain. But the "train toward psychosis leaves the station early, and we are trying to capture it before it derails."

She cited several examples of research that is advancing the knowledge needed for early psychosis identification, including the Philadelphia Neurodevelopmental Cohort, which is seeking to describe how genetics impact trajectories of brain development and cognitive functioning in adolescence and understand how abnormal trajectories of development are associated with psychiatric symptoms. In this study, nearly 10,000 youth presenting at Children’s Hospital of Philadelphia for nonpsychiatric reasons have received a comprehensive genetic, psychiatric, and cognitive assessment, with a subsample of these participants receiving multimodal neuroimaging.

Read more about this and other studies laying the groundwork for early psychosis intervention in the Psychiatric News article "Expert Says Early Identification of Psychosis Should Be Priority."

(Image: Mark Moran/Psychiatric News)

Stimulant Use for ADHD Varies Widely and Is Tied to Socioeconomics, Physician Supply

There appear to be wide variations across states, regions, and counties in use of stimulants to treat attention-deficit/hyperactivity disorder (ADHD)—especially in primary care, where most patients prescribed stimulants are managed—according to the report "Geographic Variation and Disparity in Stimulant Treatment of Adults and Children in the United States in 2008" in the November Psychiatric Services.

Researchers from Abt Associates, a public-policy and business consulting firm, obtained records of 24.1 million stimulant prescriptions dispensed to insured and uninsured patients from approximately 76% of U.S. retail pharmacies. They found that stimulant treatment prevalence among states varied widely, and the variation among counties was even wider. Two-thirds of the variation among counties in stimulant treatment prevalence was associated with supply of physicians, socioeconomic composition of the population, and, among children, funding for special education.

“One plausible interpretation of our findings is that physicians, schools, and parents in locales where pediatric treatment rates were closer to the estimated national ADHD prevalence rates are more effective in identifying, diagnosing, and treating ADHD and, perhaps to a lesser extent, other conditions for which stimulants are indicated,” the researchers said. “The strongest predictor of treatment was the availability of physicians in the area—a common finding in studies of geographic variations among other types of medical treatment.”

For more information about the use of medications to treat ADHD, see the Psychiatric News articles, "Blood Pressure Doesn't Spike With Long-term Stimulant Use" and "Teens Not Overmedicated, NIMH Study Finds."

(Image: Tang Yan Song/shutterstock.com)

Brain Stress Systems May Be Key Piece of the Addiction Puzzle

The brain’s stress systems appear to play a key role in the transition to addiction and maintaining addiction once it is initiated. People addicted to drugs take those substances not to feel good, but to avoid the anxiety, stress, irritability, or dysphoria of drug withdrawal, said George Koob, Ph.D., of the Scripps Research Institute in La Jolla, Calif., in a talk at the Society of Neuroscience meeting today in San Diego.

Excessive use of drugs triggers negative emotional states that activate the stress systems within areas of the brain known to mediate emotions, including the amygdala and basal ganglia, said Koob, who will become director of the National Institute on Alcohol Abuse and Alcoholism in January.

Two neurotransmitters—corticotropin-releasing factor (CRF) in the amygdala and the dynorphin-κ opioid system in the basal ganglia—are in those brain areas and mediate anxiety-like behavior, fear conditioning, and dysphoria-like behavior in animal models, Koob noted. He hypothesized that brain stress response systems are activated by excessive drug intake, then activated again during repeated withdrawals, and continue during abstinence.

 “A role of the brain stress systems in addiction not only provides insight into the neurobiology of the emotional misery of addiction but also provides novel targets for the treatment of addiction,” he concluded.

For more in Psychiatric News about George Koob's research on addiction, see "People With Addiction Exhaust Brain’s Limited Reward System."

(Image: Aaron Levin/Psychiatric News)

Untreated Schizophrenia Raises Risk of Violence, Study Finds

A study that tracked released prisoners convicted of violent crimes found that mental health treatment affected rates of subsequent violence among those with schizophrenia. Most of the 967 prisoners in the study had no psychosis at about nine months after their release. However, 94 were diagnosed with schizophrenia, 29 with a delusional disorder, and 102 with drug-induced psychosis.

After adjusting for demographic factors, psychiatric comorbidities, and substance use, former prisoners whose schizophrenia was untreated during or after imprisonment were found to be three times more likely to be violent after their release than were prisoners who received psychosis treatment or those without psychosis, wrote Robert Keers, Ph.D., of Queen Mary University of London, and colleagues, online today in AJP in Advance. The presence of persecutory delusions appeared to explain at least part of that association, they said.

“[O]ur findings are consistent with those in studies of treatment compliance in psychosis that report that nonadherence to medication is associated with increased risk of violence,” the researchers said. “They are also in line with findings from studies of first-episode patients that suggest that the risk of violence is higher at first presentation than following treatment.”

The fact that a prisoner was untreated for psychosis should be considered a risk factor for violent recidivism, they concluded.

To read more about early detection and treatment of schizophrenia, see the Psychiatric News column "Early Detection of Schizophrenia: The Time Is Now." Also see the book Essentials of Schizophrenia from American Psychiatric Publishing.

(Image: Rolf_52/Shutterstock.com)

Kennedy Says Release of Parity Rule Is Only Part of the Battle

Speaking to the APA Assembly the day after Friday's release of the final rule implementing the federal mental health parity law, the law's chief sponsor, Patrick Kennedy, emphasized that "while the final rule may have been written, the final word on mental health is not yet written." It will have to be written by psychiatrists "on the front lines" who battle to make mental health care as routine as the rest of medical care, he told Assembly members. He lamented the stubborn stigma that still attaches to mental illness as well as the thousands of suicide deaths that could be prevented every year if people weren't ashamed of having an illness affecting the brain rather than other parts of the body. He added that it was appropriate to use the slogan that AIDS activists used in their fight against stigma a couple of decades ago: "Silence = Death."

Kennedy, a former member of Congress who fought for 12 years to get the mental health parity law passed, said that the battle against mental illness discrimination "is part of the march toward progress embodied in the civil rights movement in our country and in the historic human rights movement that occurred in South Africa."

"What you're fighting for at APA," he said, "is giving a connection to human beings who feel marginalized because their illness is so shamed and stigmatized, much like Americans who are marginalized because of the color of their skin, their gender, their sexual orientation, or their religious ethnicity."

He ended by describing how receiving mental health treatment changed his life for the better, allowing him to experience the joy of seeing the parity law enacted, its final rule issued, and of being a father able to give his children the foundation in life that all children need. Kennedy now serves as a senior advisor to APA.

Insurers Must Cover Intermediate Care Levels, Provide Transparency to Patients, Parity Rule States

In a significant step forward for patients receiving mental health care, the final rule to implement the federal parity law, issued on Friday, says that insurers must provide their beneficiaries with the medical necessity standards and the processes—such as concurrent review and prior authorization—that the insurer uses to implement them.
In addition, the final rule clarifies that the classification of benefits defined in the Mental Health Parity and Addiction Equity Act was never intended to exclude intermediate levels of care, such as intensive outpatient, partial hospitalization, and residential treatment.

The law stipulates six classification of benefits—inpatient in and out of network, outpatient in and out of network, emergency care, and prescription drugs—but it was unclear what the status of certain intermediate levels of care might be under the law. The final rule clarifies that plans must assign intermediate services in the behavioral health area to the same classification as plans or issuers assigned intermediate levels of services for medical/surgical conditions, according to a preliminary analysis of the rule by APA.

The final rule is effective for plan years beginning on or after July 1, 2014. In practice, the bulk of plan years end December 31, so the effective date for most plans will be January 1, 2015.

“People with mental illness have long faced discrimination in health care through unjust and often illegal barriers to care,” said APA President Jeffrey Lieberman, M.D., in response to the rule. “The final rule provides a crucial step forward to ensure that consumers receive the benefits they deserve and are entitled to under the law. In addition to providing equal benefits for mental illness as physical illness, I am hopeful that there will be strong monitoring and enforcement at both the state and federal levels."

“As we review the final rule [http://www.dol.gov/ebsa/pdf/mhpaeafinalrule.pdf], we look forward to a new chapter in mental health care that delivers on the promise of the parity law. APA will remain vigilant and continue working toward full equity for people with mental illnesses and substance use disorders,” Lieberman said.

Join the parity conversation by following @APAPsychiatric and #mhparity.

Psychotropic Prescriptions to Young Children Decline, Study Finds

Researchers from the Cincinnati Children’s Hospital Medical Center analyzed medical records of approximately 45,000 children aged 2 to 5 to assess the prevalence of psychotropic prescriptions to this age group from 1994 to 2009. 

Results showed that within 15 years overall psychotropic prescriptions to young children decreased approximately 50 percent, but increased among boys, Caucasian children, and those without private health insurance. In addition, the likelihood of receiving a behavioral diagnosis increased from 2006 to 2009, but was not accompanied by an increase in psychotropic prescriptions. The authors speculated that the overall decrease for prescriptions is likely due to numerous warnings for health risks associated with psychotropic use.

“This study documents shifting practice patterns with respect to the use of psychotropic medication in the treatment of very young children,” David Fassler, M.D., a child and adolescent psychiatrist and APA treasurer, told Psychiatric News. “While the results are interesting, they should be interpreted with caution. Ultimately, the real question isn't just how many young children are receiving a specific medication; it's whether those who are most at need are getting the most effective and appropriate intervention possible.” Fassler concluded that more studies are needed to evaluate the long-term effects of psychotropic-medication exposure in young children.

To read more about psychotropic drug use in young children, see the Psychiatric News articles “Shared Decision Making Aids Parents of Children With ADHD” and “ADHD Outcome Data in Adults Show Value of Early Treatment.”

(Image: Nikolich/shutterstock.com)

Final Mental Health Parity Rule to Be Released This Morning; Web Briefing to Follow

A long-awaited final rule from the Centers for Medicare and Medicaid Services providing a regulatory framework for implementing the 2008 mental health parity law is to be published at 11:15 a.m. EST in the Federal Register. The Department of Health and Human Services is also offering a web briefing about the rule that will be streamed at 12:30 p.m. EST at http://www.hhs.gov/live.

"Today, we congratulate the Obama administration for taking a significant step toward eliminating barriers to mental health and substance abuse services," said CEO and Medical Director Saul Levin, M.D., M.P.A. "The final rule for the Mental Health Parity and Addiction Equity Act of 2008 will ensure that our patients receive the benefits they deserve and to which they are entitled under the law."

In a New York Times article this morning, APA President-elect Paul Summergrad, M.D., is quoted saying he hoped the final rule would end “the uniquely discriminatory form of prior authorization and utilization review” applied to emergency care for patients with mental illness. “A person who has a heart attack or pneumonia and goes to a hospital will routinely be admitted, with electronic notice sent to the insurer on the next business day,” Summergrad said. By contrast, he said, if a person who is profoundly depressed and tried to commit suicide goes to a hospital, an emergency room doctor must call a toll-free telephone number, “present the case in voluminous detail, and get prior authorization.”

Former Congressman Patrick Kennedy, a cosponsor of the 2008 law, said the rule could particularly help veterans. “No one stands to gain more from true parity than the men and women who have served our country and now need treatment for the invisible wounds they have brought home from Iraq and Afghanistan,” he said.

Kennedy is the spokesperson for APA’s new PSA series “A Healthy Minds Minute” and has partnered with APA in pursuing the long-awaited release of the final rule. To view Kennedy’s newest PSA on the need for veterans to have access to the mental health care they deserve, click here.

(photo: Sergey Ivanov)