Mindfulness-Based Relapse Prevention Found Effective for Substance Abuse, Study Finds

Relapse is highly prevalent following substance abuse treatment, indicating that there is an urgent need for effective aftercare interventions. Now a new study has found that cognitive-behavioral relapse prevention (RP) and mindfulness-based relapse prevention (MBRP) are both effective aftercare interventions for substance abuse treatment, but that the latter may have an especially enduring effect as far as reducing drug-use days and heavy drinking are concerned. The study was headed by Sarah Bowen, Ph.D., an assistant professor of psychiatry and behavioral sciences at the University of Washington. The results appear in JAMA Psychiatry.

RP helps patients identify environmental situations that precipitate relapse and teaches them how to avoid such situations or cope with them. MBRP is based on some of the components of RP, such as identifying situations that precipitate relapse. However, it also includes mindfulness training—that is, it teaches patients how to become aware of emotional or physical states that might provoke a relapse, to learn to relate to the discomfort of such states more skillfully, and to identify underlying needs that might be driving a craving, such as a need for relief or comfort.

They study included 286 individuals who had completed treatment for substance use disorders. They were randomized to treatment as usual—that is, 12-step programming and psycho-education—RP, or MBRP. Between-group differences were not found at the three-month follow-up. However, at the six-month follow-up, both RP and MBRP subjects had a significantly reduced risk of relapse to drug use and/or heavy drinking compared with treatment-as-usual subjects. And at the 12-month follow-up, MBRP was found to be even more effective than RP in reducing drug use and heavy drinking.

"This is a very interesting study," John Renner, M.D., associate chief of psychiatry at the VA Boston Healthcare System and an addiction psychiatrist, told Psychiatric News. "It provides a useful comparison of the efficacy of CBT-based RP treatment and MBRP. Previous studies of MB treatments for substance use disorders have been promising, but have provided only two- or four-month follow-up data. The 12-month follow-up data from this study are of particular importance, since longer-term efficacy is a critical issue for any intervention of substance use disorders.... [The 12-month follow-up data] suggest that MBRP may provide better long-term outcomes than RP. Clinicians will be interested to see if this important finding is replicated." Renner is a member of the APA Council on Addiction Psychiatry.

Extensive information about treating substance abuse disorders can be found in the "American Psychiatric Publishing Textbook of Substance Abuse Treatment, Fourth Edition." Also see the Psychiatric Services article, "Substance Abuse Intensive Outpatient Programs: Assessing the Evidence."

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Study Finds Metformin Most Effective Intervention for Antipsychotic-Induced Weight Gain

What is the best pharmacological strategy for countering antipsychotic-induced weight gain? By pooling the effects of 40 studies representing 19 interventions for antipsychotic-induced weight gain, researchers have found the diabetes drug Metformin to be the most effective. The study's senior scientist was Hiroyuki Uchida of Keio University School of Medicine in Tokyo. The results are published in Schizophrenia Bulletin.

"Schizophrenia is like a perfect storm for metabolic syndrome, and reduced life span is alarming," William Carpenter, M.D., director of the Maryland Psychiatric Research Center at the University of Maryland and a schizophrenia expert, told Psychiatric News. "Metabolic abnormalities are associated with the illness, then lifestyle behavioral risks are added, and finally adverse effects of many antipsychotic drugs. Uchida and colleagues provide clinicians with a comprehensive review on the role of medications to address metabolic abnormalities associated with schizophrenia."

"Obesity and associated metabolic consequences represent a serious concern in patients with schizophrenia," Deanna Kelly, Pharm.D., director and chief of the Treatment Research Program at the Maryland Psychiatric Research Center, said. "Attenuation and reversal of weight gain is difficult, and behavioral modifications are challenging in this population. Accumulating evidence, as in this meta-analysis, suggests that some pharmacologic treatments may help attenuate weight gain. Metformin, despite its modest ability to attenuate weight gain, may be an important addition for many patients who are at risk for weight and related consequences."

For more information about this topic, see the American Journal of Psychiatry article, "Metformin for Weight Loss and Metabolic Control in Overweight Outpatients With Schizophrenia and Schizoaffective Disorder." More information about antipsychotic medications and their side effects can be found in American Psychiatric Publishing's "Essentials of Clinical Psychopharmacology, Third Edition."

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Risk of Psychiatric Diagnosis Increases for ICU Patients on Ventilation Devices, Study Finds

Though more people are surviving critical illness due to advances in medicine, severely ill patients are often exposed to respiratory distress and delirium, which may negatively impact their mental health. Hannah Wunsch, M.D., M.Sc., of Columbia University College of Physicians and Surgeons and colleagues assessed the prevalence of psychiatric diagnoses and medication prescriptions given before and after critical illness to patients who were connected to a mechanical ventilation device while in the intensive care unit (ICU).

The analysis, published in the Journal of the American Medical Association, showed that among the 24,179 critically ill patients in the study, 6.2% had one or more psychiatric diagnoses within the five years prior to the severe illness, compared with 2.4% of people in the general population. Critically ill patients were also more likely to have prescriptions for a psychoactive medication than were those in the general population (48.7% vs. 33.2%.). Previous ICU patients with no history of psychiatric disorders were 25 times more likely to receive a psychiatric diagnosis after hospitalization than the general population and 18 times more likely to be given a prescription for psychoactive drugs within three months after ICU release. The differences in psychoactive prescriptions between former ICU admittees and the general population decreased after one year.

“Our data suggest both a possible role of psychiatric disease in predisposing patients to critical illness and an increased but transient risk of new psychiatric diagnoses and treatment after critical illness,” said the authors. They concluded that psychiatric history and management of psychiatric symptoms post-ICU may be an important focus for interventions concerning mental health among critically ill patients.

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Heart Association Panel Says Depression Should Be Listed as Major Cardiac Risk

This week in the journal Circulation, a scientific statement was issued by an American Heart Association (AHA) panel in response to a systemic literature review, which could lead to depression being considered as a major risk factor in heart disease among adults. The panel reviewed 53 studies—with more than 100 patients each—that indicated an association between depression and coronary artery disease.

After evaluating studies, the panel issued the following statement: “….[Despite] heterogeneity in the published findings….the preponderance of evidence supports the recommendation that the AHA should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.”

Former APA President Carolyn Robinowitz, M.D., commented to Psychiatric News that the relationship between depression and heart disease has been of particular interest to APA since her presidency in 2007-2008. “The AHA report sets the stage for a broad array of research questions related to the role of depression in cardiovascular illness. Psychiatrists have well been aware of the impact of depression on cardiovascular disorders, and we must continue to work to educate our medical colleagues—outside of mental health care—on this relationship by encouraging screening for depression in the general medical and cardiovascular settings. We very much appreciate the careful analyses of the American Heart Association and APA member Lawson Wulsin, M.D., [a member of the AHA's panel of experts], in addressing this important issue.”

To read more about depression and heart disease, see Psychiatric News articles, "Building a Bridge Between Cardiology, Psychiatry," and "Red Blood Cell Size Linked to Depression in Heart-Disease Patients."

(Image courtesy of AHA)

APA to Present Live Webcast on Economic Impact of Integrated Care

APA will host a roundtable discussion on the promise of integrated medical-behavioral and primary care models on Friday, April 4, from 10 a.m. to noon EDT.

The event, titled "Integrated Primary and Mental Health Care: Reconnecting the Brain and the Body," will feature the release of a new report by Milliman Actuaries outlining the economic impact of the effective integration of medical and behavioral health services. Michael Hogan, Ph.D. (left), former commissioner of the New York State Office of Mental Health, will offer keynote remarks to open the discussion.

The event will be held at the National Press Club in Washington, D.C., and will be webcast live. Webcast participants will be able to submit questions for the panelists during the webcast.

Other confirmed speakers include APA President Jeffrey Lieberman, M.D.; APA President-elect Paul Summergrad, M.D.; and APA CEO and Medical Director Saul Levin, M.D., M.P.A. Also participating are John O'Brien, senior policy advisor at the Centers for Medicare and Medicaid Services; Henry Chung, M.D., chief medical officer of the Montefiore Care Management Organization and its ACO, Montefiore Accountable Care Organization; and Richard Frank, Ph.D., a professor of health economics at Harvard Medical School and assistant secretary designate for planning and evaluation in the Department of Health and Human Services.

To register for the webcast, click here.

For more in Psychiatric News about integrated care, see "Psychiatrist Leads Effort to Integrate Care at Pioneer ACO" and "Collaborative Care: An Integral Part of Psychiatry's Future."

Study Shows Benefits of Collaborative Care in Pediatric Practices

A collaborative care model based in pediatric practices showed significant advantages over enhanced usual care in a randomized trial, reported David Kolko, Ph.D., a professor of psychiatry, psychology, and pediatrics at the University of Pittsburgh School of Medicine, and colleagues online in Pediatrics.

Most (64 percent) of the 321 children in the study (average age, 8 years) were diagnosed with attention–deficit/hyperactivity disorder (ADHD) or disruptive behavior disorder. The Doctor Office Collaborative Care (DOCC) program used treatment based on family-oriented cognitive-behavioral therapy for children with behavioral problems being treated in pediatricians' offices. A care manager in those offices coordinated a variety of interventions for children and their caregivers. Enhanced usual care included psychoeducation and a referral to a local mental health provider.

Children in both cohorts improved over time. However, 99 percent of the children in the DOCC arm of the study used services, compared with 54 percent of those in the enhanced usual care arm, the researchers noted. The former also engaged in more hours and weeks of services, were more likely to complete the course of treatment, and were less likely to need outside referrals or drop out of treatment. The clinicians in the DOCC arm also reported that there was increased involvement with treatment and better ADHD medication management skills.

“Implementing a collaborative care intervention for behavior problems in community pediatric practices is feasible and broadly effective, supporting the utility of integrated behavioral health care services,” the researchers concluded.

For more in Psychiatric News about collaboration with pediatricians on mental health issues, see the article, “Pediatricians Get Help Managing Psychotropic Drugs in Children.”

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APA Wins Prestigious Award From Advertising Federation

A graphic that APA included in a public-service announcement about mental health issues in veterans and military service members has won a top honor from the American Advertising Federation, which oversees the world's largest advertising/communications competition. The foundation says that the award, known as an Addy, "represent[s] the true spirit of creative excellence by recognizing all forms of advertising from media of all types, creative firms of all sizes and entrants of all levels from anywhere in the world.” The APA "infographic" won a Gold Addy Award. It was created by APA in conjunction with Home Front Communications.

Commenting to Psychiatric News on the award, APA President Jeffrey Lieberman, M.D., said, "Psychiatry and the military have had a long and interesting history, even when they didn't realize how much they needed and had to offer each other. This award-winning graphic demonstrates how far we have come in our knowledge of the brain and the effects of stress and experiential trauma on it—and how much psychiatry can and must do to help our military personnel."

APA CEO and Medical Director Saul Levin, M.D., M.P.A., said, "We will continue to seek out creative ways to raise awareness of the mental health needs of our men and women in uniform and to end the unnecessary stigma against those with mental illness."

Task Force Finds Insufficient Evidence to Recommend Screening Adults for Cognitive Impairment

The United States Preventive Services Task Force (USPSTF) has concluded that evidence is insufficient to assess the benefits and harms associated with screening adults for cognitive impairment or dementia.

In clinical guidelines published online in the Annals of Internal Medicine, the task force said that there is not enough evidence to recommend widespread screening of adults for cognitive decline and dementia. Task force members reviewed the data on the benefits, harms, and sensitivity and specificity of screening instruments for cognitive impairment in older adults and of commonly used treatment and management options for older adults with mild cognitive impairment or early dementia and their caregivers.

“Evidence is adequate that some screening tools can accurately identify dementia," the report noted. "Treatment of mild to moderate dementia with several drug therapies and nonpharmacologic interventions results in small improvements in measures of cognitive function and caregiver outcomes, but the clinical significance of these improvements is uncertain. The USPSTF found no published evidence on the effect of screening on decision making or planning by patients, clinicians, or caregivers. Evidence on the harms of screening and nonpharmacologic interventions is inadequate…. Overall, the USPSTF was unable to estimate the balance of benefits and harms of screening for cognitive impairment.”

This recommendation applies to universal screening with formal screening instruments in community-dwelling adults who are older than age 65 and have no signs of cognitive impairment.

For more information see the Psychiatric News article, “Plasma APOE Levels Linked to Dementia Risk.”

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Early Intervention May Help Prevent Development of Antisocial Personality, Study Suggests

An intervention involving group parental training appears to improve behavior and reading performance among children with severe antisocial behavior who have been identified as needing treatment. Study findings were published in AJP in Advance. The intervention was less successful for a group of “high risk” children identified in the community as being at risk for antisocial behavior but not necessarily requiring treatment.

Researchers in England and the United States conducted two follow-up studies of randomized trials of group parental training. One involved 120 clinic-referred 3- to 7-year-olds with severe antisocial behavior for whom treatment was indicated, 93 of whom were reassessed between ages 10 and 17. The other involved 109 high-risk 4- to 6-year-olds with elevated antisocial behavior who were selectively screened from the community, 90 of whom were reassessed between ages 9 and 13. The primary psychiatric outcome measures were antisocial behavior and antisocial character traits. Also assessed were reading achievement (an important domain of youth functioning at work) and parent-adolescent relationship quality.

In each study, the intervention group received "The Incredible Years" basic videotape program, which covers play; praise and rewards; limit setting; and handling misbehavior. In each session, videotaped scenes of parents and children together are shown, depicting “right” and “wrong” ways of handling children. Each study also had a control group that received usual care in the form of individual mental health treatment or (in the high-risk study) telephone counseling.

In the indicated sample, both elements of antisocial personality were improved in the early intervention group at long-term follow-up compared with the control group. Additionally, reading ability improved, parental expressed emotion was warmer, and parental supervision was closer. In contrast, in the selective high-risk sample, early intervention was not associated with improved long-term outcomes.

“The findings provide the first evidence that parent training for young children with clinical-level antisocial behavior may reduce the poor outcomes and high cost of later antisocial personality,” the researchers stated.

For more information on research studies of antisocial behavior, see the Psychiatric News article, "Early Disregard for Others' Pain May Foretell Antisocial Behavior." Also see the article, "Behavioral Management for Children and Adolescents: Assessing the Evidence" in Psychiatric Services in Advance.

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Depression May Magnify APOE e4 Variant's Impact on Cognitive Decline, Study Finds

When an older person is not only depressed, but also has one or two copies of the APOE e4 gene variant, the risk of cognitive decline is even greater than if he or she had either depression or the variant alone. This is the finding from a large population study published in Psychosomatic Medicine, which was led by Kumar Rajan, Ph.D., an assistant professor at the Rush Institute for Healthy Aging at Rush University Medical Center. The study included 4,150 participants aged 65 or older from African-American or European backgrounds. About a third of the cohort had one or more copies of the APOE e4 variant.

"This finding has important implications for older adults, health care practitioners, scientists, and public-health experts—further demonstrating the complex interplay of mental health and genetic markers on late-life cognitive health," Rajan and his team concluded.

And in an accompanying editorial, Michelle Luciano, Ph.D., of the Center for Cognitive Aging and Cognitive Epidemiology at the University of Edinburgh, said: "Given that the APOE genotype is fixed in an individual, one of the questions that the research of Rajan et al. raises is the potential to curb cognitive decline through interventions targeting depression."

Information about the APOE e4 variant can be found in the Psychiatric News article "Disclosure of APOE Genotype Affects Memory Performance." To read more about depression in older individuals, see the Psychiatric News article "Resilience, No Depression Best Predict Successful Aging." For additional information on these topics, see Essentials of Geriatric Psychiatry, Second Edition, from American Psychiatric Publishing.

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Smoking Cessation Linked With Multiple Mental Health Benefits, Study Finds

Stopping smoking is associated with significant improvements in anxiety, depression, stress, positive affect, and psychological quality of life. And the strength of the association appears to be similar for both the general population and clinical populations, including those with psychiatric disorders, according to findings from a meta-analysis reported in the British Medical Journal by Paul Aveyard, a professor of behavioral medicine at the University of Oxford in England, and colleagues.

The meta-analysis included 26 studies that measured subjects' mental health before and after they quit smoking. The studies examined six measures of mental health: anxiety, depression, mixed anxiety and depression, positive affect, psychological quality of life, and stress. Eleven of the studies were cohort studies, 14 were secondary analyses of cessation interventions, and one was a randomized trial.

"This study illustrates the importance of providing tobacco-cessation treatment to individuals with behavioral health conditions, to help with both improvement in symptoms of mental illness and overall physical health," Lori Raney, M.D., told Psychiatric News. "Psychiatrists have an important role to play in assisting in this treatment and can provide guidance and support to patients and in helping our colleagues in other medical settings." In addition to being medical director of Axis Health System in Durango, Colo., Raney has a special interest in the relationship between smoking cessation and mental health.

More information about the importance of smoking cessation for patients with mental illness can be found in the Psychiatric News articles "Decline in Smoking Lags Among Patients With Mental Illness" and "Smoking Cessation for Patients Called an Urgent Priority."

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Family-Focused Therapy Reduces Bipolar-Associated Symptoms in Teens, Study Finds

Family-focused treatments have been found to be an effective adjunctive therapy to mood stabilizing medicine in adults with bipolar disorder, but whether this approach holds true in adolescents, has been unclear. Researchers from the University of California at Los Angeles (UCLA) evaluated 145 adolescents with bipolar disorder to determine if combinational pharmacotherapy and nine months of family-focused therapy (FFT) was more effective than pharmacotherapy with brief psychoeducation in reducing the severity of bipolar-associated symptoms, the recovery time from episodes, and incidence of bipolar episodes. The study, “Pharmacotherapy and Family-Focused Treatment for Adolescents with Bipolar I and II Disorders: A 2-Year Randomized Trial,” is published in AJP in Advance.

Study results showed that adolescents receiving combinational pharmacotherapy and FFT were more likely to have less-severe manic symptoms after two years than those receiving pharmacotherapy with brief psychoeducation. The researchers found no significant difference in recovery time and recurrence of episodes among the two treatment groups.

“The emphasis in FFT on early recognition of prodromal signs of recurrence and communication and problem-solving skills may not translate into benefits for patients until families have implemented these strategies during new cycles of illness,” David Miklowitz, Ph.D, director of the Children and Adolescent Mood Disorders Program at UCLA, told Psychiatric News. Miklowitz concluded that intensive family interventions may be most useful when high family stress and the long-term course of hypomanic or manic symptoms are primary treatment targets.

To read more about bipolar disorder in adolescents, see the Psychiatric News article, “Targeting Specific Factors Might Improve Bipolar Disorder Outcomes." For comprehensive information about treating adolescents with bipolar disorder and other psychiatric illnesses, see Clinical Manual of Child and Adolescent Psychopharmacology, Second Edition from American Psychiatric Publishing.

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Protein Active in Fetal Development May Also Protect Against Alzheimer's in Late Life

A new study published yesterday in Nature suggests that a protein thought to be a key element in the brains of fetuses during development may play a critical role in dementia in older people. The protein, known by the acronym REST, is severely depleted in the brains of older adults with Alzheimer's disease (AD) and other dementias, but seems to offer protection against those disorders in healthy older adults, according to research led by Tao Lu, Ph.D., of Harvard Medical School and colleagues. "REST represses genes that promote cell death and Alzheimer's disease pathology and induces the expression of stress response genes," the researchers explain. But "REST is lost from the nucleus" in AD and other dementias, they point out, but was found in levels three times as high in subjects aged 73 and older who did not display dementia symptoms. The protein is barely detectable in young adults, they note.

“This is one of the most fascinating genetic studies in medicine I have seen in a long time," geriatric psychiatrist and former APA President Dilip Jeste, M.D., told Psychiatric News. "Whereas typical genetic investigations focus on genes and proteins that increase the risk of specific diseases, this study examines the role of a protective protein—REST—that appeared to reduce the risk of developing dementia in highly vulnerable older adults with multiple plaques and tangles in their brains.... The suggested reactivation of a fetal protein in old age that may serve to protect against Alzheimer’s disease and other dementias is remarkable. Finally, the reported association of lithium with promoting REST activity may open new windows into our understanding and possible treatment of dementias. It may also shed new light on the cognitive impairment that is commonly seen in people with mood disorders. Obviously, any specific study has its limitations, and much further work is needed to replicate and extend these results. Nonetheless, there is reason for cautious optimism that new discoveries may be on the horizon.”

Read more about Alzheimer's research in the Psychiatric News articles, "High BDNF Levels May Offer Protection Against Alzheimer's" and "Plasma APOE Levels Linked to Dementia Risk."

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Cultivating the Next Generation of Psychiatrists

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, Carolyn Rodriguez, M.D., Ph.D., and Jonathan Amiel, M.D. Please send your comments to pnupdate@psych.org.

The beginning of a psychiatrist’s career after residency or fellowship is an exciting, but daunting, time. Whatever career path he or she is pursuing—clinical practice, academics, public sector, or industry—the transition from trainee to professional is critically important and often stressful. There is the challenge of having primary responsibility for one’s own patients. The desire to become comfortable in a new work environment and with new colleagues. The understanding that no matter how thorough our training has been, there remain difficult situations that arise in practice, testing our knowledge and mettle.

APA well understands the need to support psychiatrists at this stage of their development and even has a special name for them: early career psychiatrists (ECPs). Every psychiatrist and member of APA has faced this juncture in their careers. Consequently, we recently reviewed APA membership survey data to learn what special needs and services applied to this important constituency of our profession.

We were surprised to see that while resident-fellow members saw value and were pleased with APA membership, many weren’t continuing their membership as they entered the field and the professional workforce. We wondered whether this may be due to the fact that, in a changing and challenging environment, we may too often focus on the challenge of the moment over our longer term professional needs and enrichment. This problem was particularly concerning since APA membership is especially helpful early in one’s career for educational and mentoring resources. And more importantly, young members strengthen APA and shape the Association now and for the future.

Read more here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman.

Study Finds 10 Percent of Young Hospital Patients Have Psychiatric Diagnoses

Almost 1 in 10 hospitalizations of children and adolescents aged 3 to 20 are due to a mental illness, according to study released online March 17 in the journal Pediatrics. About 9.6% of young patients in the Kids’ Inpatient Database (KID), covering 4,121 general hospitals in 44 states in 2009, had a primary mental health diagnosis, as did 3.3% of inpatients in a smaller sample of free-standing children’s hospitals, said Naomi Bardach, M.D., an assistant professor of pediatrics at the University of California, San Francisco School of Medicine, and colleagues. The study did not cover freestanding psychiatric hospitals.

Between 17% and 22% of these patients had a primary or comorbid mental health diagnosis, and all the hospital stays added up to $3.5 billion in aggregate charges to the health care system. The most common diagnoses at the general hospitals were depression (44.1%), bipolar disorder (18.1%), and psychosis (12.1%). Substance abuse was a common comorbidity. In the freestanding hospitals, depression (42.2%), externalizing disorder (10.8%), and bipolar disorder (10.6%) were the most common psychiatric diagnoses.

The authors concluded that their study “supports the creation of diagnosis-specific quality measures for all hospitals that admit children.”

For the latest information about the treatment of mental illness in children and adolescents, see Clinical Manual of Child and Adolescent Psychopharmacology, Second Edition and Cognitive-Behavior Therapy for Children and Adolescents, both from American Psychiatric Publishing.

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Early Intervention Appears to Cut First Psychosis Hospitalizations

A program spanning a dozen years provides evidence that early identification and community-wide intervention could help reduce the burden of psychosis on young patients and their families. The Portland [Maine] Identification and Early Referral program (PIER) began in 2001 and identified youths and young adults aged 12 to 35 at high risk for psychosis. After assessment, these individuals were provided treatment for 24 months. The researchers compared rates of first hospital admission for psychosis in the Greater Portland area with three similar urban areas in Maine.

The intervention provided was the Family-aided Assertive Community Treatment (FACT), a mix of psychoeducational multifamily group treatment, assertive community treatment, and supported employment and education, wrote William McFarlane, M.D., of the Maine Medical Center, and colleagues online in Psychiatric Services in Advance.

Based on data from 148 individuals, there were 29.7 fewer first hospitalizations per year over the course of the study, compared with the two years before the start of the study. The mean annual rates of first admissions dropped by 26 percent in Portland but rose by a (nonsignificant) 8 percent in the control areas. “In addition, in the Greater Portland area the rate of first hospital admission for psychosis was inversely correlated with PIER intakes, suggesting that changes in the admission rate were largely associated with the intervention program,” concluded the authors. “The approach shows promise in reducing the tremendous personal, social, and economic burdens imposed by psychotic disorders.”

For more in Psychiatric News about early intervention in psychosis, see the articles, “Maryland Undertakes Ambitious Effort at Early ID of Psychosis” and "Expert Says Early Identification of Psychosis Should Be Priority."

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Poor Cardiovascular Fitness at Age 18 Linked with Early-onset Dementia, Study Finds

It a large population-based cohort study, researchers have found a link between poor cardiovascular fitness and low cognitive performance at age 18 and the later onset of  dementia. The study's lead researcher was Jenny Nyberg, Ph.D., of Sweden's  University of Gothenburg. Results appear in the new issue of Brain.

The study included more than 1 million Swedish men. At age 18, they underwent mental and physical exams as part of their military conscription. These men were then followed up for up to 42 years to see which ones developed early-onset dementia. The researchers then used the data to see whether there was an association between cardiovascular and cognitive fitness at age 18 and early-onset dementia.

The researchers found that such an association did exist. Both low cardiovascular and cognitive performance in early adulthood were associated with an increased risk for future early-onset dementia, but the highest risks were observed for individuals who had poor performance in both areas.

"This technically well-executed study is among the first to link cardiovascular fitness and cognitive functioning at a young age with early-onset dementia," Kostas Lyketsos, M.D., chair of psychiatry at Johns Hopkins Bayview Medical Center and a geriatric psychiatrist, told Psychiatric News. "As the study is observational, high confidence in a causal link is not possible. However, the findings are consistent with other research linking cardiovascular health or disease and cognitive functioning or reserve with late-onset dementia decades later. Much research is needed to translate this finding into a specifically actionable preventative intervention. For now, active efforts to maintain cardiovascular and cognitive fitness through the lifespan, starting at a young age, offer some promise of preventing or delaying the onset of dementia at mid- or later life."

Another large study identified still other risk factors for early-onset dementia. See the Psychiatric News article, "Early-Onset Dementia Linked to Alcohol Abuse, Other Factors."  In addition, extensive information about dementia can be found in American Psychiatric Publishing's Clinical Manual of Alzheimer Disease and Other Dementias.

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Legislation Introduced to Increase Psychiatric Workforce in VA

Legislation was introduced in Congress last week to address the ongoing psychiatric workforce shortage within the Veterans Health Administration (VHA).

Reps. Larry Bucshon (R-Ind.), a heart surgeon, and David Scott (D-Ga.) introduced the Ensuring Veterans’ Resiliency Act (HR 4234), which would establish a demonstration project to recruit psychiatric physicians for full-time employment in the VHA by offering medical loan repayments commensurate with other public and private entities.

“This legislation will help ensure that our nation’s veterans, who often face significant mental health challenges, have access to needed mental health care,” said APA President Jeffrey Lieberman, M.D. Several studies place the rate of posttraumatic stress disorder in veterans of wars in Iraq and Afghanistan at approximately 40 percent, and each year some 6,000 veterans die by suicide.  Most veterans do not receive adequate treatment for mental illnesses in a timely fashion.

APA CEO and Medical Director Saul Levin, M.D., M.P.A., said, “Given that the acute mental health needs of our veterans will be ongoing for years to come, APA strongly supports this legislation. APA commends Reps. Bucshon and Scott for their leadership on this issue and their commitment to ensuring the resiliency of all of our nation’s veterans.”

Specifically, the legislation would establish a three-year demonstration program under the VA modeled on the Department of Defense Health Professions Loan Repayment Program, which offers physicians up to $60,000 in medical school loan repayment for each year of service. It also authorizes the VA to recruit at least 10 psychiatric physicians into the loan repayment program each year; the VA would hire these physicians permanently to fill full-time vacant positions, and program participants must demonstrate a long-term commitment to the VA. Finally, the bill requires a report to Congress on the program’s impact on psychiatric vacancies and recruitment and authorizes a GAO study on pay disparities among psychiatric physicians at the VA.

“Many of the brave men and women who have served our country are returning home without proper attention to their mental health needs,” said Bucshon.  “During my career as a physician and my time working at the VA, I’ve seen firsthand the need for new, dedicated methods that encourage more psychiatrists to choose a career helping veterans. Our veterans have made tremendous sacrifices for this country, and I firmly believe we should do everything in our power to support them. This legislation is a good first step that will help hire many qualified psychiatrists across the country to provide our veterans the assistance they need and deserve.”

For more information on military psychiatric needs, see Care of Military Service Members, Veterans, and Their Families from American Psychiatric Publishing.

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Former APA President and Visionary Robert Gibson, M.D., Dies

Robert Gibson, M.D., APA's 105th president, died March 8 in his Parkton, Md., home.

Gibson was president of APA for the 1976-77 term and had been secretary of the Association from 1972 to 1975. He received his medical degree from the University of Pennsylvania Medical School and served his psychiatric residencies at the Veterans Administration Hospital in Coatesville, Pa., the U.S. Naval Hospital in Bethesda, Md., and the private mental hospital Chestnut Lodge in Rockville, Md. He remained at Chestnut Lodge as clinical administrator until 1960.

In 1960, Dr. Gibson moved to the Sheppard and Enoch Pratt Hospital in Baltimore as director of clinical services. He became medical director and CEO in 1963 and served in that position until 1982, when he was named president and CEO of the hospital.

APA leaders hailed Gibson as a leader who emphasized integrity, accountability, and public service. “Dr. Gibson was an example to us all—a man ahead of his time,” said APA CEO and Medical Director Saul Levin, MD., M.P.A. “Not only was he an exceptionally gifted psychiatrist, teacher, and administrator, he was key in earning the public’s trust in the profession, initiating a team approach to psychiatry, and ensuring that individuals from all backgrounds had access to psychiatric care. Let us honor Dr. Gibson for his vision and tireless leadership for patients.”

Past APA President Steven Sharfstein, M.D., who succeeded Gibson as president of the hospital in 1992, described him as a visionary who helped to introduce the idea of providing a continuum of services in a hospital setting. Sharfstein told Psychiatric News, “At Sheppard Pratt , a private, not-for-profit, long-stay hospital within the psychoanalytic tradition, he brought, during his 30-year tenure as president from 1962 to 1992, day programs, a community mental health center—the only one in the country at the time sponsored by a private psychiatric hospital—an education center, and an employee assistance program. He wrote and spoke widely on the economics of psychiatric care. He was a wonderful mentor to me when I joined Sheppard Pratt in 1986. As APA president in 1976, he fought for third-party coverage of psychiatric treatments, both inpatient and outpatient. He loved APA, our professional standards and ethics. Psychiatry has lost one of its best leaders.”

Study Demonstrates 'Mismatch Negativity' as Potential Biomarker for Psychotic Disorder

A new biomarker may be on the horizon to more accurately identify psychiatric patients who may later develop fulminant psychosis, according to a study published in yesterday's Biological Psychiatry.

Daniel Mathalon, M.D., Ph.D., a professor of psychiatry at the University of California San Francisco, led a study evaluating the amount of mismatch negativity (MMN)—an auditory signaling process that travels to the frontal lobe regions in response to sound—in 101 individuals with a high clinical risk for psychosis, or schizophrenia or no history of mental illness.

The results revealed that MMN was significantly reduced in subjects with schizophrenia and who were at high clinical risk for psychosis, compared with control. There was no difference in MMN among schizophrenia patients and those with elevated risk for psychotic disorder. In addition, MMN was significantly reduced in those high-risk patients who later developed fulminant psychosis compared with those who remained in the high-risk category.

"Our study results show that mismatch negativity deficits precede the onset of psychosis in clinical high risk individuals, and further shows that the larger the deficit, the more imminent the risk for conversion to a psychotic disorder," commented Mathalon. “This remarkable convergence of findings points to the mismatch negativity as a promising electroencephalography-based biomarker of psychosis risk that, with further development, could enhance our ability to identify which individuals are at greatest risk for psychosis and in greatest need of early treatment, particularly if the treatment is associated with potential adverse effects (such as antipsychotic medication)."

To read about other potential biomarkers for detecting the onset of psychosis, read Psychiatric News article,  “Blood Biomarkers Could Aid Prediction of Psychosis Risk.”

Electronic Cigarettes May Be Gateway to Traditional Smoking Among Youth

Electronic cigarettes (e-cigarettes) are marketed to help people quit smoking regular cigarettes and subside nicotine addiction, but a recent study published in JAMA Pediatrics demonstrates that it may be doing the opposite in adolescents.

Researchers from the Center for Tobacco Control Research an Education at the University of California San Francisco conducted the first analysis of the relationship between e-cigarette use and conventional smoking among adolescents in the United States. Data were gathered from the National Tobacco Youth Survey, which included nearly 40,000 middle- and high-school-aged youth. The analysis revealed that e-cigarette use among students doubled between 2011 and 2012, from 3.1 percent to 6.5 percent. In addition, use of e-cigarettes was associated with increased risk to begin conventional cigarette smoking.

Jill Williams, M.D., director of the Division of Addiction Psychiatry at Rutgers University Robert Wood Johnson Medical School, who was not involved with the study, expressed to Psychiatric News that these findings are concerning since the rates of conventional smoking had been declining to record lows. 

“Behavioral health professionals, including psychiatrists, should do more to assess and treat their adolescent and adult patients for tobacco dependence, just as they would for any other substance use disorder," said Williams. "The tobacco industry has a history of marketing 'safer' products to the public, and we should remain skeptical until this is proven with scientific information.” 

Williams concluded that if these products continue to go unregulated, the popularity of e-cigarettes has the potential to undo decades of progress in denormalizing tobacco use and making it more attractive to those with nicotine addiction.

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Researchers May Have Identified Biomarker for Concussion

Finding an objective biomarker to help clinicians diagnose the severity and likely course of a concussion would raise cheers from players of many contact sports, as well as from their families. Now researchers in Sweden report measuring a protein in the blood whose levels appear to do just that. They tested 288 professional hockey players before the start of the season and then followed them from September 2012 through January 2013.

Of those players, 35 received concussions, and 28 of them were included in the study. The researchers used a new immunoassay that was 1,000 times more sensitive than previous techniques, they said.

Total plasma levels of tau, a protein specific to the central nervous system, were elevated for up to six days in the players who had concussions, reported Pashtun Shahim, M.D., of the Clinical Neurochemistry Laboratory at Sahlgrenska University Hospital in Molndal, Sweden, and colleagues online today in JAMA Neurology. “Importantly, [total]-tau concentrations at one hour after concussion predicted the number of days it took for the concussion symptoms to resolve and the players to have a safe return to play,” they said.

The study needs to be replicated in more subjects and with a longer follow-up time, but “represents an important contribution to this field and introduces an innovative technology that may have wide applicability,” said Joshua Gatson, Ph.D., of the University of Texas Southwestern Medical Center in Dallas, and Ramon Diaz-Arrastia, M.D., Ph.D., of the Uniformed Services University of the Health Sciences, in Bethesda, Md., in an accompanying editorial.

To read more about concussions and biomarkers, see the Psychiatric News article, “Researchers Pinpoint Biomarker to Detect Brain Injury.” Also see the book, Management of Adults With Traumatic Brain Injury, from American Psychiatric Publishing.

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Study Finds Chromosome 22q11.2 Deletion Associated With Psychotic, Other Psychiatric Disorders

A large international research project has validated previous findings that chromosome 22q11.2 deletion syndrome, a neurogenetic disorder characterized by deletion of a small part of chromosome 22, is associated with high rates of schizophrenia, attention-deficit/hyperactivity disorder (ADHD), and anxiety and unipolar mood disorders. The study, “Psychiatric Disorders From Childhood to Adulthood in 22q11.2 Deletion Syndrome: Results From the International Consortium on Brain and Behavior in 22q11.2 Deletion Syndrome,” is published in AJP in Advance.

Researchers participating in the International Consortium on Brain and Behavior in 22q11.2 Deletion Syndrome assessed 1,402 study subjects aged 6 to 68 who have been diagnosed with 22q11.2 deletion syndrome for psychiatric disorders with validated diagnostic instruments. They found that ADHD was the most frequent disorder in children (37.1%) and was overrepresented in males. Anxiety disorders were more prevalent than mood disorders at all ages, but especially in children and adolescents with the deletion disorder. Anxiety and unipolar mood disorders were overrepresented in females with the disorder. Psychotic disorders were present in 41 percent of adults over age 25.

“To the authors’ knowledge, this is the largest study of psychiatric morbidity in 22q11.2 deletion syndrome,” the researchers stated. “It validates previous findings that this condition is one of the strongest risk factors for psychosis. Anxiety and developmental disorders were also prevalent. These results highlight the need to monitor and reduce the long-term burden of psychopathology in 22q11.2 deletion syndrome.”

For more information about genetics and psychiatric illness, see the Psychiatric News column, "Change, Challenge, and Opportunity: Psychiatry Through the Looking Glass of Research." Read more on this topic in the book, Psychiatric Genetics: Applications in Clinical Practice, from American Psychiatric Publishing.

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Study Links Indoor Tanning by Teenagers to Other Risky Health Behaviors

Teens who use indoor tanning facilities are more likely than their peers to engage in other risky health behaviors such as binge drinking and drug use, according to a study published in JAMA Dermatology and led by Gery Guy, Jr., Ph.D., a health economist at the Centers for Disease Control and Prevention (CDC), suggesting that indoor tanning is a behavior about which psychiatrists might want to ask. In 2009, and again in 2011, the CDC conducted a Youth Risk Behavior Survey, based on a nationally representative sample of U.S. high school students. Out of approximately 31,000 students surveyed, 26,000 answered a question about indoor tanning, with the researchers using these data for their study.

They found that 16% of the teenagers responding to the 2009 survey and 13% responding to the 2011 survey said they engaged in indoor tanning. The prevalence was significantly greater among the female high school students. Yet among both male and female students, indoor tanning was significantly associated with other risky health behaviors, such as binge drinking and unhealthy weight-control practices. Additionally, indoor tanning among female high school students was linked with illegal drug use and having had sexual intercourse with four or more partners. Use among male students was linked with daily cigarette smoking and taking steroids without a physician's prescription. Also of note, attempted suicide was associated with indoor tanning among male students.

"This study highlights that indoor tanning is fairly common in adolescents and can be associated with other high-risk behaviors," Cathryn Galanter, M.D., a visiting associate professor of psychiatry and director of the Child and Adolescent Psychiatry Training Program at SUNY Downstate Medical Center, said in an interview with Psychiatric News. "Child and adolescent psychiatrists and other health care providers should be aware of the high rates of tanning and its association with other high-risk behaviors and should consider inquiring about indoor tanning with their patients."

More information about the relationship between indoor tanning and mental health can be found in the Psychiatric News article, "Obsessive Tanning Resembles Addictive Behavior."

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CMS Withdraws Proposal Limiting Access to Psychiatric Drugs in Part D

APA applauds the Centers for Medicare and Medicaid Services (CMS) for dropping its plan to make changes to its Medicare Part D prescription program that would have eliminated protected status for certain antidepressants and, in the future, antipsychotics. The plan was met with heavy bipartisan opposition on Capitol Hill as well as from APA, patient groups, and other medical and mental health organizations that argued that it would severely limit access to valuable medications needed by Medicare beneficiaries. APA recently submitted letters to the CMS and Congress on the evidence base for continuing the protections afforded antidepressants and antipsychotics used for the treatment of Medicare beneficiaries. Rep. Tim Murphy (R-Pa.) quoted APA's letter in his questioning of a CMS official in which he strongly opposed the agency's proposed removal of protected status for the two classes of psychiatric drugs.

Today CMS Administrator Marilyn Tavenner wrote, “We will engage in further stakeholder input before advancing some or all of the changes in these areas in future years.... We are committed to continuing to work with Congress to continue to ensure that Parts C and D work best for Medicare beneficiaries.”

“I am delighted to report that APA has been successful in its efforts to help sustain full access to the psychotropic medications for Medicare patients,” said APA President Jeffrey Lieberman, M.D. “Today’s decision by CMS corrects what could have been an unwarranted limitation to the quality of mental health care. Thanks also to Congressman Tim Murphy for his vigorous actions to support psychiatrists and patients with mental illness.”

“We are pleased to see that CMS recognized the potential harm inherent in its proposal to remove the protections currently afforded to antidepressant and antipsychotic medications in Medicare Part D," said APA CEO and Medical Director Saul Levin, M.D., M.P.A. "This is the right decision for Medicare beneficiaries, who will now retain access to these valuable medications.”

Medicare's Part D program has six protected drug categories. CMS proposed eliminating two of those starting in 2015—antidepressant drugs and those that help suppress the immune system. The agency also said in its draft rule proposing to eliminate the classes that it was considering dropping protected status for antipsychotic drugs in 2016.

Lieberman Applauds Rep. Murphy for Stand on Psychotropic Drugs in Part D

APA has submitted a letter to the Centers for Medicare and Medicaid Services (CMS) urging the agency to not move forward with its proposed Medicare rule to remove antidepressants and antipsychotics from protected coverage status. Such status allows Medicare Part D beneficiaries to have access to "all or substantially all" medications in those therapeutic classes.  APA President Jeffrey Lieberman, M.D., was pleased to see that APA’s concerns were discussed at length during a recent House Energy and Commerce Subcommittee on Health convened to discuss the proposed rule.

At that hearing, Rep. Tim Murphy (R-Pa.), a clinical psychologist, read parts of APA's letter to the committee, highlighting in particular CMS’s mischaracterization of APA’s practice guidelines to justify curtailing access to psychotropic medications. During questioning, Murphy queried CMS Principal Deputy Administrator Jon Blum as to whether any psychiatric expert consultation had been consulted in CMS’s clinical review, among other important topics.

Medicare Part D currently has six “protected” classes: antipsychotic agents, antidepressants, anticonvulsants, immunosuppressants, antiretrovirals, and antineoplastics. Part D plans must carry “all or substantially all” of the chemically distinct drugs in these categories on their formularies. For other categories, the plans can typically carry one brand-name drug and one generic drug.

“It is fundamental to the mission of APA to promote scientific inquiry and evidence-based approaches to the treatment of mental illnesses and to ensure that policy is based upon the scientific evidence available,” said Lieberman. “APA has always stated, and its practice guidelines clearly stress, that all antidepressants and antipsychotics are absolutely not comparable nor are they in any way interchangeable. We need to ensure that our patients have access to full range of psychotropic drugs now available to maximize the effectiveness of their treatment and to reduce suffering.”

APA's Board of Trustees is meeting this weekend to discuss this and other issues.

More information is on APA's website.

Hearing Impairment Associated With Depression In Adults, Study Finds

Previous studies have found a link between hearing impairment and depression in children, but data are lacking on whether this holds true for adults as well, according to a study published yesterday in JAMA Otolaryngology-Head and Neck Surgery.

Chuan-Ming Li, M.D., Ph.D., a health and medical researcher at the National Institute on Deafness and Other Communication Disorders, and colleagues conducted a study in more than 18,000 individuals aged 18 and older to assess the impact of hearing loss on depression rates in adult populations. The study found that the rate of moderate to severe depression was 11.4 percent in adults who self-reported hearing impairment, compared with 7.1 in those with “good” hearing and 4.9 percent for individuals with “excellent” hearing. Women were more likely than men to have an association between moderate hearing impairment and depression. There was no association found between self-reported hearing impairment and depression among people aged 70 and older.

After adjusting for health conditions and others factors associated with depression, the data showed that self-reported hearing impairment was in fact independently associated with depression, particularly in women. The authors urged health care professionals to be alert to an increased risk for depression in adult patients who have hearing loss.

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Risk Factors for Development of Major Depression Differ Among Genders, Study Reports

Kenneth Kendler, M.D., a professor in the departments of Psychiatry and Human and Molecular Genetics at Virginia Commonwealth University School of Medicine, led a study identifying factors that distinguish the onset of major depression between men and women. The study, “Sex Differences in the Pathways to Major Depression: A Study of Opposite-Sex Twin Pairs,” is published in AJP in Advance.

Kendler and colleagues assessed 1,057 adult opposite-sex dizygotic twin pairs for the incidence of major depression within a given year, as well as 20 risk factors that may contribute to such incidences. The results showed that 11 of the 20 risk factors differed across gender lines as they relate to the development of major depression. Parental warmth, neuroticism, divorce, social support, and marital satisfaction had the strongest impact on depression in women, whereas childhood sex abuse, conduct disorder, drug abuse, history of major depression, and distal and dependent proximal stress life events had the largest impact in men. Kendler told Psychiatric News that "the developmental pathways to depression in men and women share some important elements, but on average differ from each other in some important ways." He added that whether the findings from his new study can translate into differences in psychotherapeutic treatment responses between men and women is a question that remains to be answered.

To read more about differences in depression between men and women, see the Psychiatric News article, "Do Men Experience Depression Differently From Women?"

(Image: Courtesy of  Virginia Commonwealth University School of Medicine)

The Politics of Psychiatry and Mental Health Care

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 Patrick Kennedy, a senior advisor to APA and a former member of Congress. Please send your comments to pnupdate@psych.org.

Winston Churchill said, “Politics is not a game; it is an earnest business,” and finally we are getting serious about the politics of mental health care. After decades if not centuries of neglect, the bona fide health care disparity is receiving an unprecedented amount of attention. In part, this is due to the efforts to reform our nation’s health care delivery and financing systems to improve quality and rein in costs. But it represents an attitudinal change in our society toward mental illness prompted by the egregious deficiencies in our mental health care policies, sensationally and shockingly, reflected by the rising number of people with mental illness involved in civilian massacres, imprisoned by the criminal justice system, and homeless on the street. However undesirable the factors that may have occasioned it, the increased public attention to mental health care is welcome.

Most recently, we saw this reflected in the November 2013 release of the final rule for the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA), the goal of which is to improve the quality of and access to care for people with mental illness. But this goal can be achieved only if accompanied by adequate oversight and enforcement of the law among insurance companies and providers.

We must be sure health insurance plans are explicitly required to show exactly how their general medical benefits line up with their mental health benefits. Government monitors must be able to determine whether insurance plans are adhering to parity standards in all settings—from primary care offices to specialized mental health and addiction settings.

Read more here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman.

NIMH to Implement New Strategy for Evaluating Psychiatric Research Proposals

The National Institute of Mental Health (NIMH) will make several major changes in the way it selects and funds clinical trials to advance the next generation of therapies for mental disorders. “[F]uture trials will follow an experimental medicine approach in which interventions serve not only as potential treatments, but as probes to generate information about the mechanisms underlying a disorder,” said NIMH Director Thomas Insel, M.D., in a new policy announcement. “In the current climate, with funding tight and clinical needs urgent, we will be shifting to trials that focus on targets as a way of defining the next generation of treatments.”

Investigators will have to identify a target or mediator on which the intervention must have some effect, as well as influencing symptoms, said Insel. Researchers will also have to move more quickly through the approval, recruitment, and completion processes. They must meet stringent transparency standards for trial registration, monitoring human protection, and posting their results. Finally, new clinical trials will not be supported under previous funding announcements.

“We believe that better outcomes will require a deeper understanding of the disorders,” he said. “These new clinical trials are designed to provide that.”

To read more in Psychiatric News about clinical trials in psychiatry, see the article, “Psychiatrist Norquist Chairs Outcomes-Research Project.”

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Innovative Integrated Care Program Helps Communities Affected by Gulf Oil Spill

The BP/Deepwater Horizon disaster in April 2010, not only dumped 4.9 million barrels of oil into the Gulf of Mexico but also left coastal populations in Louisiana, Alabama, Mississippi, and Florida with increased symptoms of posttraumatic stress disorder, depression, and generalized anxiety, according to surveys by the Department of Psychiatry at Louisiana State University Health Sciences Center (LSUHSC).

In response, and with the help of a court-approved financial settlement, the affected states each organized a Mental and Behavioral Health Capacity Project (MBHCP) to “increase knowledge and provide sustainable evidence-based services” in the area, said Howard Osofsky, M.D., Ph.D., a professor and chair of psychiatry at LSUHSC, online yesterday in Psychiatric Services in Advance.

In Louisiana, the MBHCP consulted with local practitioners and community members and then developed “an interprofessional stepped-care collaborative” to provide care in mainly rural, underserved communities. Psychiatrists or psychologists work in each of five primary care clinics, which offer behavioral health care screening, diagnosis, acute and emergency care, and follow-up treatment. The specialist mental health providers work closely with the primary care staff, both to collaborate on treatment and to help expand the latter’s understanding of behavioral health. In addition, care managers monitor progress and maintain contacts among patients and clinicians.

This model might be adaptable for other communities affected by disasters and also rural communities in general that face shortages of mental health clinicians, concluded Osofsky and colleagues.

To read more about the mental health sequelae of the BP oil spill, see the Psychiatric News article, "MH Care Benefits From Oil Spill Settlement." And to read more about the benefits of integrated care in treating mental health problems, see the article, "Looking at Psychiatry Through a Population Lens."

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