Researchers Call for More Studies to Clarify Relationship Between Autism and GI Symptoms

Parents often report gastrointestinal (GI) problems in children diagnosed with autism spectrum disorder (ASD), yet great uncertainty remains about the association and any possible causation. Now a new meta-analysis of studies covering 2,215 children finds a greater risk of some gastrointestinal symptoms in children with ASD that in peers without the disorder.

Children with ASD experience more general gastrointestinal symptoms, diarrhea, constipation, and abdominal pain, report Barbara McElhanon, M.D., and colleagues in the Department of Pediatrics at Emory University School of Medicine. However, the studies, often based on parents' reports or retrospective chart reviews, frequently lacked methodological rigor, said the authors, writing online April 28 in the journal Pediatrics. “No studies included confirmation of GI problems by a third-party care provider such as a physician."

They said that too few data were available from the original studies to draw conclusions about connections between ASD and organic pathologies or behavioral factors such as toilet training or feeding problems.

“As a result, the most logical conclusions remain that rates of other GI pathophysiology in ASD are similar to those observed in the general population, and there is no evidence suggesting a unique GI pathology in ASD,” they concluded. “Additional research is needed to elucidate the etiology, prevalence, topography, and remediation of GI problems in ASD, with consideration of the potential interwoven contributions of factors such as immune abnormalities, mucosal barrier dysfunction, gastrointestinal motility, feeding and toileting concerns, and the gut microbiome.”

For more in Psychiatric News about the intersection between psychiatric and gastrointestinal disorders, see "Childhood Stomach Pains May Foretell Adult Anxiety Disorders."

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Legalizing Marijuana Could Harm Adolescents, Say Child Psychiatrists

“Marijuana use is not benign, and adolescents are especially vulnerable to its many known adverse effects,” the American Academy of Child and Adolescent Psychiatry says in a new policy statement. The academy therefore opposes efforts to legalize marijuana, even as more states pass legislation to permit its sale, either for recreational or medicinal purposes.

"The academy’s policy statement reflects the growing body of research documenting the detrimental effects of marijuana on adolescent brain development and functioning,” said child and adolescent psychiatrist David Fassler, M.D., a clinical professor of psychiatry at the University of Vermont and APA treasurer, in an interview with Psychiatric News. “The policy specifically notes concerns about the increased risks and severity of substance abuse, as well as mood and anxiety disorders.”

While nominally restricted to adults, legalized sale of marijuana will likely increase use among parents and cause adolescents to dismiss the drug’s harmful effects, according to the statement.

Many child and adolescent psychiatrists believe that the criminalization of marijuana possession and its use has also harmed children and families, Fassler noted. “For this reason, the academy’s policy emphasizes the importance of improved access to appropriate and effective treatment for adolescents, rather than encouraging enhanced criminal charges and penalties,” he said.

To read more about the legalization of marijuana and its potential effects on young people, see the Psychiatric News column, “Marijuana Legalization and Young Brains: Time for Serious Study.”

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Comparison of Youth Diagnosed With ADHD Using DSM-IV and DSM-5 Supports Criteria Revisions

A comparison of young people diagnosed with attention-deficit/hyperactivity disorder (ADHD) using DSM-IV criteria and the new DSM-5 criteria that extends the age of onset from age 7 to 12, appears to support that change. The study appears online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Kathleen Merikangas, Ph.D., and colleagues at the national Institute of Mental Health compared the prevalence and clinical correlates of ADHD as described in the two DSM editions in a nationally representative sample of U.S. youth based on the age-of-onset criterion. The sample included nearly 1,900 participants aged 12 to 15 from cross-sectional National Health and Nutrition Examination Survey (NHANES) surveys conducted from 2001 to 2004. Data on DSM-IV and DSM-5 criteria for ADHD were derived from administration of the parental ADHD module of the National Institute of Mental Health Diagnostic Interview Schedule for Children, Version IV (DISC-IV).

The researchers found that the extension of the age-of-onset criterion from 7 to 12 led to an increase in the prevalence rate of ADHD from 7.38% (DSM-IV) to 10.84% (DSM-5). Importantly, youth with later age of onset did not differ from those with earlier age of onset in terms of severity and patterns of comorbidity. “The comparability of the clinical significance of the early and later age-of-onset groups supports the DSM-5 extension of the age-of-onset criterion in ADHD,” Merikangas and colleagues concluded.

For more about changes to ADHD criteria in DSM-5, see the Psychiatric News article, "Clinicians in DSM-5 Field Trials Have Positive Response to Revisions." To order any of the publications in the DSM-5 library, click here.

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Personality May Mediate Effects of Childhood Trauma in Patients With Psychosis, Study Finds

Certain adaptive personality traits—such as openness, agreeableness, and conscientiousness—appear to mediate the relationship between traumatic experiences and quality of life and social withdrawal among patients with psychotic disorders, according to a study published online in Schizophrenia Bulletin.

Lindy-Lou Boyette, M.D., of the Department of Psychiatry at the Academic Medical Centre University of Amsterdam, and colleagues used the Five-Factor Model of personality traits (neuroticism, openness, agreeableness, extraversion/introversion, and conscientiousness) to examine these traits and their relationship to quality of life and social withdrawal in 195 patients with psychotic disorders and 132 controls who had experienced either high or low levels of childhood trauma. The researchers assessed whether patients with different profiles differed in social functioning and quality of life (QoL), while controlling for possible confounders.

Patients with higher levels of self-reported traumatic experiences generally showed lower QoL and more social withdrawal compared with patients with lower traumatic experiences. But patients with high levels of trauma who had lower neuroticism and higher extraversion, openness, agreeableness, and conscientiousness also had higher levels of QoL and better social functioning in several areas, compared with patients with both high and low levels of trauma who did not have those adaptive traits. “Our findings indicate that personality may 'buffer' the impact of childhood traumatic experiences on functional outcome in patients with psychotic disorders,” they concluded.

For research on treatment for psychosis that can improve patients' quality of life, see the Psychiatric News article, "Form of CBT Can Improve Stubborn Psychosis Symptoms."

 

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Migraines May Affect Outcomes in Bipolar Disorder Patients, Study Finds

Migraine headaches are significantly more common in individuals with bipolar disorder than in those without, especially in women with bipolar disorder. And individuals who have both bipolar disorder and migraines experience significantly more frequent depressive episodes and significantly more severe depressions over the long term than individuals who have bipolar disorder alone.

These are several of the findings that Erika Saunders, M.D., executive vice-chair of psychiatry at Penn State Milton S. Hershey Medical Center, and colleagues made in a longitudinal study of 569 subjects—412 of whom had bipolar disorder and 157 of whom served as healthy controls. Thus, "Migraine is a common comorbidity with bipolar disorder and may impact the long-term outcome of bipolar disorder, particularly depression," the researchers concluded in their paper, which appears in the Journal of Clinical Psychiatry.

Their findings have clinical implications, Saunders told Psychiatric News. "Clinicians should screen for migraine headaches in patients with bipolar disorder, particularly adolescents with early onset of bipolar disorder, and clinicians should be alert for hypomania and mixed symptoms in men with migraine. We can hypothesize that poor control of migraine headaches could worsen the course of illness of bipolar disorder, but we don't know from our data if it was the presence of the migraine headaches or whether it was poor control of the migraine headaches that caused the worse depressive outcomes." Saunders added that in treating patients with migraine and bipolar disorder, "I collaborate with the provider treating the migraines to optimize care for improvement of both the mood and pain outcome."

More information about bipolar disorder can be found in American Psychiatric Publishing's Clinical Guide to Depression and Bipolar Disorder. Information on how migraines impact the brain can be found in the Psychiatric News article, "Long-Term Brain Changes Linked to Migraine With Aura."

(Image: Erika Saunders, M.D.)

Study Finds Link Between Diabetes and Both Impulse Control Disorders and Depression

In a large international study, researchers found a significant link between binge-eating disorder, bulimia nervosa, major depressive disorder, and intermittent explosive disorder and the later occurrence of type-2 diabetes.The study was headed by Peter de Jonge, Ph.D., a professor of psychiatry at the University of Groningen in the Netherlands. The results are described in the April Diabetologia, which is published by the European Association for the Study of Diabetes.

De Jonge and colleagues surveyed about 52,000 adults in 19 countries. The World Health Organization Composite International Diagnostic Interview was used to retrospectively evaluate the lifetime prevalence and age at onset of 16 DSM-IV  mental disorders. Subjects were also asked whether their physicians had diagnosed them as having type-2 diabetes, and if so, when the diagnosis was made. The researchers then assessed any significant associations between the mental disorders of interest and subjects' subsequent diagnosis of type-2 diabetes, while taking comorbidity of the various mental disorders into account. They found associations with four mental disorders—binge-eating disorder, bulimia nervosa, major depressive disorder, and intermittent explosive disorder.

"Although affective disorders are well known to be associated with diabetes, this international epidemiological study finds an association between glucose dysregulation and a variety of other psychiatric disorders as well," psychiatrist Thomas Wise, M.D., medical director of Inova Health Systems in Falls Church, Va., and a psychosomatic medicine expert, told Psychiatric News. "[The research] reinforces the urgent need to develop practical models of psychiatric integration into primary and specialty care settings to work as part of a team utilizing disease and behavioral approaches for such serious comorbid disorders," said Wise, who is also a former chair of the American Psychiatric Publishing Board of Directors.

To read more information about the interaction between psychiatric illness and diabetes, see the Psychiatric News article, "Dementia-Risk Rises in Patients With Depression and Diabetes."

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FDA Proposes New Rule to Control E-Cigarettes, Other Tobacco Products

The U.S. Food and Drug Administration yesterday proposed a rule extending the agency’s authority to regulate electronic cigarettes and other tobacco products.

“E-cigarettes” vaporize liquid nicotine for inhalation. They are controversial because they are seen by some as devices that only perpetuate nicotine addiction and by others as a useful way to wean smokers off ordinary cigarettes, much like nicotine patches or gum. E-cigarettes are also a public health concern for individuals with severe mental illness because of their high rate of nicotine use.

Besides the addictive potential of e-cigarettes, the liquid nicotine used by e-cigarettes can be toxic when ingested or absorbed through the skin. Poison control officials have raised concerns about that danger, especially for young children who pick up bottles of the liquid that adults use for refilling the e-cigarettes.

The FDA already regulates cigarettes and cigarette tobacco, as well as snuff and chewing tobacco. Along with e-cigarettes, the agency seeks to add cigars, pipe tobacco, nicotine gels, and hookah tobacco to its purview. The proposal would add age restrictions to sales of such products, add health warnings, and prohibit sales from vending machines accessible to young people.

The proposed rule, said FDA Commissioner Margaret Hamburg, M.D., in a statement, “would also help to correct a misperception by consumers that tobacco products not regulated by FDA are safe alternatives to currently regulated tobacco products.”

The FDA has opened a 75-day period for anyone who wishes to comment on the proposal.

For more in Psychiatric News about e-cigarettes, see "Electronic Cigarettes May Be Gateway to Tobacco Smoking."

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Marijuana Legalization and Young Brains: Time for Serious Study

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 Robert DuPont, M.D. Please send your comments to pnupdate@psych.org.

While we debate and differ on the risks and benefits of legalization, decriminalization, and medical uses of marijuana, all will agree (or say they do) that marijuana should remain illegal for young people. However, we should not deceive ourselves; just like with alcohol and tobacco, young people will almost certainly have ready access to pot with the liberalization of our laws and the commercialization of marijuana. What we are missing in fully understanding the ramifications of this new legislation, which can have broad effects on our country and culture, is firsthand knowledge of how marijuana affects the brain, particularly the young brain. Without more scientific evidence, we are gambling with the health and safety of our young people based on speculation and wishful thinking. Moreover, our national wager will increase as more states move to legalize marijuana.

The irony is that we currently have the capacity to determine whether there are harmful effects of marijuana on the developing brain. The rapid growth of brain science in the last two decades has provided the capacity to measure the effects of drugs on behavior and mental functions and to identify brain changes in structure and function—something not previously possible. Substantial evidence from animal models and several human studies has shown that drug use produces a sensitization of brain circuits that leads to sustained drug use and to progression to additional damaging drug use and to perpetuation and relapse during abstinence. The tragic death of Philip Seymour Hoffman is a prime example of these enduring effects. After a period of extensive drug use in his youth, he was drug-free for 20 years, only to fall victim to a common prescription for a pain medicine that triggered a fatal relapse into addiction at age 46.

The National Institute on Drug Abuse (NIDA) has funded groundbreaking research to understand specifically how drugs change the brain in a way that impairs mental functions and leads to addiction. This research has revealed how otherwise dissimilar drugs act through common neural pathways of reward to cause addiction. These fundamental pathways are hijacked by drugs that stimulate them far more intensely than do natural rewards like food and sex, which affect the same brain-reward system. That is why food and sex pathologies have so much in common with addiction to tobacco, alcohol, and other drugs, including marijuana.

To read more, click here.

You can follow Dr. Lieberman on Twitter at @DrJlieberman. To do so, go here, log in or register, and click on “Follow.”

Aerobic Activity in Young Adulthood May Preserve Midlife Cognitive Function, Study Finds

Young adults who participate in cardio fitness activities such as running may be doing more than helping to preserve their heart function—they may be helping to preserve their memory and thinking skills as well, according to a recent study published in Neurology. Researchers at the University of Minnesota conducted a study with nearly 3,000 healthy individuals in their mid-20s to assess the relationship between aerobic exercise and cognitive function. The participants were subjected to one year of treadmill tests starting at study initiation and another series of treadmill tests, in addition to cognitive tests, 20 to 25 years later. During the treadmill tests, participants were evaluated on their ability to endure increasing speeds and inclines without shortness of breath.

Study results showed that participants lasted an average of 10 minutes on treadmills during young adulthood, compared with an average of 7.1 minutes at middle age. Every additional minute completed on the treadmill during young adulthood was significantly associated with more words and numbers being recalled on tests evaluating memory and psychomotor speed at ages 45 to 55—even after adjusting for factors such as smoking, diabetes, and cholesterol level.

“Normal aging is associated with worsening of memory and slowing of psychomotor speed in middle and old age,” Dilip Jeste, M.D., director of the Sam and Rose Stein Institute for Research on Aging at the University of California, San Diego, and a professor of psychiatry and neurosciences, told Psychiatric News. “Though the [present] findings need to be replicated in prospective longitudinal research,…the findings suggest that activities such as running can potentially reduce cognitive impairment in later life. Following these adults into old age may help determine if neurocognitive disorders such as dementia are less common in the individuals who engaged in vigorous exercise at younger age.” Jeste, who is a past president of APA, urged clinicians to encourage physical activity, especially aerobic exercise, in all of their patients—young and old—according to the patient’s personal physical capacity. “It can help not only their muscles and heart, but possibly also their brains in later life.”

To read more about research on the impact of exercise on cognitive preservation, see the Psychiatric News article, “Cardiovascular Fitness May Help Prevent Early-Onset Dementia. ”For extensive information on neurocognitive disorders, see American Psychiatric Publishing's Clinical Manual of Alzheimer Disease and Other Dementias.

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Intravenous Ketamine May Be Effective in Treating Chronic PTSD, Preliminary Study Suggests

Intravenous ketamine appears to produce rapid reduction in symptom severity in patients with chronic PTSD, according to the report of a “proof-of-concept” study reported online in JAMA Psychiatry. The findings need to be replicated and extended, but could lead to novel pharmacologic treatments of this condition if results are replicated.

Researchers at the Icahn School of Medicine at Mount Sinai conducted a proof-of-concept randomized, double-blind, crossover trial comparing ketamine with an active placebo control, midazolam. Subjects received intravenous infusion of ketamine or midazolam. The primary outcome measure was change in PTSD symptom severity, measured with the Impact of Event Scale–Revised. Secondary outcome measures included the Montgomery-Asberg Depression Rating Scale, the Clinical Global Impression-Severity and Clinical Global Impression–Improvement scales, and adverse-effect measures.

Ketamine infusion was associated with significant and rapid reduction in PTSD symptom severity, compared with midazolam, when assessed 24 hours after infusion. It was also associated with reduction in comorbid depressive symptoms and improvement in overall clinical presentation. Ketamine was generally well tolerated.

Lead author Adriana Feder, M.D., told Psychiatric News that the study is the first proof-of-concept, randomized clinical trial of a single intravenous dose of ketamine for patients with chronic PTSD, compared to a single intravenous dose of midazolam. Since it is a proof-of-concept study, however, she said that "longer-term clinical trials will be necessary to determine whether ketamine will be a useful treatment for PTSD in clinical practice. To date, few pharmacotherapies have been shown to be sufficiently effective in the treatment of PTSD. These findings may lead to novel approaches in the treatment of this condition.” Feder noted that she and the study's principal investigator, Dennis Charney, M.D., have been named as inventors on a patent application covering use of ketamine for PTSD treatment. The study was funded by a grant from the Department of the Army-U.S. Navy Medical Researcher Acquisition Activity.

To read about research on other possible uses of ketamine in treating mental illness, see the Psychiatric News article, "Ketamine Outperforms ECT in Depression Study."

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Study Find Substantial Evidence for Effectiveness of Skill Building in Patients With Psychosis

Skill building—which involves strategies for helping adults with serious mental illness manage their illness, develop daily-living skills, and succeed in recovery—should be a foundation for rehabilitation services covered by comprehensive insurance benefit plans. That’s the finding from the study, "Skill Building: Assessing the Evidence,” published in Psychiatric Services in Advance.

Researchers from multiple institutions searched meta-analyses, research reviews, and individual studies from 1995 through March 2013. In this review, they examined four key components of skill building: social skills training (including life skills training), social cognitive training, cognitive remediation, and cognitive-behavioral therapies that target skills for coping with psychotic processes. The researchers chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology.

More than 100 randomized controlled trials and quasi-experimental studies support rating the level of evidence as high. Study outcomes indicated strong effectiveness for social skills training, social cognitive training, and cognitive remediation, especially if these interventions are delivered through integrated care approaches. Results are somewhat mixed for life skills training (when studied alone) and cognitive-behavioral approaches.

"The current body of research has established the value of skill-building approaches," the researchers said. "Although further research will help clarify their effects on some outcomes, research is not needed to support the decision to include skill-building approaches as covered services, particularly for individuals with schizophrenia and other psychotic disorders."

The article is part of a series of literature reviews being published in Psychiatric Services, commissioned by the Substance Abuse and Mental Health Services Administration. To read more about the "Assessing the Evidence" series, see the Psychiatric News articles, "Study Finds Evidence Showing Supported Employment Works" and "Housing Programs Effective, but Studies Plagued by Limitations."

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Antidepressants Alter Brain Response to Both Positive and Negative Stimuli, Study Finds

Yina Ma, Ph.D., a research scientist at Johns Hopkins' Lieber Institute for Brain Development, conducted a meta-analysis of 60 fMRI studies, involving some 1,600 subjects, to determine how antidepressants work in the brain. Based on her findings, she concluded that those medications, when given along with cognitive-behavioral therapy (CBT) may produce optimal therapeutic effect.

As she reports in Molecular Psychiatry, "Antidepressants act to normalize abnormal neural responses in depressed patients by increasing brain activity to positive stimuli and decreasing activity to negative stimuli in the emotional network and [by] increasing engagement of the regulatory mechanisms in the dorsolateral prefrontal cortex." The dorsolateral prefrontal cortex is known to be a key region in mediating the regulation of both positive and negative emotions, she explained.

These findings about the action of antidepressants in the brain "have important implications in the treatment of depression," she noted, as does evidence about the effectiveness of CBT. Although both antidepressant and cognitive-behavioral treatments "affect emotion-related and prefrontal circuits to a similar end state of normalized emotional network and prefrontal activity, the mechanisms by which each treatment acts may differ. Although it has been proposed that CBT targets prefrontal function as it focuses on increasing inhibitory executive control, the current findings raise the possibility that antidepressants may act more directly on the emotional network. Taken together, a combination of an early antidepressant medication and follow-up CBT may therefore result in a better therapeutic effect, a possibility that needs to be directly addressed in future research."

To read more about how antidepressants work in the brain, see the Psychiatric News articles, "What Is the Link Between SSRIs and Fear Extinction?" and "Study Uncovers More Clues About Antidepressants' Action."

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Drug Education Prompts Elderly to Reduce Benzodiazepine Use, Study Finds

According to a study published in this week’s JAMA Internal Medicine, discontinued use of benzodiazepines by the elderly is made easier when patients are educated about the medication’s potential harm.

Researchers from the departments of pharmacy and geriatrics at the University of Montreal conducted a study to determine whether educating older patients on the health risks of benzodiazepines would serve as an effective method to discourage the use of such drugs. The study included 303 long-term users of benzodiazepines, aged 65 to 95. The participants were randomly selected to receive a booklet describing adverse health risks of benzodiazepines, along with instructions on how to safely reduce use of the medication and information on alternative strategies for treating insomnia and anxiety.

At the six month follow-up, the results showed that 62 percent of the patients who received booklets initiated a conversation with their physician or pharmacist about benzodiazepine therapy cessation, while 27 percent completely discontinued use. Patients who were not educated on the potential harms of benzodiazepines had a discontinuation rate of 5 percent.

The authors wrote, "In an era of multimorbidity, polypharmacy, and costly therapeutic competition, direct-to-consumer education is emerging as a promising strategy to stem potential overtreatment and reduce the risk of drug harms." The authors concluded that "the value of the patient as a catalyst for driving decisions to optimize health care utilization should not be underestimated."

To read about treatments and diagnosis of sleep disorders and anxiety, see Essentials of Geriatric Psychiatry, Second Edition from American Psychiatric Publishing.

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Effects of Childhood Bullying Extend Well Into Middle Age, Study Finds

A study published in today’s AJP in Advance—"Adult Health Outcomes of Childhood Bullying Victimization: Evidence From a Five-Decade Longitudinal British Birth Cohort"—suggests that impact of being bullied in childhood may persist at least until midlife.

Researchers from the Institute of Psychiatry at King’s College, London, gathered data from the British National Child Development Study—which follows the lives of all children born in England, Scotland, and Wales during one week in 1958—to assess the ramifications of childhood bullying victimization into adulthood. The researchers analyzed data of nearly 8,000 participants with information concerning bullying exposures between ages of 7 and 11 and who participated in follow-up well-being assessments between ages 23 and 50.

The results showed that participants who were victims of childhood bullying had higher rates of depression, anxiety, and suicidal ideation at age 45, compared with those who were not bullied. In addition, victims of childhood bullying were less likely to be living with a partner and have social relationships and were more likely to endure economic hardships and have a poor perceived quality of life at age 50.

David Fassler, M.D., a clinical professor of psychiatry at the University of Vermont, and a child and adolescent psychiatrist, stated during an interview with Psychiatric News, “Despite increased awareness and the widespread implementation of school-based prevention programs, bullying remains a common experience for many young people. The current results underscore the importance of early recognition and access to appropriate and ongoing treatment for both bullies and their victims, as well as the need for additional research on the efficacy of programs designed to reduce the incidence of childhood bullying."

To read more about the impact of childhood bullying on mental health, see the Psychiatric News article, “Effects of Bullying Don’t End When School Does.” Also see the book Preventing Bullying and School Violence from American Psychiatric Publishing.

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Problem-Solving Therapy May Help Prevent Onset of Major Depression In Elderly, Study Finds

According to a study published in Psychiatric Services, problem-solving therapy for primary care (PST-PC)—an intervention delivered by nonmental health professionals to help patients improve coping skills and confidence—may serve as a beneficial therapy for older adults who are at risk for major depression.

Charles Reynolds III, M.D., a professor of geriatric psychiatry at the University of Pittsburgh Medical Center, and colleagues evaluated the efficacy of PST-PC in preventing episodes of major depression and reducing depressive symptoms in elderly adults. The study, "Early Intervention to Preempt Major Depression Among Older Black and White Adults," included approximately 250 individuals with subsyndromal depressive symptoms who received 15 months of PST-PC, a technique that has been shown to reduce stress, or dietary coaching, which had been shown to reduce depression risk in an elderly population in a previous study by Reynolds. The two cohorts were compared with each other, in addition to being compared with age-matched cohorts from previously published studies of those who received neither therapy for subsyndromal depressive symptoms.

After two years, the analysis showed PST-SC to be just as effective as dietary coaching in preventing episodes of major depression in this at-risk cohort. Incident rates for major depression in both cohorts were approximately 9%, compared with published rates of 20% to 25% in those who received neither treatment. The researchers also observed a significant reduction in depressive symptoms in both PST-SC and dietary-coaching groups.

“Avoiding episodes of major depression can help people stay happy and engaged in their communities...," commented Reynolds. “This project tells us that interventions in which people actively engage in managing their own life problems...tend to have a positive effect on well-being and a protective effect against the onset of depression.”

To read more about the role of problem-solving therapy in treating mental illness, see the Psychiatric News article, "Future Looks Promising for Mental Illness Prevention."

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Psychiatrists' Role in the Brave New World of 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 Grant Mitchell, M.D. Please send your comments to pnupdate@psych.org.

Health care reform has been a long time coming. Although many date the start of the health care reform process with the passage in 2010 of the Affordable Care Act (aka Obamacare), the economic and social forces that are driving it have been building for decades. (Think Medicare, Medicaid, HMOs, managed care, Hillary Clinton, and Harry and Louise [see here]). However, even now, many health care providers, and physicians in particular, would prefer to deny the inevitable: the transformative changes that will occur in the U.S. health care system.

It is true that we don’t know whether this change will be a gentle set of waves or a tsunami, and we don’t know into what form the health care system and the roles of its providers will ultimately be reconfigured. We just know that a comprehensive transition is looming.

In a previous column (“Change, Challenge, and Opportunity: Psychiatry in the Age of Health Care Reform,” Psychiatric News, October 4, 2013), Howard Goldman and I discussed the health care reform process from the macro health policy and economic perspectives. In this article, Grant Mitchell and I discuss how this will impact individual psychiatrists.

The goal of a transformed health care system is to expand care, improve quality, and lower costs. These goals may seem antithetical. Indeed, this is especially concerning to patients with mental illness and limited resources who have historically had limited access to care. Psychiatrists know firsthand this frustration, and that of their patients and their families, with the current models of care and financing: limited payments and visits, with silos between physicians that contribute to fragmented care. And although it’s gratifying that timely and ongoing treatment of psychiatric disorders is finally being recognized as critical to controlling health care costs, we are waiting for stronger policies that will remove the barriers to access to care and payment for such care.

Read more here.

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

Evaluation of Integrated Care at CMHCs Reveals Successes, Challenges

Integrated care can take many forms. One is to offer primary and other general medical care services to patients already receiving psychiatric services at a community mental health center (CMHC), notes a new report by Deborah Scharf, Ph.D., of the RAND Corp. To test that care paradigm, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) began awarding Primary and Behavioral Healthcare Integration (PBHCI) service grants to expand primary care access at CMHCs.

The evaluation of the programs found that patients enrolled in PBHCI clinics show improvement in measures of dyslipidemia, hypertension, and diabetes but not on others, like smoking or excess weight, compared with those receiving services at non-PBHCI clinics. “SAMHSA and its partner agencies may benefit from replicating successful initiatives, refining delivery of services, and working with state policymakers to further coordinate policies affecting delivery of integrated care,” the researchers concluded.

"As project director for one of the PBHCI grant projects studied by RAND, I am pleased to see that access to care for our medically at-risk populations can be improved by integrated on-site availability in the mental health setting,” said psychiatrist John Kern, M.D., chief medical officer at Regional Mental Health Center in Merrillville, Ind., in an interview with Psychiatric News.

To read more about the move to integrated care, see the Psychiatric News articles, "NIMH Fosters ‘Practice-Ready’ Solutions to Integrating Primary, MH Care" and "Get Started in Integrated Care by Picking Up the Phone," which is written by Kern. Read previous findings from the same research group in the Psychiatric Services
article, "Integrating Primary Care Into Community Behavioral Health Settings...."
 

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Study Finds Varying Rates of PTSD In and Out of VA Health System

Only about half of U.S. veterans who served in Iraq or Afghanistan seek care from the Veterans Health Administration (VHA), and the VHA says that 22% of that cohort were diagnosed with posttraumatic stress disorder (PTSD). Other surveys of veterans, however, record much lower rates, noted Christine Vaughan, Ph.D., and colleagues from the RAND Corporation in the Psychiatric Services in Advance study, "Prevalence of Mental Health Problems Among Iraq and Afghanistan Veterans Who Have Received and Not Received VA Services.” The authors said that their data point to the need for connecting more veterans with mental health care services.

The study of a sample of 913 veterans living in New York state found that rates of probable PTSD (23%), probable depression (21%), or either diagnosis (30%) for those using the VHA system were about three times higher than for those not receiving VHA care. The comparable rates for those not using VHA services were 6%, 8%, and 11%, respectively. Those differential results suggest that rates for these psychiatric disorders among VHA patients don’t reveal the wider dimensions of veterans’ health problems. Still, the lower rates for nonusers should be cause for concern, the researchers noted.

“Given the size of the previously deployed force and the low rate of VHA enrollment, this proportion represents a significant number of veterans whose treatment needs are not being met by the VHA,” concluded Vaughan and colleagues. “Considerable improvement in the health status of veterans may be achievable if they can be connected with high-quality services.”

To read more about mental health care for veterans, see the Psychiatric News articles, "Military Mental Health Issues Will Be in Meeting Spotlight" and "Knowledge of Military Life Facilitates Vets' Mental Health Care."

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Bipolar Disorder Patients in Integrated Primary Care May Need More-Intensive Services, Study Shows

Primary care patients with bipolar disorder enrolled in an integrated care system in Washington state may require more intensive services than currently provided in a collaborative care model, according to a study, “Bipolar Disorder in Primary Care: Clinical Characteristics of 740 Primary Care Patients With Bipolar Disorder,” which is published online today in Psychiatric Services.

Researchers from the University of Washington identified 740 primary care patients with bipolar disorder in the statewide mental health integration program (MHIP) between January 2008 and December 2011 using the Composite International Diagnostic Interview and clinician diagnosis. The MHIP uses collaborative care based on the IMPACT model (Improving Mood–Promoting Access to Collaborative Treatment) to improve recognition and systematic treatment of patients with psychiatric disorders in primary care settings.

Primary care patients with bipolar disorder had high symptom severity on both depression and anxiety measures using the Patient Health Questionnaire and the Generalized Anxiety Disorder scale. Psychosocial problems were common, with approximately 53% reporting concerns about housing, 15% reporting homelessness, and 22% reporting lack of a support person. Yet only 26% of patients were referred to specialty mental health treatment.

Study co-author Wayne Katon, M.D. (photo above), vice chair of the Department of Psychiatry at the University of Washington, said that the study indicates that these patients may need more-intensive care than is currently provided in a collaborative care model, in which a care manager, supervised by a psychiatrist, provides the direct patient care. “The importance of this article is that the U.S. federally qualified primary care clinics, as well as many primary care clinics that treat both uninsured and Medicaid patients, are likely to have a significant percentage of patients with bipolar illness, especially bipolar 2 illness,” Katon told Psychiatric News. “This article emphasizes that despite the fact that only about one-third improve with treatment in these clinics, few are being referred to community mental health clinics or actually attend when referred. These clinics already had integrated collaborative care—that is, the use of a care manager supervised by a psychiatrist—so the inference is that these patients may need more-intensive psychiatric treatment, which could occur if psychiatrists are integrated into the clinics either in person or via telemedicine. Alternatively, the clinics need to establish better links with community mental health.”

To read more about integrated and collaborative care, see the Psychiatric News article by Katon, "Three Decades of Working in Integrated Care."

APOE-4 Allele May Confer Greater Alzheimer's Risk for Women, Study Suggests

Presence of the APOE-4 gene, the strongest genetic risk factor for Alzheimer disease identified to date, appears to confer greater risk for women, according to a study published online in Annals of Neurology. Researchers at Stanford University examined the APOE-4-by-sex interaction in the risk for conversion from healthy aging to mild cognitive impairment (MCI) in 5,496 controls and from MCI to Alzheimer’s disease in 2,588 patients with MCI. The interaction was also tested in cerebrospinal fluid biomarker levels of 980 subjects from the Alzheimer's Disease Neuroimaging Initiative.

Among controls, male and female carriers of the gene were more likely to convert to MCI or Alzheimer's, but the effect was stronger in women. The APOE-4-by-sex interaction on biomarker levels was significant for MCI patients and showed that women carriers were more likely to have defects in the "tau" protein in the brain, which has been linked with the characteristic neurofibrillary tangles associated with dementia.

“These findings have important clinical implications and suggest novel research approaches into AD pathogenesis,” the researchers said.

To read more about research on this subject, see the Psychiatric News article, "Plasma APOE-4 Levels Linked to Dementia Risk." Also see the American Journal of Psychiatry study, "Effect of Knowledge of APOE Genotype on Subjective and Objective Memory Performance in Healthy Older Adults."

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New Study Investigates Association Between Obesity and ADHD

Various studies have linked attention-deficit/hyperactivity disorder (ADHD) with obesity. But questions have been raised about whether ADHD contributes to development of obesity or obesity contributes to development of ADHD. A prospective, longitudinal, population-based study suggests that both answers may be correct. Childhood ADHD symptoms significantly predicted adolescent obesity, rather than the opposite. Yet one contributor to obesity—a lack of physical activity in childhood—predicted inattention in adolescence.

The study included some 8,000 children and was headed by Alina Rodriquez, Ph.D., a visiting professor in epidemiology and biostatistics at the Imperial College London School of Public Health. Results appear in the April Journal of the American Academy of Child and Adolescent Psychiatry.

The study findings have clinical implications, Rodriquez and her team said in their report, in that children with ADHD should be monitored for being overweight or obese at an early age, thus potentially averting a developmental trajectory of obesity. Also, since physical inactivity was found to mediate the association between ADHD and obesity, physical activity should be encouraged in youngsters with ADHD. And since a lack of physical activity in childhood predicted inattention in adolescence, "physical activity may also alleviate ADHD symptoms in the long term," they said.

More information about ADHD can be found in the American Psychiatric Publishing book, Essentials of Child and Adolescent Psychiatry. For a comprehensive text about the field of overweight and obesity, see The Gravity of Weight: A Clinical Guide to Weight Loss and Maintenance, also from American Psychiatric Publishing.

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In Spite of Mixed Clinical Trial Results, NMDA Receptor Enhancers May Still Prove Useful

Although a phase-2 clinical trial reported recently in JAMA Psychiatry suggested that an NMDA receptor enhancer called bitopertin might be effective against the negative symptoms of schizophrenia, two phase-3 trials concerning bitopertin to treat negative symptoms gave disappointing results, according to the drug's manufacturer, R. Hoffmann-LaRoche Ltd. in Switzerland.

Whether bitopertin eventually turns out to be an effective drug for negative symptoms, two experts on the subject remain hopeful that NMDA receptor enhancers might prove beneficial in countering schizophrenia's negative symptoms, at least for certain patients. One is Donald Goff, M.D., a professor of psychiatry at New York University and an expert in translational schizophrenia research. The other is Serdar Dursun, M.D., Ph.D., a professor of psychiatry and neuroscience at the University of Alberta in Canada.

"It's possible that a subgroup of patients might benefit from these agents, but Roche wasn't able to identify a biomarker that would predict response," Goff said in an interview. And as Dursun told Psychiatric News, "There must be improved clinical-trial methods that include identification of biomarkers so as to reduce the patient heterogeneity problem in schizophrenia."

For more about research into the use NMDA receptor enhancers to treat negative symptoms, see the Psychiatric News article "Surprising Drug Improves Schizophrenia Symptoms."

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Study Links Major Depression in Childhood With Cardiac Risk Factors in Adolescence

Depression in adults has been identified as a risk factor both for incident coronary heart disease and for cardiac events among patients with established heart disease, but how early in life does this association start? Perhaps as early as childhood, a study headed by Jonathan Rottenberg, Ph.D., of the University of South Florida and published in Psychosomatic Medicine suggests.

The study included 566 adolescents—210 who had a major depressive episode in childhood, 195 never-depressed siblings of those children, and 161 healthy control youth with no history of a major psychiatric disorder. All subjects were evaluated for cardiovascular risk factors such as smoking, obesity, and sedentary behavior. The group that had been depressed was found to smoke significantly more, to be significantly less active physically, and to have a significantly higher rate of obesity than their siblings and the controls.

"This is an interesting study and importantly provides additional evidence to support early treatment of depression," Kayla Pope, M.D., J.D., director of Neurobehavioral Research at Boys Town Nebraska/Iowa, told Psychiatric News. "We know that a diagnosis of depression is associated with an increase in morbidity and mortality, and this study provides further insight into the disease pathway. This study also speaks to the need for treatment strategies to address lifestyle issues as well as depressive symptoms and to target exercise, diet, and smoking cessation as key components of a treatment plan."

More information about the depression-cardiovascular association can be found in the Psychiatric News articles "Depression-Cardiovascular Link Found in Young Adults" and "Collaborative Care for Depression Can Reduce Risk for Heart Attacks, Strokes."

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Antipsychotic Use in Children on Medicaid Needs Close Monitoring, Researchers Suggest

Very young children and those in foster care who are enrolled in Maryland’s Medicaid program are more likely to be taking atypical antipsychotic medications for attention-deficit/hyperactivity disorder (ADHD) that is not comorbid with other illnesses than other young people receiving Medicaid benefits. Noting the "profound" increase in off-label use of antipsychotics, including for ADHD, researchers from the University of Maryland, Johns Hopkins University, and Morgan State University, all in Maryland, examined administrative data on 266,590 youth. About 2.5% of the 2- to 12-year-olds and 5.2% of the 13- to 17-year-olds were prescribed atypical antipsychotics for ADHD in 2006, reported Julie Zito, Ph.D., a professor of pharmacy and psychiatry at the University of Maryland School of Pharmacy, online Tuesday in the Journal of Child and Adolescent Psychopharmacology.

Zito and colleagues found differences in atypical antipsychotic medication use that varied by age, Medicaid eligibility, and diagnostic status. For example, youth in foster care diagnosed with ADHD and no other comorbid illness were three times more likely to be taking atypical antipsychotics and for an additional 100 days per year than their peers enrolled in Medicaid because of low family income. Since side effects such as weight gain, high cholesterol, elevated blood glucose, or insulin resistance can occur with use of antipsychotic drugs, the researchers urged careful review of each case before prescribing and continued monitoring and research to assure that the benefits of these medications outweigh the risks in children and adolescents. They concluded, "Exposure to atypical antipsychotics in Medicaid-insured youth, in particular for children in foster care and those diagnosed with ADHD, was substantial, warranting outcomes research for long-term effectiveness, safety, and oversight for appropriate cardiometabolic monitoring."

To read more in Psychiatric News about the use of antipsychotic medications in young people, see the article, “Increase in Off-Label Antipsychotic Use Seen in Canadian Youth.” Also see Clinical Manual of Child and Adolescent Psychopharmacology, Second Edition, from American Psychiatric Publishing.

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Experimental Nasal Spray May Treat Social Anxiety Disorder, Study Indicates

An experimental intranasal spray known as PH94B may be a novel, effective, and well-tolerated acute treatment for performance and social anxiety in women with social anxiety disorder. The finding appears in the study, "Effect of an Acute Intranasal Aerosol Dose of PH94B on Social and Performance Anxiety in Women With Social Anxiety Disorder," published in AJP in Advance.

Researchers at several institutions conducted a phase 2, multicenter, randomized, double-blind, placebo-controlled, single-dose study of PH94B. Ninety-one women aged 19 to 60 with generalized social anxiety disorder received placebo intranasal spray (single-blind) 15 minutes before laboratory-simulated public-speaking and social-interaction challenges. Patients who experienced significant distress during at least one challenge returned a week later to receive either intranasal PH94B or placebo aerosol spray (double-blind) before repeat challenges.

Patients who received PH94B during the second set of challenges had a significantly greater decrease in mean Subjective Units of Distress scores during the public-speaking and social-interaction challenges, compared with the first set of challenges, than did patients who received placebo for both sets of challenges. A significantly greater proportion of the PH94B group were much or very much improved from the first to the second sets of challenges, compared with the placebo group (75% and 37%, respectively).

“Continued positive findings for PH94B would suggest a novel mechanism of drug action via human nasal chemosensory receptors,” the researchers said. “If so, this could lead to the ability to treat psychopathological states with nanomolar doses of drugs that do not even enter the systemic circulation and may represent a distinct advance in psychotherapeutics.”

To read more about research into treatments for social anxiety, see the Psychiatric News article, “CBT Proves its Mettle in Social Anxiety Treatment.”

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APA Annual Meeting Mobile App Now Available

APA has just launched its mobile app for the 167th Annual Meeting to be held May 3 to 7 in New York, giving you 24-hour access to the meeting. Downloading is easy. The app can be used with all Web-enabled smartphones and tablets. You can use the app to plan your schedule and better navigate the meeting. There are several easy-to-use interactive capabilities designed to enhance your meeting experience.

These include:

· Use "My Schedule" to create your schedule with one click, adding sessions and exhibitors in which you are interested. You can create your schedule via your computer and save and access the schedule onsite via your mobile device.

· Search the scientific program sessions by day, format, and topic or by speaker.

· Use maps to view each floor of the meeting hotels and the Exhibit Hall in the Javits Convention Center. When searching on the scientific program, you can view the room location on the map.

· Receive important real-time alerts from APA regarding meeting reminders and program updates.

· Browse the exhibitors and locate who you want to visit on the Floor Plan Map.

· Connect with attendees and new colleagues using the “Friends” feature.

Ten Times More People With Serious Mental Illness in Jails Than Hospitals

Ten times more individuals with serious mental illness are residing in state prisons and county jails today than in the nation’s state psychiatric hospitals, according to a new study released today by the Treatment Advocacy Center (TAC). “The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey” found that in 44 states the largest institution housing people with severe psychiatric disease is a prison or jail. Nationwide, the study reports that there are an estimated 356,000 mentally ill inmates compared with 35,000 public-hospital patients.

The survey provides state-by-state illustrations of how protocols for treating mentally ill inmates who are deteriorating or acutely ill create obstacles that leave inmates without treatment for extended periods or indefinitely, especially in county jails. The report also contains several recommendations, including use of court-ordered outpatient treatment—deemed by the Department of Justice to be an evidence-based practice for reducing crime and violence—to help at-risk individuals live more safely and successfully in the community.

“The lack of treatment for seriously ill inmates is inhumane and should not be allowed in a civilized society,” said psychiatrist E. Fuller Torrey, M.D., founder of TAC and lead author of the study. “This is especially true for individuals who – because of their mental illness – are not aware they are sick and therefore refuse medication.”

In comments to Psychiatric News, Torrey said, “it is remarkable that we have let this situation deteriorate to this point.” He added, “Jails and prisons are not built to be mental hospitals, and corrections personnel are neither hired nor trained to be mental health workers. We have returned to the situation that existed in the 1830s when Dorothea Dix began the reform movement to get mentally ill persons removed from jails and prisons and put into hospitals. The fact that we are where we were almost 200 years ago should give us all pause.”


To read more on this subject, including strategies to reverse the trend, see the Psychiatric News article, "Judges, Psychiatrists Confer on Handling Mental Illness in Justice System." Also see "Prevalence of Mental Illnesses in U.S. State Prisons: A Systematic Review" in Psychiatric Services in Advance.

 

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CDC Reports Continuing Rise in Autism Prevalence Rates

The Centers for Disease Control (CDC) reports that 1 in 68 8-year-old children in the United States (14.7 per 1,000) had autism spectrum disorder (ASD) in 2010, the most recent year for which these data are available. This number is about 30% higher than the prevalence of ASD that the CDC reported in its previous survey released two years ago, which was 1 in 88 children (11.3 per 1,000). The CDC said a child meets its criteria for ASD "if a comprehensive evaluation of that child completed by a qualified professional describes behaviors consistent with the...DSM-IV-TR diagnostic criteria for any of the following conditions: autistic disorder, pervasive developmental disorder–not otherwise specified (including atypical autism), or Asperger disorder."

"The CDC report was based on a review of records rather than actual clinical assessments," David Fassler, M.D., a clinical professor of psychiatry at the University of Vermont, a child and adolescent psychiatrist, and APA treasurer, told Psychiatric News. "As a result, it tells us more about how often autism is being diagnosed as opposed to changes in the underlying incidence. The data were also derived from relatively few states—just 11 were surveyed. However, even in this limited sample, the geographic variations are quite striking and clearly warrant further investigation. From a clinical perspective, increased awareness is leading to earlier recognition and more accurate diagnoses. The real challenge is to make sure that all these kids have access to the comprehensive services they need and deserve."

More information about autism and research into potential treatment options can be found in the Psychiatric News articles, "Pieces of Autism Puzzle Slowly Coming Together" and "Oxytocin Treatment May Improve Social Communication in Autism."

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Anxiolytic and Hypnotic Medications Associated With Increased Mortality Risk, Study Finds

In a study published in the British Medical Journal, researchers at Warwick Medical School in the United Kingdom led a study assessing rates of mortality associated with antianxiety and sleeping medications. The study compared 37,727 patients who had a prescription for anxiolytic or hypnotic drugs with 69,418 patients with no prescription for such medications. Patients were tracked for an average of 7.6 years. The results showed that "there was an overall statistically significant doubling of the hazard of death (hazard ratio 2.08) after adjusting for a wide range of potential confounders, including physical and psychiatric comorbidities, sleep disorders, and other drugs."

Daniel Buysse, M.D., a sleeping disorder expert and professor of psychiatry at the University of Pittsburgh School of Medicine, told Psychiatric News that though hypnotic drugs are “are efficacious for the treatment of insomnia...they can have short-term and possible long-term side effects. These drugs are statistically associated with increased mortality risk, but retrospective cohort studies cannot completely control for potential confounds, such as severity of illness and multiple comorbidities." Buysee emphasized that psychiatrists, along with their patients, should carefully consider the pros and cons before prescribing such medications and should monitor side effects regularly once the patient begins taking the medication.

To read about diagnosis and treatment of anxiety and sleep disorders, see the Psychiatric News articles, "DSM-5 Sleep-Wake Disorders Section Targets Comorbidity" and "DSM-5 Updates Depressive, Anxiety, and OCD Criteria."

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APA Unveils Report on Cost-Effectiveness of Integrated Care

“The key to the sauce of health care reform is mental health, and the key ingredient in that sauce is integrated care,” said APA President Jeffrey Lieberman, M.D. (at right in photo), opening a press briefing and roundtable discussion sponsored by APA this morning in Washington, D.C., on “Integrated Primary and Mental Health Care: Reconnecting the Brain and the Body.”

The event marked the release of a new report, “The Economic Impact of Integration: Implications for Psychiatry,” by the international actuarial firm Milliman Inc. That report found that general medical costs for patients who have behavioral health disorders are 2-3 times higher than for those without behavioral illness. In fact, the additional health care costs incurred by people with behavioral comorbidities were estimated to be $293 billion in 2012. Effective integration of medical and behavioral care could save $26 billion to $48 billion annually in general health care costs, according to the report. The report considers commercial, Medicare, and Medicaid patient populations and includes utilization and cost data from millions of patients. Moreover, it compares data from those with both chronic medical conditions and behavioral conditions with data from those with only chronic medical conditions.

“Mental illness is important not only because of the pain and suffering it causes, but because it is too large to ignore,” said APA President-elect Paul Summergrad, M.D. (at left in photo) at the press conference.

The event brought together leaders in the movement toward integrated and collaborative care who emphasized that a key to addressing rising costs in American health care is integrated care that addresses the mental health needs of patients in primary care, as well as the primary care needs of those in specialty mental health settings. Speakers included Michael Hogan, Ph.D., former commissioner of the New York State Office of Mental Health; John O’Brien, senior policy advisor at the Centers for Medicare and Medicaid Services; Michael Shoenbaum, Ph.D., senior advisor for mental health services, epidemiology, and economics at NIMH; Elinore McCance-Katz, M.D., chief medical officer at SAMHSA; Henry Chung, M.D., medical director for the Montefiore Accountable Care Organization; Frank deGruy, M.D., professor and chair of the Department of Family Medicine at the University of Colorado School of Medicine; and Keris Myrick, Ph.D., M.B.A., president of the National Alliance on Mental Illness.

“Together we believe we can reunite the brain and the body,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Now is the time to do it.”

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