Long ADHD Treatment Delays in Adults Have Complex Sources, Study Finds

A large survey conducted by the National Institute on Alcohol Abuse and Alcoholism found that only 55% of adults with attention-deficit/hyperactivity disorder (ADHD) had ever sought treatment for their condition. Comorbid psychiatric disorders, sociodemographic characteristics, and gender were associated with treatment delay, said Elias Dakwar, M.D., an assistant professor of clinical psychiatry in the Division on Substance Abuse at Columbia University, and colleagues in a report in the December Psychiatric Services titled "First Treatment Contact for ADHD: Predictors of and Gender Differences in Treatment Seeking."

“The median delay to treatment seeking from ADHD onset was estimated at over 20 years, which is greater than that for general psychiatric disorders in the United States, but consistent with estimates for childhood-onset disorders,” they pointed out.

Men over age 60, with less than a 12th-grade education, or who overuse alcohol were less likely to seek treatment. However, single men with some comorbidity like depression, a personality disorder, or a phobia were more likely to seek treatment. Women with age of ADHD onset prior to age 11 or with alcohol dependence or bipolar disorder were more likely to seek treatment. Women with less than 12 years of education or who were African American sought out treatment less frequently.

They concluded from their ADHD treatment study that "research is needed to better understand how to optimize receipt of treatment for cases that persist beyond childhood,” concluded Dakwar and colleagues.

For more in Psychiatric News about adults and ADHD, see the article “ADHD Outcome Data in Adults Show Value of Early Treatment.”

(Image: PathDoc/Shutterstock.com)

Clinician Training Can Improve Counseling, Treatment for Smoking Cessation, Study Shows

An intensive training program for behavioral health professionals increased tobacco treatment visits and patient quit attempts, according to the report "Increasing Tobacco Dependence Treatment Through Continuing Education Training for Behavioral Health Professionals," published online in Psychiatric Services in Advance.

Jill Williams, M.D. (in photo) of Rutgers University-Robert Wood Johnson Medical School and colleagues examined the effectiveness of a two-day training curriculum on changing clinical practice by reviewing clinical charts from 20 clinicians who attended the training in 2012. Ten medical records were randomly selected for review from each clinician’s outpatient practice at a large behavioral health system, including five charts from smokers seen within six months before and after training.

The training included a comprehensive review of behavioral and pharmacologic treatments and techniques on how to work with less-motivated smokers and to develop treatment plans for smokers with behavioral health conditions. Several sessions involved interactive learning through case studies, small-group problem solving, and skills practice sessions.

Documentation of tobacco use significantly increased between baseline and post-training. Also, after the training, clinicians advised significantly more outpatients to quit (9% before versus 36% after) or referred them to individual or group counseling. Discussion of nicotine replacement was documented more frequently in charts (10% versus 31%), and prescriptions for smoking-cessation medications increased significantly in the post-training period, although overall prescribing remained low. The number of patients making quit attempts also significantly increased after the training (10% versus 39%), suggesting that providers were delivering more tobacco treatment than was reflected in charts.

“This study was the first to evaluate how training behavioral health professionals through a CE [continuing education] curriculum affects the delivery of tobacco-dependence treatments in the behavioral health setting,” the researchers said. “This preliminary report indicates that subsequent to attending a two-day CE curriculum...psychiatrists and nurses increased their tobacco-dependence treatment practices.”

To read about smoking-cessation treatment in people with mental illness, see the Psychiatric News article "Smoking Cessation for Patients Called an Urgent Priority."

(Image: courtesy Jill Williams, M.D.)

NIH Forum Focuses on Huge Longitudinal Study of Adolescent Substance Use

Last week, the leaders of four National Institutes of Health (NIH) institutes (National Cancer Institute, National Institute on Alcohol Abuse and Alcoholism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and National Institute on Drug Abuse) hosted a special open forum in Washington, D.C., to discuss their upcoming Adolescent Brain Cognitive Development (ABCD) study.

The ABCD will follow 10,000 children for a decade, from ages 10 to 20, to see how nicotine, alcohol, marijuana, and other drugs affect the trajectory of a developing brain. The study will incorporate advanced neuroimaging data along with other evaluations of mental, physical, and social health. NIH held this special event, which coincided with Neuroscience 2014 (the annual meeting of the Society for Neuroscience) to welcome additional suggestions or concerns on how to optimally configure such a large and complex adolescent cohort study.

The forum touched on several key topics, with issues of sample composition, data sharing, and the reliability of functional magnetic resonance imaging (fMRI) leading to some particularly lively discussions. Harvard Medical School neurology professor Michael Charness, M.D., who moderated the event, noted that the NIH would also accept additional comments related to ABCD for a while longer before the study design is finalized. NIH anticipates the official funding announcement will be released in early 2015.

Anyone wanting additional information about ABCD or to make suggestions for the study can contact Susan Weiss, Ph.D., NIDA associate director for scientific affairs at (301) 443-6487 or at sweiss@nida.nih.gov, or Peggy Murray, Ph.D., director of the International Research Program at NIAAA at (301) 443-2594 or at pmurray@mail.nih.gov).

To read more about the need to conduct research into the effects of substance abuse in youth, see the Psychiatric News column, “Marijuana Legalization and Young Brains: Time for Serious Study.”

(NIH)

Senators Hear Testimony on MH Care and Suicide Prevention for Veterans

A bipartisan group of U.S. senators expressed concern at a hearing Wednesday about what they see as the slow pace of change in the Veterans Health Administration’s (VHA) mental health care system—a concern intensified after listening to two women whose sons, veterans of Iraq or Afghanistan, had died by suicide.

“When people are hurting, they don’t want to wait to get help,” stressed committee chair Sen. Bernie Sanders (I-Vt.), who then asked how the $5 billion authorized for hiring additional clinicians was being spent. Those funds were not specifically allocated for mental health care providers, replied psychiatrist Harold Kudler, M.D. (above, right), chief mental health services consultant for the VHA. However, the agency was nevertheless allocated a share of those funds to recruit more providers, increase points of access, and test new modes of outreach in rural areas.

Still other avenues could be explored in the effort to reduce the number of veterans who die by suicide, said psychiatrist Elspeth Cameron Ritchie, M.D., M.P.H., (above, left), a retired Army colonel who is now chief clinical officer of the Washington, D.C., Department of Behavioral Health and a member of an Institute of Medicine panel that studied the effectiveness of treatments for posttraumatic stress disorder.

The VHA should, for example, conduct more research to understand which of its patients are at increased risk for suicide, Ritchie said. Service members also should be screened with closer attention to specific tasks they performed while deployed, as well as for any toxic exposures—like Agent Orange or the antimalarial drug mefloquine—which might produce symptoms of psychiatric illness or increased suicide risk.

The testimony was presented as the Senate considered the Clay Hunt SAV [Suicide Prevention for American Veterans] Act, which includes measures for suicide prevention and medical school loan forgiveness for psychiatrists and certain other practitioners who join the VHA.

For more about mental health issues that affect veterans and the findings of the Institute of Medicine report, see the Psychiatric News article “Pentagon, VA Lack Data to Assess PTSD Care Systems.”

(Image: Aaron Levin/Psychiatric News)

Great American Smokeout Is a Day to Focus on Quitting the Habit

Today marks this year's Great American Smokeout, a day when the American Cancer Society (ACS) encourages smokers to make a plan to quit, or to plan in advance and quit smoking that day. "By quitting—even for one day—smokers will be taking an important step towards a healthier life—one that can lead to reducing cancer risk," the ACS emphasizes. "Tobacco use remains the single largest preventable cause of disease and premature death in the U.S.," the organization points out, yet despite all the warnings and data documenting severe health risks, about 20% of Americans still smoke.

And the benefits of quitting smoking are by no means limited to improvements in physical health. "Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal to or larger than those of antidepressant treatment for mood and anxiety disorders," researchers have found in a study published in BMJ based on a systematic review of research and a meta-analysis. "Smokers can be reassured that stopping smoking is associated with mental health benefits," the researchers emphasized.

For more on smoking and mental health, see the Psychiatric News article "Smoking Cessation for Patients Called an Urgent Priority."

APA is holding a #YourMH @twitter chat today on smoking cessation in observance of the Great American Smokeout. Join your APA colleagues in responding to questions and comments from the public from noon to 1 p.m. EST. To join, use #YourMH (stands for "Your Mental Health") or @apapsychiatric. If you haven't created a Twitter account yet, click here to do so now. Here's your chance to share your knowledge and insights.

Study Finds Brain Region Is Reduced in Teens With History of Early Childhood Depression

A recent study published in JAMA Psychiatry shows that a key region of the brain involved in emotion may be smaller in size in youth who had been diagnosed with depression as preschoolers, compared with their peers who were not diagnosed with depression.

Joan Luby, M.D. (photo), director of the Early Development Program at Washington University School of Medicine in St. Louis, and colleagues conducted a study in which approximately 130 youth with and without a previous diagnosis for major depressive disorder (MDD) were followed from preschool-aged years to adolescence to assess the psychopathological and long-term neuroanatomical consequences of the onset of MDD in early childhood.

The results showed that more than 55% of those with early childhood MDD displayed pathological guilt during their preschool years, compared with 20% in the nondepressed group. Using magnetic resonance imaging (MRI), the researchers found that the right anterior insula—involved in emotion and self-perception—was smaller in adolescents with a history of MDD and guilt during early childhood, compared with that of their counterparts without such medical history. The data also showed that adolescents with smaller insula were more prone to experiencing recurrent episodes of clinical depression as they aged.

The researchers noted that “excessive guilt and depression may put preschoolers on a developmental trajectory that contributes to problems with depression later in childhood and even throughout life.” They concluded that the current findings concerning the brain’s right anterior insula "are consistent with mounting research in adult MDD suggesting that insula function and structure may be a target biomarker for major depression."

To read more about how the size of brain regions may serve as biomarkers for psychiatric disorders, see the Psychiatric News article "Brain-Region Size May Be Long-Sought Biomarker."

(Image Courtesy of Washington University School of Medicine)

Recovery Model Helps Reduce Use of Seclusion, Restraint in Large Hospital System

From 2001 to 2010, the use of mechanical restraint and seclusion in the Pennsylvania state hospital system declined significantly after incorporation of targeted strategies and a recovery-oriented model of care, according to a report in Psychiatric Services in Advance titled “Correlation Between Reduction of Seclusion and Restraint and Assaults by Patients in Pennsylvania’s State Hospitals.” Additionally, patient-to-patient assaults declined slightly, although patient-to-staff assaults were unaffected.

Researchers affiliated with the Pennsylvania state hospital system conducted a prospective study to assess the use of seclusion and restraint from 2001 through 2010. They examined 12,900 anonymized records involving the 1,801 civilly committed individuals who were physically or mechanically restrained and secluded in the nine civil state hospitals during the study period. They found that the use of mechanical restraint declined significantly from .37 to .08 episodes per 1,000 days, and the use of seclusion declined significantly from .21 to .01 episodes per 1,000 days.

The researchers attribute the change to the incorporation of “The Six Core Strategies for Reducing Seclusion and Restraint Use” issued by the National Association of State Mental Health Program Directors. These strategies include better leadership, data transparency, use of clinical alerts, workforce development, policy changes, enhanced use of response teams, implementation of dialectical behavior therapy, and discontinuation of the use of PRN (or "as needed") orders) to prevent or limit agitation, anxiety, and physical aggression. They also attribute the change in part to a systemwide recovery-oriented model of care. “Pennsylvania’s commitment to a recovery approach has transformed its service-delivery system to emphasize community services and supports,” they said. “This commitment is the overall reason for the significant reduction in use of seclusion and restraint.”

For more on how hospitals are dealing with seclusion and restraint concerns, see the Psychiatric News article "Psychiatric Hospital Aesthetics Affect Seclusion, Restraint Use."

(Image: Stokkete/shutterstock.com)

New Study Finds Sleep Learning Effective in Curbing Smoking

A new study suggests that smoking can be curbed, at least in the short term, through subliminal learning during early stage sleep. These findings from researchers at the Weizmann Institute in Israel were presented yesterday at the Society for Neuroscience annual meeting in Washington, D.C.

The study enrolled 76 smokers to receive one session of aversive conditioning by pairing the smell of cigarette smoke with the noxious smell of rotten eggs or rotten fish. The participants were divided into three groups—one received the conditioning while awake, the second received the conditioning during stage 2 sleep, and the third during deep REM sleep.

All the participants kept a smoking diary that tracked their behaviors one week before and one week after their aversive-conditioning session. The smokers who received their stimuli during stage 2 sleep reported a 34% reduction in smoking over the next week, while those who received the smells during REM sleep reported a more modest 12% reduction; the smokers who were awake reported no changes.

Previous studies have tested various forms of aversive conditioning such as bad smells, bad tastes, or mild electric shocks as a smoking cessation tool, though such trials have not been remarkably successful, possibly because the participants were awake and anticipating the stimuli. These new positive findings reinforce the idea that indirect behavioral therapy through sleep or hypnosis, for example, may offer more benefit.

To read more about why quitting smoking is important for mental well-being, see the Psychiatric News article, "Smoking Cessation Bestows Multiple Mental Health Benefits." Read more about smoking cessation treatment in the November American Journal of Psychiatry study, “Combination Treatment With Varenicline andBupropion in an Adaptive Smoking Cessation Paradigm.”

(shutterstock/Paul Cowan)

FDA Flags Generic Versions of ADHD Medication

Yesterday, the Food and Drug Administration (FDA) released a statement concerning the therapeutic benefits of two generic versions of Concerta tablets (methylphenidate hydrochloride extended-release tablets), intended to treat attention-deficit/hyperactivity disorder (ADHD) in adults and children. The agency is asking whether the generic products are bioequivalent to the brand-name drug.

The FDA’s inquiry was prompted by an internal reexamination of previously submitted data for the three approved generic versions of Concerta, which included non-brand-name methylphenidate hydrochloride extended-release tablets manufactured by Mallinckrodt Pharmaceuticals, Kudco Ireland Ltd, and Concerta manufacturer Janssen Pharmaceuticals. The results showed that while Janssen’s generic version was therapeutically equivalent to brand-name Concerta—releasing medicine in the body over a period of 10 to 12 hours—the generic versions manufactured by Mallinckrodt and Kudco were more likely to deliver the medicines at a slower rate during the designated time range, which may lessen the drug’s desired effect in some patients.

As a result, the FDA changed the therapeutic equivalence (TE) rating for the Mallinckrodt and Kudco products from AB to BX—meaning that the products are still approved and can be prescribed, but are no longer recommended as automatic substitutes for Concerta at pharmacies. The FDA has asked Mallinckrodt and Kudco to confirm the bioequivalence of their products within six months or to voluntarily withdraw them from the market.

In a statement, the FDA said, “If you or your health care professional are concerned the drug product is not providing the desired effect and you do not know the manufacturer, contact the pharmacy where the prescription was filled to verify the product’s manufacturer.... [Also] contact the prescribing health care provider to discuss whether or not a different drug product would be more appropriate.” The FDA has not identified any serious safety concerns with the two generic products.

Read the FDA press release on generic versions of Concerta here.

Potential Biomarker for Alcohol-Dependence Drug Identified

Researchers at the Mayo Clinic have identified a potential biomarker to identify which people would most benefit from acamprosate treatment for alcoholism. In a genetic study that evaluated 225 individuals who were participating in either a residential or outpatient sobriety program, the research team found that a variant of the GRIN2B gene was associated with longer alcohol abstinence over the three-month study period.

The GRIN2B gene encodes a portion of the NMDA receptor, which is involved in learning and memory but has also been tied to several alcohol-related issues including dependence, withdrawal, craving, and relapse.

A second analysis of 110 alcohol-dependent subjects in Germany identified a similar connection between GRIN2B and sobriety in people taking acamprosate, which provides a key step forward for future applications in pharmacogenetic screening.

"Previous studies have suggested other genes as possible biomarkers for sobriety," said lead author Victor Karpyak, M.D., Ph.D., an assistant professor of psychiatry at Mayo, "but this is the first time we have verified a biomarker in an independent population."

Karpyak did note that since all the participants were taking acamprosate, other biological mechanisms cannot yet be ruled out. His group is preparing a blinded, placebo-controlled study to confirm whether the abstinence effects are connected with acamprosate usage.

To read about another potential medication that can improve alcohol abstinence, see the Psychiatric News article "Anticonvulsant Drug Shows Efficacy in Treating Alcoholism."

(Image: shutterstock/foxterrier2005)

To Better Help Troops, Civilian Clinicians Urged to Learn About Military Culture

Psychiatrists and mental health professionals who never served in the Armed Forces are increasingly called upon to provide mental health care services for military veterans, and successfully engaging that population in treatment will require understanding of the military's unique culture.

That culture includes some obvious attributes such as service branch, rank, uniforms, or medals, said Andrew Pomerantz, M.D., the national mental health director for integrated care at the White River Junction VA Medical Center in Vermont and an associate professor of psychiatry Dartmouth Medical School. But there is much more to it than that, said Pomerantz, who spoke on a webinar Monday as part of a series cosponsored by the Joining Forces Program and APA.

“Military service members see themselves less as individuals and more as members of a group focused on a mission,” said Pomerantz. “They have an emotional investment in the group.” This may be reflected in their perception and labeling of health matters. To maintain a self-image of strength to serve the group, they may delay seeking care and minimize symptoms, especially mental health symptoms, he said. Reintegration back into civilian life is not easy, but most veterans just need a little help and support.

“All veterans are profoundly affected by their service,” said Pomerantz. “Understanding military culture is important for understanding them and earning their trust and respect.”

(Image: Peppersmint/Shutterstock.com)

AMA Leaders Debate Benefits, Harm of Solitary Confinement

Solitary confinement of juveniles in correctional settings is severely detrimental to adolescent health, with long-term consequences for development, and should be prohibited.

That’s what psychiatrists told delegates at the 2014 Interim Meeting of the AMA House of Delegates. During reference committee hearings yesterday (where reports and resolutions are discussed before being sent to the House), delegates debated a resolution from the Medical Student Section to oppose the use of solitary confinement in all circumstances. Some emergency and other physicians testified that seclusion of adults is necessary and unavoidable in certain emergency hospital settings, and physicians working in correctional facilities argued the same for adults in jails and prisons.

But representatives from the AMA Section Council on Psychiatry insisted that there should be a separate policy for juveniles, especially in correctional facilities. “The potential psychiatric consequences of prolonged seclusion include depression, anxiety, and psychosis,” said David Fassler, M.D., alternate delegate from the American Academy of Child and Adolescent Psychiatry. “Juveniles in particular are at risk for such consequences. We also know that the majority of suicides in juvenile correctional facilities occur when the person is isolated or in solitary confinement.”

Barry Wall, M.D., delegate from the American Academy of Psychiatry and the Law (pictured above), acknowledged that confinement policies for adults in correctional and other settings are far more complex and offered to work with the Medical Student Section on a separate resolution about adults at next year’s House of Delegates meeting. “If the resolution were to focus on juvenile detention facilities only, we would certainly oppose the use of solitary confinement because of the developmental vulnerability of juveniles.”

The fate of the resolution on solitary confinement will be determined today when the full House of Delegates meets. For more on this subject, see the Psychiatric News article, “Drastic Reform Urged for Solitary Confinement.”

(photo: Mark Moran, Psychiatric News)

VA Secretary Says Veterans Are the 'Canary in the Coal Mine' of Mental Illness

"We are the canary in the coal mine" when it comes to mental health, said Veterans Administration Secretary Bob McDonald in an interview with Psychiatric News. "Mental health care is a problem in this country--it's not just a problem for those who have suffered PTSD or traumatic brain injury in combat; it is a problem for football players, hockey players, police officers, and many others. We have got to get ahead as a society on mental health."

McDonald spoke to reporters after a speech to the AMA's House of Delegates, which held the opening session of its 2014 Interim Meeting yesterday in Dallas. During his speech to delegates outlining efforts to reform the VA in the wake of publicity about substandard care and unusually long waits for appointments in some VA facilities, McDonald specifically addressed the need for better psychiatric care, including increased reimbursement for psychiatrists. Regarding reimbursement, psychiatry won a recent victory that will bring their pay to more competitive levels effective November 30.

"As I've gone around the country, I've discovered we don't have enough students in medical school studying mental health," he said. "Why? Insurance reimbursement rates are low, and there's a stigma in society about mental health.

"The good news is that at the VA we know about mental health," McDonald said. "We are on the cutting edge of mental health....It's a big issue, and as a society we have to get on top of it."

For related information, see the Psychiatric News article "Psychiatrists’ Pay to Rise at Veterans Health Administration."

 

(Image: Mark Moran)

Improve Your Treatment Skills for Military Patients

In observance of Veterans Day, APA is cosponsoring a webinar that will help APA members and other health care professionals provide more effective care to members of the military and veterans. The free webinar, "Military Culture Counts: Assisting Service Members and Veterans," will be held Monday, November 10, from noon to 1 p.m. The organizations partnering with APA are the Association of American Medical Colleges and Joining Forces, a public-private partnership created by First Lady Michelle Obama and Jill Biden, Ed.D. Register now.

Scully Honored at AMA House of Delegates

Former APA Medical Director James H. Scully Jr., M.D., was one of three recipients of the AMA's Medical Executive Lifetime Achievement Awards yesterday during the opening session of the AMA’s 2014 Interim Meeting in Dallas.

Presenting the award, AMA Board Chair Barbara L. McAneny, M.D., told delegates that Scully, during his 11-year tenure at APA, revitalized staff functions, restored financial stability, and replenished reserves while leading APA’s advocacy efforts around parity coverage of mental illness, access to care, and reduction of stigma around mental disorders.

Scully, who is also a past chair of the AMA Section Council on Psychiatry and was active for years in the House of Delegates, told delegates in acceptance of the award that his work with other specialty society executives in the House revealed over and over again that “the problems we share in common and the solutions [we need] are much greater than the things that divide us.”

For more about Scully, see the Psychiatric News article “Scully to Retire After Whirlwind Decade.”

(Image: Mark Moran)

VA Undergoing Changes to Improve MH Care, Says VHA Official

The VA wants to be an employer of choice for mental health providers across the United States, Marsden McGuire, M.D., deputy chief consultant for mental health standards of care at the Veterans Health Administration, told members of APA’s Assembly at its meeting in Washington, D.C., today.

McGuire, a psychiatrist and APA member who oversees national mental health policy at the VHA, was invited to address the Assembly by Speaker Jenny Boyer, M.D., to update members on the steps being taken at the VA to provide timely, high-quality mental health care to veterans and regain their trust in a system whose deficiencies made headline news earlier this year.

McGuire noted that the new secretary of Veterans Affairs, Bob McDonald, has begun to make institutional changes in the VA’s culture that reflect his previous work in the private sector as head of Procter & Gamble. The changes coalesce around the theme “My VA”—meaning that the VA is shifting organizationally to put the population it serves at the center of its decision making and understand veterans’ needs through their eyes.

Of the 21,000 mental health professionals working in VHA settings, about 3,000 are psychiatrists, but many more are needed, said McGuire. There are 24 million veterans in the United States, one-third of whom are enrolled in VA care, and the demand for mental health services is growing. The recently enacted Veterans Access, Choice, and Accountability Act of 2014, which APA supported, includes initiatives to expand access to mental health care (including care from non-VHA physicians) and increase the number of mental health clinicians in the VHA, opening up new opportunities for psychiatrists.

Going forward, McGuire said there would be more efforts to support common goals with the private sector, such as medical school loan forgiveness programs and increased emphasis on telepsychiatry. He thanked APA for its partnership and support to ensure that this country’s veterans are front and center in getting the mental health care they need and that the principles of recovery and resilience are applied to the fullest for them.

"The VA can’t do it alone. We need a lot of help from you,” said McGuire.

 

(Image: David Hathcox)

Youth Pastors Regularly Encounter Mental Illness, Yet Feel Ill-Equipped to Help, Study Finds

Almost all pastors who deal with adolescents will encounter a mental health and/or substance abuse issue among their congregation and can serve as a valuable source of guidance, yet only a quarter of them feel that they are qualified to recognize problems and help these troubled youth.

This finding comes from a study carried out by researchers at Baylor University who surveyed a broad scope of youth and college pastors across Texas.

The survey found almost 80 percent of youth pastors worked with at least one adolescent a year whom they knew or at least suspected had a mental health issue. However, fewer felt prepared for these situations; about 50 percent reported having some training related to mental illness, while only 26 percent felt qualified to work with young people dealing with a mental problem.

Many of these pastors did refer their adolescents to other professionals; 76 percent referred people to Christian counselors, 51 percent to a psychologist, and 34 percent to a psychiatrist. The pastors felt that a lack of connections was the biggest barrier in preventing them from working with mental health professionals with more frequency.

“Youth and college pastors want to get involved, which is a very positive sign,” said lead author Matthew Stanford, Ph.D., a professor of psychology and neuroscience at Baylor. “They could be a key group that can help build a bridge between the psychiatric and religious communities.”

To read about APA’s efforts at bringing together psychiatry and faith, see the Psychiatric News article “APA Hosts Meeting to Build Bridges Between Faith, Mental Health Communities.” You can also read APA President Paul Summergrad, M.D.’s column, “Psychiatry and the Faith Community.”

(Shutterstock/iluistrator)

Rehospitalization Rates Higher for Patients With Mental Disorders, Study Finds

Psychiatric illness may contribute to higher 30-day hospital readmission rates for patients with heart failure (HF), acute myocardial infarction (AMI), and pneumonia, according to a study of 160,169 patients served by 11 U.S. health systems.

From 2009 to 2011, about 21.7% of patients with psychiatric comorbidity went back to the hospital within 30 days of discharge, compared with 15.5% of those without such diagnoses, said Brian Ahmedany, Ph.D., L.M.S.W., of the Center for Health Policy and Health Services Research at the Henry Ford Health System in Detroit and colleagues in Psychiatric Services in Advance yesterday.

“Individuals with comorbid anxiety, dementia, and depression had higher rates of readmission than persons with no psychiatric comorbidity regardless of whether the index hospitalization was for HF, AMI, or pneumonia,” the researchers found. “[H]ealth systems should consider adding elements of mental health assessment, diagnosis, monitoring, and treatment to interventions to prevent 30-day all-cause hospital readmissions.”

Those elements might include psychiatric screening and evaluation, discharge planning that includes a mental health component, and follow-up for psychiatric conditions that includes outpatient treatment.

Ahmedany and colleagues noted that the gap in readmission rates between patients with and without psychiatric comorbidities shrank from 6.0% in 2009 to 4.1% in 2011. That was an encouraging trend but might be narrowed still further by adoption of interventions specifically designed for these conditions.

For more on the interface between psychiatric and general medical conditions, see the American Psychiatric Publishing book, Integrated Care: Working at the Interface of Primary Care and Behavioral Health, edited by Lori Raney, M.D.

Improve Your Treatment Skills for Military Patients

In observance of Veterans Day, APA is cosponsoring a webinar that will help APA members and other health care professionals provide more effective care to members of the military and veterans. The free webinar, "Military Culture Counts: Assisting Service Members and Veterans," will be held Monday, November 10, from noon to 1 p.m. The organizations partnering with APA are the Association of American Medical Colleges and Joining Forces, a public-private partnership created by First Lady Michelle Obama and Jill Biden, Ed.D. Register now.

(Image: Chaikom/Shutterstock.com)

Psychiatrist Describes Recent Trends in Drug Abuse and Medications to Treat Addiction

Both recent trends in illicit drug use in the United States and pharmacotherapies that clinicians can use to treat certain substance use disorders, such as opioid dependence, were the focus of a symposium at APA's Institute on Psychiatric Services in San Francisco, which ended Sunday. 

“For a while, until 2000, the United States was seeing a marked decrease in heroin use" that spanned a period of nearly 10 years, Petros Levounis, M.D., M.A. (shown in photo), chair of the Department of Psychiatry at Rutgers New Jersey Medical School, said at the session. “Then we had the explosion of prescription opioid use, which became an epidemic.” In an interview with Psychiatric News, Levounis said that because heroin has become less expensive, and sometimes easier to acquire, than prescription opiates, heroin has become the drug of choice for some addicts and accounts for the rapid spread of its use throughout the country in the last few years, along with more people showing up in emergency rooms suffering from heroin overdoses and needing addiction treatment.

Levounis explained that there are currently three FDA-approved pharmacotherapies to treat opiate dependence: methadone, buprenorphine, and naltrexone/naloxone. "There is no 'one-size fits-all' treatment… [and] efficacy of the treatments may vary from person to person," he said. Levounis noted in a later interview with Psychiatric News that there are no "new" medications in the drug-development pipeline to treat opioid addiction, but there are newer formulations of FDA-approved drugs, such as probuphine, which is an implantable, long-injection version of buprenorphine that helps patients adhere to their addiction-treatment regimen.

For more information about opioid dependence, see the Psychiatric News article "Caution Urged for Clinicians Who Prescribe Opioids." Levounis is co-author of The Addiction Casebook, available from American Psychiatric Publishing, which describes strategies for diagnosing and treating patients with various types of addictions.

Improve Your Treatment Skills for Military Patients

In observance of Veterans Day, APA is cosponsoring a webinar that will help APA members and other health care professionals provide more effective care to members of the military and veterans. The free webinar, "Military Culture Counts: Assisting Service Members and Veterans," will be held Monday, November 10, from noon to 1 p.m. The organizations partnering with APA are the Association of American Medical Colleges and Joining Forces, a public-private partnership created by First Lady Michelle Obama and Jill Biden, Ed.D. Register now.

(Image: Vabren Watts/ Psychiatric News)

Psychiatrists Discuss Advantages of Long-Acting Injectable Antipsychotics

With studies showing schizophrenia to be treatment refractory in one-fifth of those affected, psychiatrists are exploring other options to the delivery of effective treatment. At APA’s Institute on Psychiatric Services in San Francisco, some of the leading experts in psychopharmacology led a research symposium on the benefits of long-acting injectable (LAI) antipsychotic medications.

“Psychiatrists who were trained during my time of training, think that long-acting injectable antipsychotics should be used for the most refractory, noncompliant, and difficult to treat patients,” Steven Potkin, M.D., director of clinical research at the University of California, Irvine, said at the symposium. “[However] there is accumulating evidence that very early in the course [of illness] that this should be offered as an option, since half of the patients with first-episode psychosis discontinue medication after they are discharged from a hospital.”

Research on part of the “accumulating evidence” on long-acting injectable antipsychotics was presented by Keith Nuechterlein, Ph.D., a distinguished professor of psychiatry at the University of California, Los Angeles, who led a randomized study comparing LAI risperidone with oral rispiderone in 83 individuals who had a first psychotic episode within the two years prior to the study. The results showed that after one year of treatment, participants who received the daily oral form of risperidone had a 33%relapse rate, compared with 5% in those treated weekly with LAI risperidone. In addition, individuals in the oral risperidone cohort were four times more likely to be hospitalized than those taking the LAI version.

"We were struck [by the fact] that these were among the most dramatic results that have occurred for long-acting injectables—and it was in first-episode patients," said Nuechterlein, during an interview with Psychiatric News. Nuechterlein added that not only did patients experience advantages regarding outcomes associated with LAIs, but the patients accepted LAI medication quite readily. (The study was funded by the National Institutes of Health and Janssen Pharmaceuticals.)

“This symposium was an invitation for psychiatrists to rethink when is it appropriate to offer patients long-acting injectable medication,” Potkin told Psychiatric News. “Should it be reserved only for refractory patients, or should it be offered to people earlier in the course [of illness]… or at any stage of illness? Of course, LAIs are not for everyone, but our patients should definitely be given options,” he concluded.

Improve Your Treatment Skills for Military Patients

In observance of Veterans Day, APA is cosponsoring a webinar that will help APA members and other health care professionals provide more effective care to members of the military and veterans. The free webinar, "Military Culture Counts: Assisting Service Members and Veterans," will be held on Monday, November 10, from noon to 1 p.m. The organizations partnering with APA are the Association of American Medical Colleges and Joining Forces, a public-private partnership created by First Lady Michelle Obama and Jill Biden, Ed.D. Register now.

(Image: Psychiatric News/Vabren Watts)

Infectious Disease Expert Cites Role For Psychiatrists in Efforts to Combat Ebola

Attendees at APA's Institute on Psychiatric Services in San Francisco on Friday were provided with an in-depth overview of the history, symptomatology, and recent outbreak of the Ebola virus, as well as information on how psychiatrists can play a role during the current period of international health concern.

“Fever is the predominate symptom seen with a person infected with Ebola,” said George Rutherford, M.D. (shown in photo), head of the Division of Infectious Disease Epidemiology at the University of California, San Francisco, and guest speaker at the Ebola update session. Rutherford explained that symptoms associated with Ebola come in various phases beginning with fever, followed by abdominal-related symptoms, such as vomiting and diarrhea, and “then it can progress to more severe symptoms such as meningitis- and cephalitis-like symptoms and [finally] to uncontrolled bleeding. Symptoms usually appear between 20 and 21 days" after infection. As of October 27, said Rutherford, there were 13,703 cases of Ebola reported worldwide, with 2,791 occurring in the prior 21 days.

So far, the United States has had nine reported Ebola cases. Rutherford noted that amid current hysteria breaking out in the United States concerning Ebola, there is a very small chance that Americans who have not been to West Africa or taken care of patients with the Ebola virus will contract it. “What is important is the epidemic in West Africa, where we need to concentrate our resources,” stressed Rutherford. “Being prepared in the U.S. is prudent and appropriate, but what is more appropriate is to be concerned about West Africa… Because if don’t stop the epidemic in West Africa, it will definitely spread.”

During an interview with Psychiatric News, Rutherford stated that the CDC has put 300 medical professionals on the front lines in West Africa to help eradicate the spread of Ebola. He said that psychiatrists are needed as well, to deal with mental health consequences associated the virus, such as posttraumatic stress disorder and stigma, which many patients and families in West Africa are now dealing with. However, he emphasized, the mental health consequences associated with Ebola are not geographically restricted. “There is also this exaggerated stigma and hyperanxiety about casual exposure [to Ebola] in the US…particularly in hospitals,” he said. He advised session participants to reach out to their local hospitals to become a part of an Ebola preparation team—which are being formed in hospitals throughout the nation—to provide an adequate mental health resource for hospital workers who treat Ebola patients. “Mental health workers are definitely needed.”

To read more about the need for mental health services in places impacted by the Ebola epidemic, see the Psychiatric News article, "Response to Ebola Crisis Will Require Attention to MH Needs."

(Image: Vabren Watts/Psychiatric News)

What Are Your Thoughts on APA’s Priorities?

To All APA Members:

APA invites you to fill out a brief survey on the future of psychiatry that will help APA’s leaders determine how the Association can best meet the challenges and opportunities that confront psychiatry now and into the future.

“We know that major changes are going on in medicine, the science that supports our field, and health care delivery,” said APA President Paul Summergrad, M.D. “We want you to know that APA has re-committed ourselves to thinking strategically about the opportunities and challenges facing both the field of psychiatry and society as a whole. For APA’s Board of Trustees to develop a focused set of priorities to drive APA’s vision and work forward over the next five years, your views are critical.”

Please note the following:

* Your response is completely anonymous and confidential. Neither APA nor our survey administrators will be able to identify respondents. In addition, data from the survey will be used only in the aggregate and cannot be used in any individually identifying way.

* The timeframe we are assessing and planning for is the next five years.

* The survey will be open until Sunday, Nov. 16, but we encourage you to complete the survey now. Your voice is important to this process.

* We request one response per person.

“Thank you for your time and your best thinking about changes in the environment and some of the potential choices we face,” said Summergrad. “We cannot make these important decisions without your help.”

(Image: Shutterstock/ISP: Irides, LLC)

Addiction Specialist Sounds 'Wake-Up Call' to Psychiatrists About Smoking

Psychiatrists should be providing smoking cessation treatment to all tobacco users, said psychiatrist Jill Williams, M.D., at APA’s  2014 Institute on Psychiatric Services.

Williams, a professor of psychiatry and director of the Division of Addiction Psychiatry at the Robert Wood Johnson School of Medicine, told attendees that the broad public health success that has been achieved with regard to decreasing smoking in the general population has not been extended to those with mental illness—especially serious mental illness. “Smoking is the leading cause of death in people with mental illness or addiction,” she said, citing statistics showing that 50 percent of deaths among people with schizophrenia, bipolar disorder, and depression are attributable to smoking, and that persons with mental illness or addiction purchase and consume up to 44 percent of all cigarettes in the United States.

Moreover, tobacco use disorder is a diagnosable condition in DSM-5. Yet psychiatrists have largely not treated their patients for smoking for a variety of reasons—including a prevalent belief that quitting smoking may actually interfere with treatment of mental illness. But Williams presented evidence showing that smoking cessation has no negative impact on treatment and does not jeopardize recovery from addiction to other substances. And she cited her own 2012 study in the Journal of Clinical Psychiatry demonstrating the safety and efficacy of varenicline in patients with schizophrenia and schizoaffective disorder.

“We as psychiatrists should provide treatment to all smokers,” Williams said. “We should intervene more during periods of temporary abstinence—we detox for other substances; we should detox for this substance. We should promote education and provide leadership to change [smoking] policies at treatment centers. And we should provide national leadership and advocate as physicians.”  

For more information, see the Psychiatric News article "Smoking Cessation for Patients Called an Urgent Priority."