Study Finds Victims of Childhood Bullying Are More Likely to Have Mental Health Problems Than Those Maltreated

Being bullied during childhood has a greater negative impact on the mental health of young adults than experiencing maltreatment early in life, according to a study published in The Lancet Psychiatry. Specifically, children who were bullied were found to be around five times more likely to experience anxiety and nearly twice as likely to report depression and self-harm at age 18 than children who were maltreated.

For the study, Dieter Wolke, Ph.D., a professor of psychology at the University of Warwick, UK, and colleagues analyzed data on maltreatment, bullying, and overall mental health from two longitudinal studies—the Avon Longitudinal Study of Parents and Children (ALSPAC) in the United Kingdom (ALSPAC) and Great Smoky Mountains Study (GSMS) in the United States.

The study included 4,026 children from ALSPAC—whose parents provided information about their exposure to maltreatment (defined as physical, emotional, or sexual abuse, or severe maladaptive parenting, or both) between the ages 8 weeks and 8.6 years; exposure to bullying was assessed during conversations with the children at ages 8, 10, and 13—and 1,420 children from GSMS, who reported information on maltreatment and bullying between the ages of 9 and 16. Symptoms of anxiety, depression, self-harm, and suicidality were measured at age 18.

Of the 4,026 children in the ALSPAC cohort, 341 (8 percent) were exposed to only maltreatment, 1,197 (30 percent) were exposed to only bullying, and 283 (7 percent) were exposed to both maltreatment and bullying. As adults, 402 (10 percent) were classified as having anxiety, 316 (8 percent) as having depression, and 361 (9 percent) as having reported self-harm in the past year. A total of 207 (15 percent) in the GSMS cohort were exposed to only maltreatment, 225 (16 percent) to only bullying, and 159 (10 percent) to both maltreatment and bullying. As adults, 135 (12 percent) were classified as having anxiety, 87 (6 percent) as having depression, and 64 (7 percent) as having reported self-harm in the past year.

After adjusting for potential confounders, the authors reported that being bullied only was a higher risk for overall mental health problems than was being maltreated only in both cohorts (OR 1.6 [95% CI 1.1–2.2] for ALSPAC; 3.8 [1.8–7.9] for GSMS). Children who were bullied were more likely to have anxiety (4.9 [2.0–12.0] for GSMS), depression (1.7 [1.1–2.7] for ALSPAC) and self-harm (1.7 [1.1–2.6] for ALSPAC) as adults than children who were maltreated by adults.

While governmental efforts have focused almost exclusively on public policy to address family maltreatment, less attention and resources have been directed at addressing bullying, the study authors note. “Since bullying is frequent and found in all social groups, and current evidence supports that bullied children have similar or worse long-term mental health outcomes than maltreatment, this imbalance requires attention,” they write.

For more on the long-term effects of bullying, see the Psychiatric News article, “Effects of Bullying Don’t End When School Does.”

(Image: Monkey Business Images/Shutterstock)

Most Children With ADHD Stay on Stimulant Medication, Study Shows

Stimulant medication continued to be used by most children three to six years after the conclusion of research known as the Preschool ADHD Treatment Study (PATS) in which they had participated. About 1 in 4 children was no longer taking medication, and about 1 in 10 was on an antipsychotic. Antipsychotic treatment was associated with more comorbidity.

Those are the findings of a prospective, naturalistic follow-up study of PATS by Benedetto Vittielo, M.D., of the National Institute of Mental Health, and colleagues at several other institutions, published in the Journal of Child and Adolescent Psychiatry. 

They reassessed 206 of the 303 children who had participated in PATS at three years and 179 children at six years after completion of the controlled study. Pharmacotherapy and clinical data were obtained from the parents. Pharmacotherapy was defined as use of a specific class of medication for at least 50 percent of the days in the previous six months.

At year three, overall, 34 percent were on no pharmacotherapy, 41.3 percent were on stimulant monotherapy; 9.2 percent on atomoxetine (alone or with a stimulant); 8.3 percent on an antipsychotic, usually together with a stimulant; and the remaining 7.2 percent were on other pharmacotherapy. Overall, 65.0% were on an indicated ADHD medication.

At year six, just under 27 percent were on no pharmacotherapy, 40.2 percent were on stimulant monotherapy, 4.5 percent on atomoxetine, alone or with a stimulant, 13.4 percent on an antipsychotic, and 15.1 percent on other pharmacotherapy. Overall, 70.9% were on an indicated ADHD medication.

Antipsychotic treatment was associated with more comorbidity, in particular disruptive behavior disorders and pervasive development disorders, and a lower level of functioning.

For related information, see the Psychiatric News article “Study Assesses Association Between Weight Gain, ADHD Medication.”

(Image: tomertu/shutterstock.com)

 

New Book From APA Describes Mental Illnesses for General Audiences

Patients, families, and others now have access to the latest information on mental disorders and available treatments through a comprehensive, easy-to-understand book that APA released today, Understanding Mental Disorders: Your Guide to DSM-5.

“We need to have a conversation in this country, and everyone has to have a greater literacy and understanding of these illnesses,” said former Rhode Island Congressman Patrick Kennedy (left) at a launch event at the National Press Club in Washington, D.C. Kennedy, who is one of the country's leading advocates on mental health issues, wrote the foreword to the 370-page book. "It empowers patients and their loved ones by giving them knowledge and understanding."

Understanding Mental Disorders is based on the latest, fifth edition of APA's Diagnostic and Statistical Manual of Mental Disorders. The organization of the book follows that of DSM-5 and lists risk factors, warning signs, symptoms, and treatments for each disorder. The book also includes brief case studies to illustrate real-life examples of people with these conditions.

“This book can lead to helpful communication between patients, their families, and their psychiatrists,” noted APA President Paul Summergrad, M.D. (right), chair of psychiatry at Tufts University School of Medicine.

Besides patients and their families, Understanding Mental Disorders will be helpful for other health professionals, law enforcement personnel, educators, coaches, members of the clergy, as well as others who want to educate themselves about mental illness.

"Psychiatrists now have an authoritative source of information on mental disorders to recommend to their patients and loved ones," said APA President-Elect Renée Binder, M.D. “The book will overcome stigma about mental illness because it emphasizes that these are brain disorders and they are treatable.”

In addition to Kennedy, Summergrad, and Binder, participating in the launch of the book at the National Press Club were Jeffrey Borenstein, M.D., a member of the book’s advisory panel; Paul Gionfriddo, president and CEO of Mental Health America; and Barbara Van Dahlen, Ph.D., the founder and president of Give an Hour.

For more in Psychiatric News about Understanding Mental Disorders, see "New Manual to Offer One-of-Kind Layperson’s Guide to DSM-5."

--aml   (Image: David Hathcox)

Anxious Parents Can Transmit Anxiety to Children, Twin Study Shows

The association between parental and offspring anxiety and neuroticism appears to be environmental rather than genetic—that is, children and adolescents learn anxious behaviors from their parents rather than inheriting anxiety genetically.

That’s the conclusion of a remarkable study titled "The Intergenerational Transmission of Anxiety: A Children-of-Twins Study" by Thalia C. Eley, Ph.D., of Kings College London and colleagues at institutions in the United States and Sweden. The study was published in AJP in Advance.

Researchers used data from the Twin and Offspring Study of Sweden comprising information on 387 monozygotic twin families and 489 dizygotic twin families. Parental anxious personality was self-reported by twins using 20 items from the Karolinska Scales of Personality. Offspring anxiety symptoms were measured using items from the Child Behavior Checklist (30). Twins, their spouses, and offspring all reported on offspring behavior over the previous six months. A method of statistical analysis called Structural Equation Modeling allowed the researchers to quantify the effects of additive genetic, common environmental—that is, nongenetic effects that make members of a nuclear family similar to one another—and nonshared environmental effects (which make members of a family different from one another) of parental anxiety.

For both anxiety and neuroticism, the models provide support for significant direct environmental transmission from parents to their adolescent offspring. In contrast, there was no evidence of significant genetic transmission, according to the report.

Robert Freedman, M.D., editor of the American Journal of Psychiatry, told Psychiatric News, “This study is a landmark, because it is the first to clearly establish the early transmission of anxiety symptoms from parents to children, not through their shared genetic background, but rather from the way in which anxious parents raise their children. Parents who are anxious can now be counseled and educated on ways to minimize the impact of their anxiety on the child's development.”

For related information, see the Psychiatric News article “CBT for Child Anxiety May Confer Long-Term Protection From Suicidality.”

(Image: ISP: Politico, LLC/shutterstock.com)

Experts Consider Best Options for Treatment, Prevention of Opioid Abuse

Opioid addiction experts from across the country were on Capitol Hill yesterday to provide expert testimony on the growing opioid epidemic in the United States and common misperceptions about factors driving this trend.

“Let me state clearly so as to leave no room for doubt,” said Rep. Tim Murphy (R-Pa., left), the chair of the U.S. House Energy and Commerce Subcommittee on Oversight and Investigations. “Our current strategies are failing, and I am not going to stop until we start moving in the direction of success defined not just as getting individuals off of street drugs and onto a government-approved opioid, but getting them to the point of drug-free living.”

The hearing included perspectives from leading experts in opioid addiction, who discussed the best options for treatment and prevention, including medication-assisted treatment and prescription drug–monitoring programs.

“I fully recognize the importance of medication-assisted treatment as a transition from street drugs and to prevent overdose from heroin,” Murphy remarked, “but relying on this as the one and only solution shouldn’t be the strategy.”

“Unlike many other disorders with high mortality rates, opioid use disorder is treatable, and a joint effort of health professionals, community advocates, and policymakers is urgently needed to reverse this tragic trend,” testified Adam Bisaga, M.D., a professor of psychiatry at Columbia University School of Medicine.

The scientific evidence base for medication-assisted treatment as part of an overall strategy to fight opioid addiction was highlighted by several members of the expert witness panel. "Opioid-addicted people need access to a broad range of treatments for opioid addiction,” said Laurence Westreich, M.D., president of the American Academy of Addiction Psychiatry. "This must include access to medication-assisted therapy and treatment for co-occurring psychiatric disorders.”

“We don’t have just an opioid misuse epidemic or an opioid overdose epidemic, we also have an opioid overprescribing epidemic,” explained Anna Lembke, M.D., an assistant professor of psychiatry and behavioral sciences at Stanford University Medical Center. “Contrary to what is commonly believed, doctors who treat addiction are not the source of the problem. The methadone that accounts for 40 percent of deaths by a single-drug opioid pain reliever is almost entirely in the form of pills prescribed for the treatment of pain, rather than coming from methadone maintenance clinics that treat individuals who are heroin dependent. Thus, it’s very important that we not only scrutinize physicians who prescribe opiates for the treatment of addiction, but also for those physicians who treat other common chronic illnesses such as pain.”

After the testimonies, Murphy told Psychiatric News that the hearing was an eye opener. “A lot of Americans who need treatment for opioid addiction are not getting the needed treatment. We need more providers to treat addiction and more regulation of the prescription practices that involve opiates," he said. "The subcommittee is definitely going to take the recommendations that were made today into consideration in hopes of bringing about change.”

To watch a recording of the hearing, click here. To read about more treatments for opioid addiction, see Psychiatric News articles "Psychiatrists Describe Trends in Medications to Treat Addiction" and "SAMHSA Releases Guidance for Initiating Medication Treatment for Opioid Overdose."

(Image: Vabren Watts/Psychiatric News)

Scientists Identify Molecular Marker of Major Depression

Increased amounts of mitochondrial DNA (mtDNA) may serve as a molecular marker of major depression, according to a study published today in Current Biology.

Researchers at the University of Oxford obtained genome sequences from 5,864 women with recurrent major depression and 5,783 women without a history of major depression who were participants in the China, Oxford, and VCU Experimental Research on Genetic Epidemiology (CONVERGE) Project. The researchers also interviewed the study participants to assess lifetime adversities, including a history of childhood sexual abuse and other stressful life events.

Sequencing of the amount of mtDNA and mean telomere length—two components of the genome suspected to be associated with adverse life experiences—revealed a significant association between major depression and the amount of mtDNA. While additional analysis found that mtDNA amount and telomere length were associated with adverse life events, conditional regression analyses showed that the molecular changes were contingent on the presence of major depression.

“We could find no evidence that stressful life events act via changes in mtDNA or telomere length to increase the risk of major depression,” the study authors noted. Nonetheless, “these findings identify increased amounts of mtDNA as a molecular marker of major depression and have important implications for understanding how stress causes the disease,” the authors concluded.

"We have only a snapshot of the relationship between the molecular markers and depression," Jonathan Flint, a professor of molecular psychiatry at the University of Oxford and senior author on the paper, stated in a press release. "We want to know how they change over time—before, during, and after a depressive illness. That information will tell us much about their clinical utility."

To read more on biomarkers for depression, see the Psychiatric News article “Scientists Closer to Finding Tests for DepressionBiomarkers.”

(The Biochemist Artist/Shutterstock)

SAMHSA, NIAAA Develop New Guidance on Pharmacotherapy for Alcohol Use Disorders

In recognition of April as Alcohol Awareness Month, the Substance Abuse and Mental Health Services Administration (SAMHSA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) have released a new guidance on the use of medications to assist in the treatment of alcohol disorders.

Despite the high prevalence of alcohol use problems in the United States and the growing recognition that these problems are a legitimate medical condition, only a fraction of people participating in counseling or a specialized treatment program receive medication to supplement their therapy.

This new guide, developed by a panel of experts in alcohol research, clinical care, medical education, and public policy, was designed for use by primary care and specialty providers, though patients and their families may find it informative as well.

The SAMHSA/NIAAA guide provides detailed information on the four medications approved by the Food and Drug Administration to treat alcohol use disorder, prevent relapse, or both: disulfiram, oral naltrexone, extended-release injectable naltrexone, and acamprosate. It includes recommendations on screening and assessing patients for potential medication use, selecting the appropriate medication based on needs and circumstances, developing a treatment plan, and monitoring patient progress.

To learn more about the topics--including medication therapy--that NIAAA will be discussing at the APA's 2015 annual meeting next month, see the Psychiatric News article “NIAAA Track Focuses on Pharmacotherapy, Alcohol Disorder Guidelines.”

Also, check out The American Psychiatric Publishing Textbook of Substance Abuse Treatment, Fifth Edition from American Psychiatric Publishing. The editors of the book are Marc Galanter, M.D., Herbert D. Kleber, M.D., and Kathleen T. Brady, M.D., Ph.D.

Study Finds Stimulants, CBT Combination Effective for Treating Patients With ADHD, Cocaine Use Disorder

Extended-release mixed amphetamine salts in robust doses along with cognitive behavioral therapy appears to be effective for treatment of co-occurring attention-deficit/hyperactivity disorder (ADHD) and cocaine use disorder (CUD), improving ADHD symptoms and reducing cocaine use, according to a report published online April 18 in JAMA Psychiatry.

Frances Levin, M.D., of the New York State Psychiatric Institute and colleagues randomized 126 patients meeting DSM-IV-TR criteria for ADHD and CUD to receive 60 mg of extended-release mixed amphetamine salts (n=40), 80 mg of the same (n=43), or placebo (n=43) daily for 13 weeks. All participants received cognitive-behavioral therapy (CBT)/relapse prevention treatment weekly from experienced M.A.- or Ph.D.-level therapists.

The main outcome for ADHD was the percentage of participants achieving at least a 30 percent reduction in ADHD symptom severity, measured by the Adult ADHD Investigator Symptom Rating Scale; for cocaine use, the main outcome was cocaine-negative weeks (by self-report of no cocaine use and weekly benzoylecgonine urine screens) and the percentage of participants achieving abstinence for the last three weeks.

More patients achieved at least a 30 percent reduction in ADHD symptom severity in the medication groups (60 mg: 30 of 40 participants; and 80 mg: 25 of 43 participants) compared with placebo (17 of 43 participants). Rates of continuous abstinence in the last three weeks were greater for the medication groups than the placebo group: 30.2 percent for the 80 mg group and 17.5 percent for the 60 mg group vs 7.0 percent for the placebo group.

“Often, stimulants are withheld from individuals with co-occurring substance use disorders because of concern of diversion and clinical worsening,” Levin and colleagues state. “Instead, this study found the opposite—patients benefited from treatment. Thus, under closely monitored conditions, pharmacotherapy should be promoted, not barred. These data emphasize the importance of screening adults with CUD for ADHD. Future research might test long-acting stimulant formulations for other substance-abusing adult populations with ADHD, such as those with alcohol or cannabis use disorders.”

For related information on the consequences of ADHD in childhood, see the Psychiatric News article, “ADHD Outcome Data in Adults Show Value of Early Treatment.”

Boston Strong as Marathon Goes On; MH Help Still Available

Runners took off this morning in the Boston Marathon, two years after the bombing that claimed three lives and left 257 injured. A jury on April 8 convicted Dzhokhar Tsarnaev on 30 counts related to the crime.

The Boston-area health care system responded well to the immediate disaster thanks to extensive prior training, said Frederick Stoddard, M.D. (left), a psychiatrist at the Massachusetts General Hospital. However, some of those wounded in 2013 or members of their families continue to face the physical and psychological consequences of the bombing. 

Since then, many have turned for help to the Massachusetts Resiliency Center, created by the state’s Office of Victim Assistance.

“We’re helping normal people dealing with abnormal circumstances that disrupt daily functioning,” the center’s executive director, Kermit Crawford, Ph.D., told Psychiatric News. He is an associate professor of psychiatry at Boston University Medical Campus. “We are a hub for services, not just providing them ourselves but coordinating with other agencies.”

The center addresses not only behavioral health issues but also matters relating to employment, compensation, medical services, brain injury, hearing loss, caregiver and peer support, and legal services—all of which can affect victims or their survivors. During the recent trial, the center placed clinicians and patient navigators in the court building for survivors or family members who chose to attend. Such options for care may be needed for some time.

“As a psychiatrist, I understand that reactions to trauma may not occur right away but often come out months or years later,” said Brent Forester, M.D., a geriatric psychiatrist at McLean Hospital who completed the 2013 marathon. “It’s important to get that message out.”

For more in Psychiatric News about the response to the Boston Marathon bombing, see “Boston Continues to Heal as Trial Wraps Up for Accused Marathon Bomber” and “Psychiatrists Act Quickly After Bombings In Boston.”

The book Disaster Psychiatry: Readiness, Evaluation, and Treatment is available from American Psychiatric Publishing at http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=7217.

--aml  (Image: Courtesy Frederick Stoddard)

Brexpiprazole Found Safe, Effective for Patients With Schizophrenia, AJP Reports

New findings from a phase 3 clinical trial, published today in AJP in Advance, suggest that a recently developed antipsychotic may prove to be one of the next treatments for schizophrenia.

Researchers from the Department of Psychiatry at Hofstra North Shore-LIJ School of Medicine conducted a randomized, double-blind, placebo-controlled study with 636 patients with schizophrenia to investigate the efficacy, safety, and tolerability of brexpiprazole—a  serotonin-dopamine activity modulator that acts as a partial agonist at serotonin 5-HT1A receptors and dopamine D2 receptors, while antagonizing serotonin 5-HT2A receptors and noradrenaline alpha receptors. 

The results showed that after six weeks of treatment, patients taking 2 mg and 4 mg of brexpiprazole had, respectively, Positive and Negative Syndrome Scale scores approximately 9 and 8 points lower than that of the placebo group. Weight gain from baseline was found to be moderate among the active groups, with the 2 mg cohort gaining an average of 1.45 kg and the 4 mg cohort gaining 1.28 kg. The most common treatment-emergent adverse event reported for brexpiprazole was akathisia, at a rate of 4.4 percent in the 2 mg cohort and 7.2 percent in the 4 mg cohort. No clinically or statistically significant changes were observed from baseline in lipid and glucose levels and extrapyramidal symptom ratings.

“Schizophrenia is a complicated disease, and while advances have been made, patients often still lack an effective treatment path,” the study’s lead author, Christoph Correll, M.D., a professor of psychiatry at Hofstra, told Psychiatric News. “It is important for clinicians and patients to have a range of treatment options to manage symptoms effectively and safely ... as response to therapy can vary greatly from individual to individual and from one medication to the next.” Correll informed Psychiatric News that the Food and Drug Administration will make its final decision about the approval of brexpiprazole for the treatment of schizophrenia as well as major depressive disorder in July.

The research was funded by Otsuka Pharmaceuticals, the manufacturer of brexpiprazole.

To read about the pipeline for psychotropic medications, see the Psychiatric News article “Candidates, Innovation Missing From Psychotropic Drug Pipeline.”

(Image: Vashchig/shutterstock.com)

Comorbid Depression, Type 2 Diabetes Associated With Increased Risk of Dementia, Study Finds

Researchers have known for some time that a diagnosis of depression or type 2 diabetes mellitus (DM) may increase a patient's risk for dementia later in life. Now, a study published online in JAMA Psychiatry on April 15 finds people diagnosed with both are at an even higher risk for dementia.

Dimitry Davydow, M.D., M.P.H., an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine, and colleagues analyzed data on more than 2.4 million Danish citizens, 50 years or older, who were free of dementia from January 1, 2007, through December 31, 2013, to estimate the risk of all-cause dementia associated with DM, depression, or both. Within this population, 477,133 (19.4 percent) had been diagnosed with depression, 223,174 (9.1 percent) with DM, and 95,691 (3.9 percent) with both.

The researchers found that over the course of the study, 59,663 participants (2.4 percent) developed dementia, and of these, 6,466 (10.8 percent) had DM, 15,729 (26.4 percent) had depression, and 4,022 (6.7 percent) had both. Compared with people without depression or DM, the authors reported that DM alone was associated a 20 percent greater risk of dementia, depression alone was associated with an 83 percent greater risk, and comorbid depression and DM were associated with a 117 percent greater risk, after adjusting for such factors as age, sex, and marital status. For those under 65 years with depression and DM, the risk for dementia appeared to be even greater.

"Given that depression in patients with DM is associated with poor self-care, nonadherence to treatment regimens, and adverse psychobiological changes, this younger group with comorbid depression and DM may be vulnerable to developing dementia later in life," the authors wrote. "From a public health perspective, developing screening and interventions to improve the quality of treatment of depression and DM in this subgroup of patients could be important in reducing the risk for dementia.”

For more on the association between diabetes and mental disorders, see the Psychiatric News article “Link Seen Between Mental Disorders, Diabetes in New Study.”

(bikeriderlondon/Shutterstock)

SGR Finally Repealed in Historic Senate Vote

Congress repealed the sustainable growth rate (SGR) component of the Medicare payment formula last night when the U.S. Senate voted 92-8 to approve the Medicare Access and CHIP Reauthorization Act. The legislation, which was approved by the House of Representatives two weeks ago, will now go to President Obama, who has already indicated he will sign it.

The new law permanently repeals the flawed SGR reimbursement formula, after more than a decade of efforts by APA, the AMA, and other physician groups. Without action, physicians would have faced a 21 percent across-the-board payment cut beginning April 15.

The SGR is a budget cap that was passed into law in 1997 as an attempt to control federal spending on physician services. Since 2003, Congress has routinely delayed devastating cuts that would have jeopardized beneficiary access to psychiatric services in the Medicare program through “patches” to scheduled SGR reductions, causing significant instability and administrative burden for physician practices.

The new law will provide a stable period of annual updates of 0.5 percent now through 2019. The 2019 rate is maintained through 2025, with the potential for additional adjustments through the creation of the new Merit-Based Incentive Payment System. Beginning in 2019 and ending in 2024, physicians may instead make themselves eligible for a 5 percent incentive payment based on participation in certain alternative payment models (APMs). In 2026, physicians who participate in these APMs will receive a 1 percent annual update, while all other physicians will receive a .5 percent annual update. The law also reauthorizes the Children’s Health Insurance Program for two years.

“Senate passage of the SGR reform bill is a major step toward a reliable and rational payment system for Medicare beneficiaries and their physicians. It is long overdue,” said APA President Paul Summergrad, M.D. “APA, our members, and the entire medical community advocated strongly for this legislation, which will eliminate uncertainty from the Medicare system to make sure patients and families can get the care they need and deserve from their physicians.”

“Repealing the SGR has been a decades-long process that has involved the advocacy of thousands of APA members and other medical experts--a grassroots effort that will truly benefit both patients and physicians,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “I commend the President and Congress for their leadership and efforts in this process.”

Look to Psychiatric News for full coverage of the new law. A summary of the legislation is posted on APA’s website.

(Image: Allison Hancock/shutterstock.com)

APA Members Urged to Contact Senators in Support of SGR Reform Bill

Legislation with the best chance in years to repeal the sustainable growth rate (SGR) component of the Medicare physician payment formula is awaiting Senate action this week. APA members are urged to contact their senators and express support for the Medicare and CHIP Reauthorization Act.

A House bill was approved two weeks ago by a wide margin just before Congress broke for its spring recess, but the Senate deferred action until after the break. If the Senate does not act this week, physician Medicare payments could be cut by 21 percent after April 15.

The Medicare and CHIP Reauthorization Act would permanently repeal the complex formula, along with the scheduled 21 percent physician pay cut.

“We support this long-overdue reform of the Medicare payment formula and elimination of the SGR,” said APA President Paul Summergrad, M.D. “The physician payment system needs to be stabilized for the sake of our patients and for our physicians who care for them.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., noted that APA’s Division of Government Relations has worked diligently over the years with the AMA and other physician organizations for payment reform. “APA strongly supports the bipartisan House-passed legislation and will continue to partner with the AMA and other medical societies to urge all senators to vote yes to send the bill to President Obama, who has already said he would sign it.”

To send a message to your senators, click here.

For the latest information on the legislation, see the Psychiatric News article "SGR Repeal Bill Passes House, Awaits Senate Action." 

(Image: Allison Hancock/shutterstock.com)

CBT Comparable to Light Therapy for Seasonal Affective Disorder, Study Finds

Cognitive behavioral therapy (CBT) is just as effective as light therapy for treating seasonal affective disorder (SAD), according to a study published online in AJP in Advance, “Randomized Trial of Cognitive-Behavioral Therapy Versus Light Therapy for Seasonal Affective Disorder: Acute Outcomes.”

While it is known that many people with SAD respond to light therapy, few studies have examined the effectiveness of other therapies. In the current study, Kelly Rohan, Ph.D., a professor of psychology at the University of Vermont, and colleagues assigned 177 adults with an episode of major depression recurrent with a seasonal pattern to receive six weeks of CBT (two 90 minute sessions per week) or light therapy (30 minute session each morning). Depression severity was measured throughout the study by two different methods: the Structured Interview Guide for the Hamilton Rating Scale for Depression–SAD Version (SIGH-SAD) and Beck Depression Inventory–Second Edition (BDI-II).

The researchers found that both treatments produced a significant and comparable response, with about half of the patients in each treatment arm reaching criteria for remission.

"These findings suggest that CBT-SAD and light therapy are comparably effective treatment modalities for targeting acute SAD," the study authors write. "Accordingly, CBT-SAD should be disseminated into practice and considered as a viable alternative to light therapy in treatment decision making."

To read about how CBT can be effective in the treatment of childhood anxiety disorder, see the Psychiatric News article, “CBT for Child Anxiety May Confer Long-Term Protection From Suicidality.”

(shutterstock/Image Point Fr)

Rates of ADHD Lower in Areas of High Altitude, Study Finds

High altitude may serve as a protective factor against attention-deficit/hyperactivity disorder (ADHD), according to a study in the Journal of Attention Disorders.

Researchers from the Department of Psychiatry at the University of Utah analyzed data from the 2007 National Survey of Children's Health report and 2010 National Survey of Children with Special Health Care Needs report to identify and compare the prevalence of ADHD diagnoses among youth aged 4 to 17 living in the 48 adjoining states and the District Columbia.

The researchers found that states with higher than average elevations were most likely to have lower ADHD diagnosis rates, with every one foot increase in average elevation above sea level decreasing diagnosis rates by 0.001 percent. Nevada, which has an average elevation of 5,517 feet above sea level, had the lowest percentage of ADHD diagnoses at 5.6 percent, followed by Utah at 6.7 percent. ADHD diagnoses were more prevalent in states with average elevations less than 1,000 feet above sea level, with North Carolina—869 feet above sea level—having the highest diagnoses rates at 15.6 percent.

The researchers speculate that the decreased rate of ADHD may be due to higher levels of dopamine produced as a reaction to hypobaric hypoxia—a condition caused by breathing air with less oxygen at higher elevations. Decreased dopamine levels have been associated with ADHD so when levels of the neurotransmitter increase with elevation, the risk for getting the disorder diminishes, the study noted.

Coauthor Perry Renshaw, M.D., Ph.D., M.B.A., a professor of psychiatry at the University of Utah, emphasized that the current findings are not implying that people should start moving to the mountains to decrease the risk for ADHD in children. However, the research results do have potential implications for treating the disorder, which may involve increasing dopaminergic activity.

To read more about other environmental factors that have been suggested to affect rates for ADHD, see the Psychiatric News article "Sunbaked Regions Often Show Lower ADHD Prevalence."

(Andrew Zarivny/shutterstock.com)

APA Commends President Obama’s Call to Ban Reparative Therapy for LGBT Youth

President Obama on Wednesday called for a ban to therapies aimed at “repairing” gay, lesbian, bisexual, and transgender youth in response to the recent death of a transgender youth by suicide following what she reported were efforts by her therapist to convert her back into a boy.

In a White House statement posted on Wednesday alongside a WhiteHouse.gov petition that was started following the death of 17-year-old transgender youth Leelah Alcorn, President Obama's senior adviser Valerie Jarrett wrote, “As part of our dedication to protecting America’s youth, this Administration supports efforts to ban the use of conversion therapy for minors.”

APA has long recognized the dangers of so-called reparative therapies. In a 2000 position statement, the Association reaffirmed its opposition to “any psychiatric treatment, such as ‘reparative’ or ‘conversion’ therapy, that is based on the assumption that homosexuality per se is a mental disorder or is based on the a priori assumption that the patient should change his or her homosexual orientation." APA noted that there were “sparse scientific data about selection criteria, risks versus benefits of the treatment, and long-term outcomes of ‘reparative’ therapies.” Moreover, these therapies are at odds with APA’s position that sexual orientation is not a mental disorder.

“We applaud President Obama for his principled and scientific stand," said APA CEO and Medical Director Saul Levin, M.D., M.P.A. "LGBT individuals deserve treatment, when they seek it, that meets the highest standard of evidence, and APA has long recognized that so-called reparative therapy doesn't meet that standard and can, in fact, be hazardous. We are pleased that the White House shares our concern about this issue, and we support the President's call for a ban on reparative therapy.”

Yesterday, in an early report in the New York Times, the newspaper had stated that President Obama was calling for an end to “psychiatric therapies" aimed at "repairing" gay, lesbian, and transgender youth. APA reacted quickly to the erroneous statement that reparative or conversion therapies are “psychiatric therapies" by contacting The New York Times. The newspaper posted an updated report by mid-evening that dropped the reference to “psychiatric therapies."

(Image: shutterstock.com/Drop of Light)

Dangerousness, Not Mental Illness or Gun Ownership, Should Guide Policy

About 8.9 percent of individuals who self-report as having patterns of impulsive angry behavior own guns, and 1.5 percent carry them outside the house, according to an analysis of the National Comorbidity Study Replication study. The study was posted online April 8 in the journal Behavioral Sciences and the Law.

Among those respondents, said Duke University Professor of Psychiatry and Behavioral Sciences Jeffrey Swanson, Ph.D., and colleagues, “Persons with impulsive angry behavior who carried guns were significantly more likely to meet diagnostic criteria for a wide range of mental disorders, including depression, bipolar and anxiety disorders, PTSD, intermittent explosive disorder, pathological gambling, eating disorder, alcohol and illicit drug use disorders, and a range of personality disorders.”

However, most of those people are legally entitled to own firearms because they have never been involuntarily committed to a psychiatric hospital. Reorienting public policy away from mental illness and toward dangerousness might reduce injury and death by firearms, the authors note.

Current approaches to restricting gun access of people with mental disorders have no impact on most of this group, coauthor Paul Appelbaum, M.D., a professor of psychiatry at Columbia University, told Psychiatric News.

“We need to reorient our firearms policies toward limiting gun possession by people who lack behavioral control—for example, by taking guns away from people who behave in dangerous ways—rather than focusing excessively on people with serious mental illnesses, as we do today.”

For more in Psychiatric News about dangerousness as a standard for firearms policy, see "Violence Risk, Not Mental Illness, Should Guide Gun Access." Also, see "Screening for Violence Risk in Military Veterans: Predictive Validity of a Brief Clinical Tool" in the American Journal of Psychiatry.

(Image: kol88/Shutterstock.com)

CMS Proposes Extension of Parity Law to Medicaid Managed Care Plans, CHIP

The Centers for Medicare and Medicaid Services (CMS) is proposing a rule that would apply requirements of the Mental Health Parity and Addiction Equity Act of 2008 to Medicaid managed care plans and the Children’s Health Insurance Program (CHIP).

Under the proposed rule, plans must make available upon request to beneficiaries and contracting providers the criteria for medical-necessity determinations with respect to mental health and substance use disorder benefits. It would also require states to provide enrollees with the reason for any denial of reimbursement or payment for mental health or substance abuse treatment.

The proposed rule does not apply to Medicaid fee-for-services plans, but it does encourage states who have such plans to adopt mental health parity rules. The full scope of the proposed rule applies to CHIP, regardless of whether care is provided through fee-for-service or managed care.

“The proposed rule, by expanding mental health parity, has the potential to greatly improve access to care for mental health and substance use disorders and the equity that our patients need,” said APA President Paul Summergrad, M.D. “We’ve made much progress in recent years under the mental health parity act and the expansion of its applicability under the Affordable Care Act, and this rule will continue that progress by providing greater opportunity for Medicaid beneficiaries to receive the psychiatric and substance use services they need and deserve.”

Summergrad noted that APA is particularly pleased to see the transparency provisions in the rule that would require states to publicly share their compliance with the parity regulations. “This will help hold states and the payors they use accountable and will allow monitoring of the progress and implementation of parity,” he said.

APA leadership is continuing to review the rule in its entirety and will be submitting comments to CMS. The proposed rule is posted at https://www.federalregister.gov/public-inspection and will be published in the Federal Register on April 10. Look for further coverage in Psychiatric News.

(Image: M DOGAN/shutterstock.com)

Time to Review Your Sunshine Act 2014 Payment Records

A 45-day window opens today (April 6) for physicians and teaching hospitals to review and dispute any incorrect data that pharmaceutical companies, biological makers, and device makers have reported about them to the Centers for Medicare and Medicaid Services (CMS) as part of the Open Payments program. The data will be made available to the public beginning June 30.

This is the second reporting cycle for the Open Payments program and covers payments made in 2014. After the review period closes on May 20, physicians can still initiate disputes, but updated data will not be displayed until the next reporting cycle.

CMS developed the Open Payments program to comply with the Physician Payment Sunshine Act (Sunshine Act), which is part of the Affordable Care Act. The Sunshine Act requires manufacturers of drugs, medical devices, and biologicals that participate in U.S. federal health care programs to report certain payments and items of value given to physicians and teaching hospitals. CMS is required to report this information annually.

The review process is voluntary, but registration in both the CMS Enterprise Identity Management System (EIDM) and the Open Payments system is required to review the data and file disputes. APA members who have not yet registered on the Open Payments database should do so now. For more information, click here.

For information on the release of the first round of data last September, see the Psychiatric News article, “Open Payments Database Debuts for Public Scrutiny.”

(Image: Shutterstock.com/wenani)

Depression Subtype May Not Be Relevant in Selecting Treatment, Study Finds

There may be no preferential antidepressant pharmacotherapy for treating subtypes of major depressive disorder (MDD), according to a study published online in AJP in Advance, “Depression Subtypes in Predicting Antidepressant Response: A Report From the iSPOT-D Trial.”

A. John Rush, M.D., a professor of psychiatry and behavioral sciences at Duke University School of Medicine, and colleagues conducted a study with 1,008 individuals with MDD to assess the proportions of participants who met at least one criteria for MDD subtype—melancholic, atypical, and anxious depression—and compared subtype profiles on remission and change in depressive symptoms after eight weeks of treatment with escitalopram, sertraline, or extended-release venlafaxine. Improvement of symptoms and likelihood of remission were quantified by the 16-item Quick Inventory of Depressive Symptomology-Self Report.

The researchers found that 39 percent of the studied individuals exhibited at least one pure form of a depressive subtype, with atypical subtype being the most prevalent at 15 percent. Approximately 36 percent of the participants met criteria for more than one subtype. As it relates to antidepressant treatment, the results showed that participants in all subtype groups exhibited a similar statistically significant reduction in symptoms and did not differ in the likelihood to remit.

“Whether pure or mixed, subtypes were not differentially predictive of overall acute treatment outcomes or differentially predictive of efficacy among the three antidepressant medications," the researchers concluded. "If replicated, these findings would suggest that the clinical utility of these subtypes in treatment selection is minimal.”

The iSPOT-D trial (International Study to Predict Optimized Treatment – in Depression) is the largest personalized medicine research study in mental health.

To read more about treatments for major depressive disorder, see the Manual of Clinical Psychopharmacology, Eighth Edition, by Alan Schatzberg, M.D., and Charles DeBattista, M.D., D.M.H., from American Psychiatric Publishing.



Please note: ABC News is holding a Twitter chat at #abcDRBchat to discuss “Understanding the Teenage Brain” on Tuesday, April 7, from 1 p.m. to 2 p.m. EDT. APA members are invited to join the conversation with moderator Richard Besser, M.D., ABC’s chief health and medical editor, to help explain why teenage brains are different from adults brains and how that might impact health and behavior.

(Image Courtesty of UT Southwestern)

Medicaid Spending on Antipsychotics Predicted to Drop Dramatically, Study Shows

Within five years, antipsychotic expenditures in Medicaid may decline to less than half their current levels because of the ongoing transition from mostly branded to mostly generic second-generation antipsychotic medications, according to an analysis, "Forecasting Medicaid Expenditures for Antipsychotic Medications," published online in Psychiatric Services in Advance.

Eric Slade, Ph.D., of the University of Maryland School of Medicine and Linda Simoni-Wastila, Ph.D., B.S.Pharm., of the University of Maryland School of Pharmacy developed forecasts of expenditures on antipsychotics in calendar years 2016 and 2019 by looking at the estimated percentage reduction in Medicaid expenditures for risperidone from 2008 to 2011, when that drug was the only second-generation antipsychotic available generically. They used state-level aggregate data on outpatient antipsychotic prescriptions from 2008 to 2011 drawn from the Medicaid state drug utilization database.

The researchers estimate that annual Medicaid expenditures for antipsychotics will decrease by $1,794 million (48.8 percent) by 2016 and by $2,814 million (76.5 percent) by 2019. Adjustment for variable prices of branded medications and changes in Medicaid enrollment only moderately affected the magnitude of these reductions, they say.

“Anticipated reductions in spending on antipsychotics should be factored into reassessments of the ongoing need for Medicaid formulary restrictions on second-generation antipsychotics,” the researchers state. “…[R]apid increases in antipsychotic expenditures following the introduction of branded second-generation antipsychotic medications in the 1990s led some states to impose formulary restrictions on access to these medications in Medicaid. However, at best, these policies result in little or no net savings to Medicaid and, at worst, adversely affect patients’ medication access and outcomes. Consequently, if Medicaid is entering a period of rapidly decreasing antipsychotic expenditures, states’ original rationale for formulary restrictions may be significantly eroded.”

For more on Medicaid formulary restrictions, see the Psychiatric News article, “When Medication Barriers Go Up, Adverse Events May Follow.”

(Image: amenic181/shutterstock.com)

Researchers Call for More Study on the Effects of Healthy Individuals' Use of Cognitive-Enhancing Drugs

The use of cognitive-enhancing drugs—ordinarily prescribed to control attention-deficit/hyperactivity disorder (ADHD), slow memory loss in Alzheimer’s patients, or promote wakefulness—appears to be growing among healthy individuals and the phenomenon deserves closer attention from researchers, clinicians, regulators, and the pharmaceutical industry, said neuroscientists Barbara Sahakian, Ph.D., of the Department of Psychiatry at the University of Cambridge; and Sharon Morein-Zamir, Ph.D., of the Department of Psychology at the University of Cambridge.

“[T]he main uses of pharmacological cognitive enhancers by healthy individuals seem to be for achievement of a competitive advantage at school, university, or work; to maintain levels of attention and performance when sleep deprived or jet-lagged; and to improve task-related motivation,” wrote Sahakian and Morein-Zamir online in The Lancet yesterday.

Researchers noted the effects of these drugs (sometimes referred to as "smart drugs") on healthy individuals are actually quite small, but too little is known about who uses them, under what circumstances, whether they are used acutely or chronically, or what effects they could have on the developing brains of young users.

“We conclude that more immediate action is needed to establish the long-term risks and benefits of pharmacological cognitive enhancers for healthy people and to continue to develop novel, more effective pharmacological cognitive enhancers for people with impairments associated with brain injury or neuropsychiatric disorders,” they said.

To read more about the need for research into cognition, see the Psychiatric News article “IOM Tackles Standards on Cognition in Depression.”

--aml (Image: Constantine Pankin/Shutterstock.com)