Tuesday, June 30, 2015

PTSD Increases Heart Disease Risks in Women

Women who display four or more symptoms of post-traumatic stress disorder (PTSD) are more likely to have a heart attack or stroke compared with women who never experienced trauma, reports a recent study appearing in Circulation.

Researchers at Columbia University's Mailman School of Public Health and the Harvard T.H. Chan School of Public Health surveyed nearly 50,000 women participating in the Nurses' Health Study II. Trauma exposure and PTSD symptoms were assessed using the Brief Trauma Questionnaire and a PTSD screen.

While 80% of the women reported experiencing a traumatic event in their lives, more than half of this group (58%) reported no symptoms of PTSD. Participants reporting symptoms of PTSD were split evenly between those reporting four or more symptoms of the disorder and those reporting one to three symptoms.

Women who reported four or more symptoms of PTSD had a 60% higher risk of cardiovascular disease risk after adjusting for age, family history, and childhood factors compared with women with no trauma exposure. The researchers also found that trauma exposure alone increased risk for heart attack and stroke by 45%—an increased risk not seen in women who had been exposed to a trauma but reported one to three PTSD symptoms.

"PTSD is twice as common in women than in men, and women with PTSD are more likely to have severe and persistent symptoms," study author Karestan Koenen, Ph.D., of Columbia University said in a press release. "Likewise, women with cardiovascular disease are more likely to be hospitalized and die from a heart attack compared with men. For all these reasons, it's critical that we understand how PTSD contributes to cardiovascular disease in women."

To read about another potential health risk of PTSD in women, see the Psychiatric News article "PTSD Linked to Increased Risk for Type 2 Diabetes in Women."

(shutterstock/Sebastian Kaulitzki)

Monday, June 29, 2015

Long-Acting Injectable Risperidone Leads to Greater Adherence, Relapse Prevention in Patients With Schizophrenia

Patients with a recent first episode of schizophrenia who are treated with a long-acting injectable (LAI) formulation of the antipsychotic risperidone may experience lower rates of psychotic relapse and better control of psychotic symptoms than those treated with oral risperidone, according to a study published this week in JAMA Psychiatry.

For the study, Kenneth Subotnik, Ph.D., a research psychologist at the University of California, Los Angeles, and colleagues randomized 83 patients with recent-onset schizophrenia to receive LAI risperidone (25 mg every two weeks) or oral risperidone (2 mg daily) over a 12-month period. Furthermore, half of the patients in each group were simultaneously randomized to receive cognitive remediation (a cognitive training program of at least one hour a week) or healthy-behaviors training (weekly instruction in relaxation, healthy eating habits, and exercise).

The results showed that psychotic exacerbation and/or relapse rate was lower for the LAI risperidone group compared with the oral group (5% versus 33%), and LAI risperidone was significantly associated with lower levels of hallucinations and delusions throughout the follow-up period. The proportion of patients who required psychiatric hospitalization was significantly lower for LAI risperidone than for oral risperidone (5.0% versus 18.6%), and treatment with the LAI risperidone led to significantly better medication adherence.

The cognitive remediation and healthy-behaviors training groups did not differ significantly regarding psychotic relapse, psychotic symptom control, or hospitalization rates. There were no significant interactions between the two medications and the two psychosocial treatments.

"The superiority of long-acting injectable risperidone extends beyond preventing psychotic symptom return," the researchers noted. "Use of long-acting injectable risperidone in our first-episode patients also led to better maintenance of intracortical myelination as well as improved cognitive functioning," they wrote. "If this trifecta of improved psychotic symptom control, cognition, and intracortical myelination can be replicated in longer longitudinal studies of patients with a first episode of schizophrenia, it would suggest that the use of long-acting injectable antipsychotics early in schizophrenia can modify the trajectory of the disorder and lead to better long-term outcomes."

Thie study was supported by grants from the National Institute of Mental Health; supplementary funding and medication were provided by Janssen Scientific Affairs, LLC. Janssen is the manufacturer of LAI risperidone.

For more on long-acting, injectable antipsychotics, see the Psychiatric News article "Some Experts Urge More Use of Long-Acting, Injectable Antipsychotics."

(Image: molekuul.be/Shutterstock.com)

Friday, June 26, 2015

Supreme Court Rules Same-Sex Marriage Is a Constitutional Right

This morning the U.S. Supreme Court ruled in a 5-to-4 decision that states do not have the right to ban or outlaw same-sex unions—giving same-sex couples the right to legally marry in every state across the nation.

"In forming a marital union, two people become something greater than once they were,” wrote Justice Anthony Kennedy for the majority. "It would misunderstand these men and women to say they disrespect the idea of marriage," the ruling continued. "Their plea is that they do respect it, respect it so deeply that they seek to find its fulfillment for themselves. They ask for equal dignity in the eyes of the law. The Constitution grants them that right."

The ruling extending from the case Obergefell v. Hodges also mandates states to recognize a marriage between two people of the same sex when legally married in another state.

"Today’s ruling strikes a blow to inequality and discrimination throughout the nation, and that’s good for Americans’ mental health," said APA President Renée Binder, M.D. "APA has a long history of supporting the rights of same-sex couples, and we have long noted that there is no scientific or medical reason to deny these couples the right to marry. This decision is a landmark step in ensuring equality and happiness for every American."

APA joined a coalition of the nation’s top health care associations including the AMA, the American Academy of Pediatrics, and others in submitting an amicus brief in support of same-sex marriage.

“The claim that allowing sex-same couples to marry undermines the institution of marriage and harms children is inconsistent with the scientific evidence,” Binder said. “In fact, the evidence strongly supports the conclusion that homosexuality is a normal expression of human sexuality and that gay men and lesbians form stable, committed relationships equivalent to heterosexual couples.

“But this issue goes well beyond the scientific evidence,” said Binder. “It is about what is the right thing to do and the fact that everyone should be free from discrimination.”

Over the past several decades, APA has issued a number of position statements on antidiscrimination policies related to the LGBT community. Those positions were consolidated in a 2013 Position Statement on issues related to homosexuality.

“Today is a watershed moment for equal rights in America,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We at APA are proud that our country—after a long period of seeking equal rights—now sees that everyone has the constitutional right to marriage.”

(Image: dencg/Shutterstock.com)

Thursday, June 25, 2015

Supreme Court Affirms Subsidies for ACA Tax Credits

The U.S. Supreme Court today upheld a key provision of the Affordable Care Act (ACA), permitting continued use of tax-credit subsidies to pay for health insurance premiums for low-income Americans.

Writing for the majority in a 6-to-3 decision, Chief Justice John Roberts rejected arguments positing a significant difference between state and federal insurance exchanges—a difference that would have eliminated the subsidies in the 34 states that did not have state exchanges.

“We are pleased that the Supreme Court upheld subsidies for more than six million people,” said APA President Renée Binder, M.D., in a statement. “Today’s decision means these Americans will continue to receive vital mental health benefits as guaranteed by the ACA. As the physician experts and leaders in mental health treatment, we know there can be no health care without mental health care.”

Acknowledging that there were “more than a few examples of inartful drafting” in the ACA, the court's majority nevertheless chose to look at the “broader structure of the Act” in holding for the government.

“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. … The combination of no tax credits and an ineffective coverage requirement could well push a State’s individual insurance market into a death spiral,” wrote Roberts. “It is implausible that Congress meant the Act to operate in this manner.”

“For many of our patients, expansion of the ACA has provided a crucial lifeline to access needed health care services, to better engage in treatment, and to experience not just recovery, but to be well again,” said Harsh K. Trivedi, M.D., M.B.A., the chair of APA’s Council on Healthcare Systems and Financing and vice chair for clinical affairs in the Department of Psychiatry at Vanderbilt University in Nashville, Tenn.

“We will continue to work with Congress, the Administration, and the medical community to ensure that mental illness and substance use disorders are treated the same as other illnesses as outlined in the ACA,” added APA CEO and Medical Director Saul Levin, M.D., M.P.A.

(Image:Gary Blakely/Shutterstock.com)

Wednesday, June 24, 2015

Psychiatrists Join in Healing Efforts After Charleston Murders

Within days after a gunman murdered nine churchgoers at the Emanuel African Methodist Episcopal Church (left) in Charleston, S.C., on June 17, faculty members from the Medical University of South Carolina’s (MUSC) Department of Psychiatry and Behavioral Sciences were supporting recovery and resilience efforts as part of a unified community response.

South Carolina Psychiatric Association (SCPA) members, along with clinicians from Community Mental Health and the MUSC's National Crime Victims Center, supported the family assistance center coordinated by the Federal Bureau of Investigation to help those affected by the tragedy.

Various agencies continue to provide emotional and practical supports and referrals to the family and friends of the victims, said psychiatrist Edward Kantor, M.D., SCPA district branch disaster liaison and an associate professor and director of residency training at MUSC, in an interview.

The center was scheduled to close after three days, but has remained open for another week to accommodate family members coming from out of town, said Kantor.

The SCPA is also undertaking a broader needs assessment, in partnership with state and local partners, to look for concrete ways that psychiatry can support recovery efforts in the city and across the state, added David Beckert, M.D., an assistant professor of psychiatry at MUSC and SCPA vice president.

“Many families are affected, not just those in Charleston,” Beckert told Psychiatric News. “We are sifting through evidence-based material to help well people who are affected by the event but are not psychiatrically ill. They still need assistance in recovering.”

Kantor was impressed by the outpouring of unity and support in the city and state after the tragedy: “It feels like there is a genuine effort across the board to really come together in good faith to figure out how to move forward together.”

Edward Kantor, M.D., and David Beckert, M.D. are contributing authors to the American Psychiatric Publishing book Disaster Psychiatry: Readiness, Evaluation, and Treatment.

(Image: Darryl Brooks/Shutterstock.com)

Tuesday, June 23, 2015

Data Show Mental Illness Alone is Not a Risk for Gun Violence

Mental illness is not a risk for gun violence, according to a study appearing in Psychiatric Services in Advance. Prior violence and substance abuse may be better indicators of risk for subsequent violence, say researchers from several institutions.

The MacArthur Violence Risk Assessment Study followed a group of 1,136 patients who had been discharged from acute civil inpatient facilities at three U.S. sites between 1992 and 1995. This sample included English-speaking male and female patients who were between the ages of 18 and 40; were of white, African-American, or Hispanic background; and had a chart diagnosis of bipolar disorder, depressive disorder, schizophrenia or other psychotic disorder, substance use disorder, or personality disorder.

Three sources of information were used to ascertain the occurrence of violent acts in the community post discharge, including interviews with patients, interviews with persons identified by the patient as being knowledgeable about his or her life, and official sources of information (arrest and hospital records).

Of the 951 persons available for at least one follow-up, 23 (2%) committed acts of violence with a gun. These 23 people tended to have admission diagnoses of major depression (61%), alcohol abuse (74%), or drug abuse (52%). Three patients (13%) were diagnosed as having bipolar disorder, none were diagnosed as having schizophrenia, and three (13%) received other diagnoses. At the time of hospital admission, the 23 people who later went on to commit gun violence displayed symptoms of substance abuse (61%), suicidal threats (65%), hallucinations (22%), paranoia (13%), delusions (9%), and anxiety (9%).

While prior hospitalization rates among discharged patients who committed gun violence were comparable to those of the overall MacArthur sample in the study (78% and 73%, respectively), the prior arrest rate of discharged patients who later committed gun violence was almost twice as high as the prior arrest rate of the overall sample (89% and 49%, respectively).

“For the small group of people with mental illness who are at risk of committing gun violence, improved collaborations with the criminal justice system are clearly indicated,” the researchers stated. “However, directly targeting mental illness as the major driver of gun violence is misguided. ... Prior violence, substance use, and early trauma are more likely to contribute to subsequent violence than is mental illness per se. In this regard, the politically inspired haste to focus gun control efforts on people being treated for a mental illness, rather than on people with demonstrated indicators of violence risk, such as restraining orders related to domestic violence, seems particularly misdirected.”

For more on this subject, see the Psychiatric News article "Capitol Hill Gets Straight Story on Gun Violence, Mental Illness."

(Image: FreeBirdPhotos/Shutterstock.com)

Monday, June 22, 2015

Study Finds HIV Pre-Exposure Medication Does Not Increase Rate or Severity of Depression

A new clinical study reports that the HIV pre-exposure prophylaxis (PrEP) medication Truvada® (emtricitabine and tenofovir disoproxil fumarate, or FTC/TDF) does not increase the risk of depression in men and transgender women who have sex with men.

These findings are the result of further analysis of the 2,500-person iPrEx study, which found that Truvada was a safe and effective prophylaxis. During the trial, depression was reported as one of the most common side effects, and there was concern whether the medication might increase the risks of depressive symptoms and suicide in a vulnerable population.

The new analysis found that the overall number of people reporting depression-related adverse events did not differ between Truvada and placebo (127 vs. 105), nor did the total number of depression events (152 vs. 144). The rate of suicide ideation or attempt also did not differ statistically between Truvada and placebo.

While these findings are encouraging, the study authors did stress that the overall rates of depression or depression-related events were high in both groups. This could be a public health issue, as depression can lead to more risky sexual behaviors while lowering adherence to prophylactic medications.

“PrEP programs may provide infrastructure for increasing access to mental health services, enabling synergistic diagnoses, and management of co-morbidities,” the authors noted.

To read more about the risks of HIV among people with mental health disorders, see the Psychiatric News article “HIV in Mental Health Facilities Sometimes Gets too Little Attention.”


Friday, June 19, 2015

Ziprasidone May Be Effective as Adjunctive Therapy for Depression

For some patients who have undergone rounds of monotherapy for major depressive disorder (MDD), achieving remission may require the use of adjunctive treatment strategies. A study published Thursday in AJP in Advance shows that the atypical antipsychotic ziprasidone may serve as a potential strategy.

Researchers from the Massachusetts General Hospital Clinical Trails Network, the Mayo School of Medicine, and the University of Alabama-Birmingham School of Medicine conducted a multisite study to test the efficacy of adjunctive ziprasidone in 139 adults who remained symptomatic for nonpsychotic unipolar MDD after receiving treatment with the antidepressant escitalopram. The patients were divided into two groups: one group received escitalopram plus ziprasidone for eight weeks; the other received escitalopram plus placebo. The primary outcome measure was clinical response, defined as a reduction of at least 50% in score on the 17-item Hamilton Depression Rating Scale (HAM-D).

At eight weeks, the analysis showed that symptoms of depression were significantly more likely to have improved from baseline in the escitalopram plus ziprasidone group than the escitalopram plus placebo group. Improvements in symptoms of anxiety were also significantly greater in the escitalopram plus ziprasidone cohort than the escitalopram plus placebo cohort. Approximately 14% of the patients in the escitalopram plus ziprasidone group discontinued treatment because of intolerance compared with none in the escitalopram plus placebo group.

“These results suggest that, similar to other atypical antipsychotic agents, adjunctive ziprasidone can represent a useful treatment option for patients with major depressive disorder,” the researchers noted. Due to the rates of discontinuance for the escitalopram plus ziprasidone, the researchers emphasized that more studies testing different dosing regimens are merited.

To read more about the use of antipsychotics as an adjunctive therapy for treatment of MDD, see the Psychiatric News article “FDA Approves Antipsychotic to Treat Bipolar Depression.”

(Image: Andrzej Wilusz/shutterstock.com)

Thursday, June 18, 2015

Study Finds Majority of Adolescents Receiving Treatment for Depression Find It Helpful

An estimated 5 to 10% of U.S. youth aged 12 to 17 experience a major depressive episode each year. A study published Monday in Psychiatric Services suggests that while the majority of these adolescents do not receive treatment for their depression, when they do, many rate the treatment favorably.

Researchers from RTI International, the National Institute of Mental Health, and the Substance Abuse and Mental Health Services Administration analyzed data from the National Survey on Drug Use and Health to investigate assessments of the helpfulness of counseling (having seen or talked to a professional about their depression) and/or prescription medication by adolescents who experienced a past-year major depressive episode.

Of the 9,100 adolescents (ages 12 to 17) with a major depressive episode (8.1%) in the sample, 2,000 (22%) reported receiving counseling but not taking depression medication, 1,300 (13%) reported receiving counseling and taking depression medication, 200 (3%) reported taking depression medication but not receiving counseling, and 5,500 (62%) reported receiving no counseling or depression medication in the past year.

The authors found that around 32% of adolescents who received only counseling reported that counseling was extremely helpful or helped a lot, 25% reported that it helped somewhat, and 44% reported that counseling was not at all helpful or helped only a little. Adolescents who took a prescribed medication and received counseling had somewhat higher assessments of helpfulness, with 47% reporting their medication was extremely helpful or helped a lot, 22% reporting that their prescription medication helped some, and 31% reported medication was not at all helpful or helped only a little.

“Although there are no standards by which to make normative judgments about these percentages, we were encouraged that more than half of the adolescents felt that counseling or medication was extremely helpful, helped a lot, or helped some,” the authors wrote. “A greater concern ... continues to be that 62% of adolescents with a major depressive episode received no treatment at all.”

For more on the treatment of adolescents with depression, see the Psychiatric News article “Most Young Girls With Depression Fail to Receive Treatment.”

(Image: auremar/Shutterstock.com)

Wednesday, June 17, 2015

Capitol Hill Hearing Underscores Urgent Need for Mental Health Reform

The Energy and Commerce Subcommittee on Health held a hearing yesterday on landmark legislation that would reform the U.S. mental health system.

The bill, HR 2646 (Helping Families in Mental Health Crisis Act), is cosponsored by U.S. Reps. Tim Murphy (R-Pa.) and Eddie Bernice Johnson (D-Texas). It builds on previous legislation put forward by both representatives.

Notably, the bill creates the position of Assistant Secretary for Mental Health and Substance Use Disorders, who must be a psychiatrist or Ph.D. clinical psychologist, within the Department of Health and Human Services to elevate the importance of mental health in that agency, coordinate mental health and related programs across different agencies, promote effective evidence-based programs, and ensure compliance with the mental health parity law.

Much of yesterday's discussion hovered around HIPAA and whether that law prevents clinicians from giving families information about the diagnosis, treatment, or appointment scheduling of relatives with mental illnesses. HR 2646 would allow disclosure in some circumstances of health information covered by the privacy rule to families or caregivers when it is in the best interests of a patient who lacks decisional capacity.

This was indeed a gray area for clinicians, said former APA President Jeffrey Lieberman, M.D. (pictured above). “Doctors fear lawsuits, and it will take more than education to solve this problem.”

Speaking in favor of the bill, Lieberman pointed out that "mental health care involves disease management, not handing out a pill. It is hard to provide because we lack co-location of services and a coherent funding stream. The tools for care are available, but we have to develop the policies to implement them. We need a big-picture approach."

"Severe mental illness is a brain disorder, and it has to be seen and treated for what it is," said Joe Pitts (R-Pa.), subcommittee chair. "This bill is comprehensive and is a big first step and makes substantial changes."

Overall, further collaboration on the bill should maintain a focus on the needs of patients, Murphy concluded. “We’ll keep working together.”

For more information on HR 2646, go to Rep. Murphy's website; also, see "APA Applauds U.S. Reps. Murphy and Johnson for Reintroducing Comprehensive Mental Health Reform Legislation."

(aml/Image: Aaron Levin)

Tuesday, June 16, 2015

States Allowing Medical Use of Marijuana Have Not Seen Increases in Teen Use, Study Says

State laws that permit medical use of marijuana do not appear to have caused an increase in adolescent recreational use of marijuana, according to a report that appears in The Lancet Psychiatry.

Researchers at multiple institutions analyzed data from the Monitoring the Future study, which conducts annual national surveys of students in 8th, 10th, and 12th grade (modal ages 13–14, 15–16, and 17–18 years, respectively), in around 400 schools per year. Students complete self-administered questionnaires that include questions on marijuana use.

The researchers analyzed data from 1,098,270 adolescents surveyed between 1991 and 2014. The primary outcome of this analysis was any marijuana use in the previous 30 days, and they used statistical modelling to examine two questions: whether marijuana use was higher overall in states that ever passed a medical marijuana law up to 2014 and whether the risk of marijuana use changed after passage of medical marijuana laws.

They found that marijuana use was more prevalent in states that passed a medical marijuana law any time up to 2014 than in other states, but the risk of marijuana use in states before passing medical marijuana laws did not differ significantly from the risk after medical marijuana laws were passed.

“Our findings, consistent with previous evidence, suggest that passage of state medical marijuana laws does not increase adolescent use of marijuana,” the researchers state. “However, overall, adolescent use is higher in states that ever passed such a law than in other states. State-level risk factors other than medical marijuana laws could contribute to both marijuana use and the passage of medical marijuana laws, and such factors warrant investigation.”

The effect of such laws on teenage marijuana use has been hotly debated, and the study received national media attention, including coverage by the New York Times. But at least one expert on substance use disorders who reviewed the report for Psychiatric News said the results should be viewed cautiously.

“Federal policy regarding medicinal marijuana did not relax until mid- 1999, and data from before that period only informs us about laws that were not particularly active, due to federal prohibitions,” said Christian Hopfer, M.D., a professor of psychiatry in the division of substance dependence at the University of Colorado, Denver. “The commercialization of marijuana and subsequent industrial growth is a recent phenomenon, and experiences from Holland’s depenalization demonstrated that it took a number of years for the full effect of depenalization and subsequent commercialization on adolescent marijuana use to be seen. Nationally, adolescent marijuana use has been on the increase over the past decade, and it is unclear to what extent news regarding marijuana’s medicinal effects and legalization has played a role in the national rise—that is, the effects of marijuana medicinal legalization may not be felt state-by-state, but on a national level through decreasing the perceived

For more information, see the Psychiatric News article "Expert Emphasizes Importance of Science in Debate Over Legalization of Marijuana."

Monday, June 15, 2015

Active Clinician Assistance Improves Smoking Cessation Odds

Clinicians in primary care settings can play a big role in helping people to quit smoking, but many of them could be more proactive in the intervention process, reports a study published today in JAMA Internal Medicine.

This study assessed over 3,300 participants of the National Lung Screening Trial—all who were smokers at the time they enrolled in the trial—one year after they had received their lung cancer screening. Around half of the participants had quit smoking since their screening and the other half were used as matched controls.

The researchers examined whether clinicians’ use of the “5As”—ask, advise, assess, assist, and arrange—during the screening process for the trial had any bearing on quit rates, and found that only the last two elements made a significant difference. Providers who assisted patients by recommending strategies like counseling or medication increased the likelihood their patients quit smoking by 40%, while those who arranged follow-up calls or visits increased the chances that patients quit by 46%.

However, the number of clinicians who were active in assisting and/or arranging was fairly low. While over 75% of physicians asked about smoking status or advised their patient to quit, only 63% assessed patient interest in quitting, 56% assisted their patients, and 10% helped make arrangements.

The authors acknowledged that many primary care clinicians are busy and may not have the time to assist every patient they see, but given the improved odds, efforts could be made to develop collaborative or integrated care programs.

To learn more about how integrated care may be valuable in smoking cessation, especially for people with mental health issues, see the Psychiatric News article “Smoking Cessation for Patients Called an Urgent Priority.” For additional information, see the Psychiatric Services study “Increasing Tobacco Dependence Treatment Through Continuing Education Training for Behavioral Health Professionals.”

(shutterstock/Image Point Fr)

Friday, June 12, 2015

APA Seeks Transparency Regarding Compliance with Mental Health Parity in New Regulations

APA wants Medicaid managed care plans and so-called Alternative Benefit Plans to be held accountable, through transparent disclosure of medical necessity criteria, for adherence to federal parity rules requiring comparable coverage of mental health and substance abuse treatment.

In a June 9, 2015 letter to the Centers for Medicare and Medicaid Services (CMS), APA CEO and Medical Director Saul Levin, M.D., M.P.A., applauded recently proposed regulations that extend mental health parity requirements to Medicaid managed care organizations (MCOs), the Children’s Health Insurance Program (CHIP), and Alternative Benefit Plans. "The application of the proposed regulations holds great promise for increasing access to medically necessary health care and for creating cost efficiencies that would otherwise be unachievable," Levin said.

But Levin also urged the agency to clarify regulations pertaining to documentation and disclosure of compliance with parity requirements. “…[T]he Proposed Regulations must strive for compliance with and accountability to the Mental Health Parity and Addiction Equity Act (MHPAEA) and its Final Rules,” Levin wrote. “Accountability can only be achieved through transparency, since this is the only basis for verifying true compliance. Full and public disclosure of all pertinent plan information that documents compliance with MHPAEA and the Final Rules is essential. This is a concern for all patients, but especially for Medicaid enrollees, whose ability to understand their benefits may be compromised.”

The 26-page letter is an extraordinarily detailed analysis of the federal proposed regulations that urges the agency to clarify a number of issues around transparency regarding compliance with parity. Among the recommendations in Levin’s letter is one that CMS stipulate “at a minimum” that documentation of compliance include a description of the methodology used by a state to perform the required regulatory tests for each applicable financial requirement, quantitative and nonquantitative treatment limitation, and all other parity requirements; the methodology used by the state to assure that there are no separate treatment limitations that apply only to mental health and substance use disorder benefits; and clear statements of the conclusions reached respecting each of these.

More information on mental health parity, including a two-page summary of APA's response to the proposed rule, can be found here.

(Image: Marco Rubino/Shutterstock.com)

Thursday, June 11, 2015

Study Suggests Heavy Alcohol Use May Alter Brain Development

Differences in brain development are apparent in the brain scans of individuals who began drinking heavily during adolescence, writes Lindsay Squeglia, Ph.D., an assistant professor at the Center for Drug and Alcohol Programs in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina in Charleston, in the June issue of the American Journal of Psychiatry.

Heavy drinkers were classified by time and frequency: one or two drinks every day or three or four drinks at a time one to three times a month, for instance. The authors used magnetic resonance imaging to compare changes in gray and white matter volume in 75 adolescents who became heavy drinkers over the course of the study with 59 who remained light- or nondrinkers. Each underwent multiple MRI scans between ages 12 and 24 and was followed for up to eight years.

Heavy-drinking adolescents showed accelerated gray matter volume reductions in the neocortex and smaller increases in white matter volumes in some structures compared with the nondrinkers, which Squeglia suggested may possibly “contribute to short-term or long-term negative effcts on cognitive, social, and academic functioning.

Causality cannot be determined from this study, she concluded. However, “[t]hese results provide a call for caution regarding heavy alcohol use during adolescence, whether heavy alcohol drinking is the cause or one of many factors in a constellation of causes of these alterations in brain development.”

For more information about adolescents and alcohol, see the Psychiatric News article "Teen Alcohol, Tobacco Use Down, E-cigarette Use Up."

--aml (Image: Nito/Shutterstock.com)

Wednesday, June 10, 2015

Psychiatrist Patrice Harris, M.D., Elected by AMA Trustees to Be Chair-Elect of Board

Psychiatrist Patrice Harris, M.D. (pictured left), elected yesterday to a second term as trustee on the AMA Board of Trustees, received another honor when her fellow trustees today elected her to be Chair-Elect of the board.

It’s a significant recognition of Harris’ effectiveness as a spokesperson for physicians by the leaders of American medicine. APA leaders say it testifies to the trust her fellow board members place in her and to the high regard in which she is held throughout the House of Delegates.

The AMA Board of Trustees is an elected body of 21 physicians who guide the AMA as it sets standards and policy for the medical profession. Harris is a former member of the APA Board of Trustees. “I am thrilled that Dr. Harris will serve as Chair-Elect on the AMA Board,” said APA President Renee Binder, M.D. “The APA Board of Trustees is looking forward to working with her as both groups strive to improve and advance the practice of medicine.”

APA CEO and Medical Director Saul Levin, M.D., M.P.A., noted: “It’s an honor to have one of our former Board of Trustees members re-elected to the AMA Board of Trustees and become Chair-Elect of the board. Dr. Harris will continue to carry the integration of psychiatry and mental health within the house of medicine.”

Harris has taken on several leadership roles at the AMA, including a term as chair of the AMA Council on Legislation. “It’s a great honor to be elected Chair-Elect to our AMA Board of Trustees,” Harris said. ”I am proud to be in this role and to have a strong voice for the patients we serve. My success in the AMA is in no small part due to the hard work of the members of the Section Council on Psychiatry.”

Harris is the Director of Fulton County (Ga.) Health Services and the head of the Fulton County Department of Behavioral Health and Developmental Disabilities. As director of health services for Fulton County, which includes Atlanta, Harris directs all county health services, including health partnerships that deliver a wide range of treatment and prevention services. She is a past president of the Georgia Psychiatric Physicians Association and served as a member of the AMA Women Physicians Congress. Harris also maintains a private psychiatric practice.

For more information about Harris, see the Psychiatric News articles “Patrice Harris, M.D., Elected Secretary of AMA Board” and “Psychiatrists Vie for AMA Positions: Harris Seeks Board of Trustees Seat.”

Tuesday, June 9, 2015

Psychiatrist Patrice Harris, M.D., Re-Elected to AMA Board of Trustees

Psychiatrist Patrice Harris, M.D. (at left), was elected to a second term as a trustee of the American Medical Association (AMA) Board of Trustees this morning during the AMA House of Delegates annual policymaking meeting in Chicago.

Harris, who is the director of health services for Fulton County, Ga., is a past member of the APA Board of Trustees. In addition to having served as a member of the AMA Women Physicians Congress and chaired the AMA Council on Legislation, Harris is a past president of the Georgia Psychiatric Physicians Association and was the founding president of that district branch's political action committee. Last year, Harris was elected secretary of the AMA Board by her fellow trustees.

In comments to the House of Delegates on Saturday, Harris recalled the words of Kent Brantly, M.D., the American physician who contracted Ebola while treating patients in Liberia: "When the going gets tough, the tough return to their calling." "What an apt description of those of us who are called to medicine," Harris said. "Our challenges are many—electronic health records, maintenance of certification, alternative payment models. But when we remember our mission and our calling, the challenges are not insurmountable. The AMA must continue to protect the practice of medicine and support physicians in choosing their own path. The challenges are real, the issues are complex, there is work to be done, and it will take all of us to do it. While I cannot promise an outcome, I can promise you the fight."

For more information about Harris, see the Psychiatric News articles “Patrice Harris, M.D., Elected Secretary of AMA Board” and “Psychiatrists Vie for AMA Positions: Harris Seeks Board of Trustees Seat.”

(Image: Ted Grudzinski/AMA)

Monday, June 8, 2015

AMA House Backs Ending Ban on Transgender Individuals Serving in Military

There is no medically valid reason to exclude transgender individuals from service in the U.S. military, and transgender service members should be provided care according to the same medical standards that apply to nontransgender personnel. So declared the AMA House of Delegates this afternoon during its 2015 annual policymaking meeting by approving a resolution introduced by the Section Council on Psychiatry in coordination with several other groups.

The resolution was widely supported during reference committee hearings and approved without debate during the meeting of the House today. “This resolution is about ending the blanket ban that prohibits transgender people from military service and transgender military service members from equal access to care,” said psychiatrist Brian Hurley, M.D. (pictured above), a delegate to the Section Council on Psychiatry from GLMA: Health Professionals Advancing LGBT Equality. (The latter is the full name of the group formerly known as the Gay and Lesbian Medical Association.)

“There is a difference between having a transgender identity and having gender dysphoria, and there is no reason that transgender status alone should exclude anyone from military service or equal access to care,” Hurley said. “This resolution asks the AMA to state that there is no medical justification for this blanket ban, and in doing so, empower military physicians and commanders to assess readiness to serve on a case-by-case basis.

“We don't exclude gay people from military service or treat gay people and straight people according to different standards of care, so there is no justification for a continuing ban that treats transgender people different from cisgender people,” Hurley said. “There are over 15,000 transgender service members who remain closeted as a matter of policy, so it is urgent that the AMA weigh in now to affirm that there is no medical justification for this discriminatory policy.”

For related information, see the Psychiatric News article “Newest AMA Section Council Member Brings Focus on LGBT Health.”

(Image: Mark Moran)

Study Identifies Symptom Profile That Can More Accurately Predict Conversion to Psychosis

Using a profile consisting of four symptoms—disorganized communication, suspiciousness, verbal memory deficits, and declining social functioning—can greatly improve the ability to predict future psychosis in some high-risk individuals, according to a study published June 5 in AJP in Advance.

Currently a person is considered to be at high risk of developing psychosis if they show one or more attenuated (not intense or severe) positive symptoms, such as unusual thoughts, delusions of grandeur, or disorganized communication.

However, as highlighted in this study, this classification does not offer a high predictive value; the authors followed 101 at-risk adolescents—based on the presence of attenuated symptoms—over a five-year period and found that only 28% of them converted to psychosis.

In more closely examining the social and cognitive symptoms of this group, along with 68 non-risk adolescents who served as controls, the authors did identify four variables (communication, suspiciousness, verbal memory, and social functioning) that were strongly associated with conversion risk. A model based on these variables could predict future psychosis with an accuracy of 81.8%.

The study authors did note their study group was fairly homogenous and only considered people with attenuated symptoms, so this profile may not apply to all at-risk individuals, such as those who may have no observable symptoms but genetic risk factors.

To read about a new study that may also help predict which patients will respond to antipsychotic medications, see the AJP in Advance study, "Early Improvement As a Predictor of Later Response to Antipsychotics in Schizophrenia: A Diagnostic Test Review," also published June 5.

(Image: shutterstock/Nicram Sabod)

Friday, June 5, 2015

Reps. Murphy, Johnson Reintroduce House Mental Health Reform Bill

Rep. Tim Murphy (R-Pa.) and Rep. Eddie Bernice Johnson (D-Texas) reintroduced the Helping Families in Mental Health Crisis Act (HR 2646) yesterday. The revamped bill builds upon the previous bipartisan version introduced last year.

“It’s not just a new bill, but marks a new dawn for mental health care in America,” Murphy (pictured above during address to the APA Assembly last year) said in a statement. “We are moving mental health care from crisis response to recovery, and from tragedy to triumph. I am tremendously proud of the work we’ve accomplished and so encouraged about our nationwide grassroots support involved in advancing our legislative vision to help families in mental health crisis.”

According to a summary of the bill prepared by Murphy’s office, the bill seeks to address, among other issues, the following:

Innovation. Establishes a National Mental Health Policy Laboratory to drive innovative models of care and develop evidence-based and peer-review standards for grant programs and dedicates funding for the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative.

Improving Transition From One Level of Care to Another. Requires psychiatric hospitals to establish clear and effective discharge planning to ensure a timely and smooth transition from the hospital to appropriate post-hospital care and services.

Shortage of Crisis Mental Health Beds. Provides additional psychiatric hospital beds for those experiencing an acute mental health crisis and in need of short-term (less than 30 days) immediate inpatient care for patient stabilization.

Mental Health Workforce. Requires the assistant secretary for mental health and substance use disorders to study and recommend a national strategy for increasing the number of psychiatrists, child and adolescent psychiatrists, and other mental health professionals; includes child and adolescent psychiatrists in the National Health Service Corps; and authorizes the Minority Fellowship Program.

Early Intervention and Prevention Programs. Authorizes, for the first time in federal law, the Recovery After Initial Schizophrenia Episode (RAISE), an evidence-based early intervention program, and launches a new early childhood grant program to provide intensive services for children with serious emotional disturbances in an educational setting.

Alternatives to Institutionalization. Incentivizes states to provide community-based alternatives to institutionalization for those with serious mental illness, such as assisted outpatient treatment and other assertive-care community approaches.

APA leaders hailed the introduction of the bill as a critical step toward mental health reform. “The nation’s mental health system needs reform and investment—especially on behalf of patients and families living with serious mental illness. We applaud Reps. Murphy and Johnson,” said APA President Renée Binder, M.D. “Among the many important provisions of this bill are strengthening enforcement of mental health parity, enhancing the psychiatric workforce, ensuring better coordination of federal resources, and improving research and treatment for persons with mental illness, including substance use disorders.”

Added APA CEO and Medical Director Saul Levin, M.D., M.P.A.: “We look forward to working with Congress to pass this bill this year."

A summary of the bill is posted at http://murphy.house.gov/uploads/Summary_The_Helping_Families_in_Mental_Health_Crisis_Act.pdf. For more information, see the Psychiatric News article “Author of House Mental Health Bill Addresses APA Assembly.”

(Image: David Hathcox)

Thursday, June 4, 2015

Study Tracks How State Education-Related Policies Affect ADHD Diagnoses

Consequential accountability reforms (those that assign consequences to schools who fail to meet standards) initiated by the No Child Left Behind (NCLB) Act were linked to increased diagnoses of attention-deficit/hyperactivity disorder (ADHD) in children from low-income households from 2003 to 2007, according to a study in Psychiatric Services in Advance. In contrast, states with laws prohibiting school personnel from recommending or requiring that a child take a psychotropic medication saw decreases in ADHD diagnoses.

Because children with ADHD often face problems with academic achievement and those diagnosed are often treated with medications that can improve standardized scores, Stephen Hinshaw, Ph.D., a professor of psychology at the University of California, Berkeley, and colleagues sought to investigate whether consequential accountability indirectly results in more ADHD diagnoses. For the study, the team analyzed data from the National Survey of Children’s Health on public school children aged 6 to 13 from 2003 to 2011.

From 2003 to 2007, public school children from low-income households residing in states first experiencing consequential accountability under NCLB showed an increase in adjusted ADHD diagnostic prevalence of 56% compared with an increase of 19% of demographically similar children residing in states that had consequential accountability prior to NCLB. This association did not continue from 2007 to 2011—a factor the authors suggest may be due to a greater short-term initial response to NCLB and the introduction of a different set of education incentives in 2009.

From 2003 to 2011, states with psychotropic drug–monitoring laws saw ADHD diagnostic prevalence decrease by 4% in contrast to the 23% increase in states without such laws.

“Future research should investigate whether children most affected by these policies are receiving appropriate diagnoses or are being overdiagnosed because of NCLB consequential accountability or underdiagnosed because of psychotropic medication laws,” the authors wrote.

For more on treating ADHD, see the Psychiatric News article “Pediatricians Urged to Adhere Better to ADHD Care Practices.”

(Image: hxdbzxy/Shutterstock.com)

Wednesday, June 3, 2015

Study Finds SSRI Use in Late Pregnancy May Increase Risk of Newborn Respiratory Disease

Taking certain antidepressants later in pregnancy may slightly increase the risk of a rare but life-threatening respiratory disease known as persistent pulmonary hypertension of the newborn (PPHN), according to a study published yesterday in JAMA.
The overall risk increase was modest, though, and only significant among full-term births.

In 2006, the Food and Drug Administration (FDA) issued a public health advisory related to the possible risk of PPHN in pregnant women taking selective serotonin reuptake inhibitor (SSRI) antidepressants. Subsequent research produced conflicting results and negative studies tended to be small, raising the possibility that they may not have been able to detect an increased risk, prompting the FDA to revise and soften their stance in 2011. 

Researchers at Brigham and Women’s Hospital examined the medical records of nearly 4 million women enrolled in Medicaid—over 128,000 of whom were taking an antidepressant during the 90 days before delivery. Overall, 7,630 infants not exposed to antidepressants were diagnosed with PPHN (~20.8 per 10,000 births) compared with 322 infants exposed to SSRIs (~31.5 per 10,000 births) and 78 infants exposed to other antidepressants (~29.1 per 10,000 births).

After adjusting for other potential risk factors, the use of SSRIs resulted in a 28 percent increased risk for PPHN among full-term births; other antidepressants were not associated with any increased risk. The study authors did stress that the risk identified was less than in previous studies, and given the rarity of PPHN, the absolute disease risk remained very small.

"Clinicians and patients need to balance the potential small increase in the risk of PPHN, along with other risks that have been attributed to SSRI use during pregnancy, with the benefits attributable to these drugs in improving maternal health and well-being," the study authors write.

To read about other reported health risks of SSRI use during pregnancy, see the Psychiatric News articles “Certain Cardiac Abnormalities Not Linked to Prenatal Antidepressant Use, Study Finds” and “Verdict Mixed on Autism Link to SSRI Use in Pregnancy.” For more on SSRIs and PPHN, see the American Journal of Psychiatry article “Persistent Pulmonary Hypertension of the Newborn and Selective Serotonin Reuptake Inhibitors: Lessons From Clinical and Translational Studies.” 
(shutterstock/wong sze yuen)

Tuesday, June 2, 2015

Study Finds New Jersey Correctional System’s Tobacco Ban Associated With Dramatic Drop in Mortality Among Mentally Ill

Restricting and ultimately eliminating tobacco from the New Jersey correctional system was associated with a decrease in mortality rates of inmates with mental health needs, according to a recent article in Psychiatric Services in Advance.

Between 2009 and 2011, the sale of tobacco within the New Jersey Department of Corrections (NJDOC) was reduced by 49 percent, concurrent with the introduction of smoking cessation programs by health care providers, the introduction of nicotine replacement lozenges in prison commissaries, the rise in cost of tobacco products, and the end of tobacco sales to inmates under 18. In 2012, NJDOC leadership made a decision to become entirely tobacco free, including on facility grounds (a policy that led to the depletion of the tobacco stocked in the prison commissaries by December 2012). As a result, tobacco sales decreased by 68 percent between 2006 and 2012, from an average of 107 to 34 products per inmate per year.

Researchers at several New Jersey institutions examined mortality rates in the total population of inmates and in a subgroup of inmates identified as having special mental health needs from January 2005 through June 2014, encompassing the period in which tobacco use was significantly reduced and then eliminated. They found that the mortality rate for people identified as having special mental health needs decreased by 48 percent, from an average of 676 per 100,000 population over the eight-year period before the ban to 353 per 100,000 in the 18 months after the ban. In contrast, the mortality rate of those not on the special needs roster remained relatively flat.

"Policies … that restrict or eliminate access to tobacco in the environment are effective strategies for reducing tobacco-related mortality in the general population," the researchers state. "This study in a correctional setting suggests that similar policies should be tried with subpopulations with mental illness in other settings as well."

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

(Image: Gts/shutterstock)

Monday, June 1, 2015

Adult ADHD May Be Distinct From Childhood ADHD

Attention-deficit/hyperactivity disorder (ADHD) in children may be distinct from and unrelated to ADHD in adults, according to a study in the American Journal of Psychiatry. The prevailing assumption has long held that adult ADHD is a childhood-onset neurodevelopmental disorder, but no prospective longitudinal study has described the childhood of adults with ADHD until now, reported Terrie E. Moffitt, Ph.D., and colleagues.

The researchers studied a birth cohort of 1,037 individuals born in Dunedin, New Zealand, in 1972 and 1973 and followed them to age 38. A number of factors were assessed, including symptoms of ADHD, associated clinical features, comorbid disorders, neuropsychological deficits, genomewide association study-derived polygenic risk, and life impairment indicators. Adult ADHD diagnoses used DSM-5 criteria.

As the researchers had expected, childhood ADHD had a prevalence of 6% (predominantly male) and was associated with childhood comorbid disorders, neurocognitive deficits, polygenic risk, and residual adult life impairment. Also as expected, adult ADHD had a prevalence of 3% (gender balanced) and was associated with adult substance dependence, adult life impairment, and treatment contact. However, the researchers were surprised to find that 90% of adult ADHD cases lacked a history of childhood ADHD. Another unexpected finding was that the adult ADHD group did not show tested neuropsychological deficits in childhood or adulthood, nor did they show polygenic risk for childhood ADHD.

The researchers concluded that if the study findings are replicated, the disorder’s place in the classification system as a neurodevelopment disorder manifesting early in development needs to be reconsidered and that research should be conducted on the etiology of adult ADHD.

(Image: shutterstock.com/Volt Collection)


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