Childhood Trauma May Increase Risk of Adolescent Drug Use, Study Shows

Children who experience traumatic events prior to the age of 11 may be more likely to use marijuana, cocaine, nonmedical prescription drugs, or other drugs as teens, according to a report online in the Journal of the American Academy of Child and Adolescent Psychiatry.

The results suggest that adolescents with a history of childhood trauma may benefit from drug prevention efforts that specifically address traumatic memories and coping strategies, and the need for treatment programs to more directly address childhood trauma.

Researchers from several institutions analyzed data from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A), which included adolescents aged 13 to 18 years (N=9,956). They examined associations between traumatic events prior to age 11 and specific types of drug use in adolescence, adjusting for parental substance misuse. (Potentially traumatic events [PTEs] included items from the Criterion A1 assessment for PTSD in the Composite International Diagnostic Interview [CIDI].)

According to the survey, 11% of participants had experienced interpersonal violence, 18% had experienced a traumatic accident, 15% had witnessed or heard about a traumatic event happening to a loved one, and 4% reported an unspecified event. For lifetime drug use, 22% had ever used marijuana, 2% cocaine, 5% prescription drugs not for medical reasons, 3% other drugs, and 6% multiple drugs.

After controlling for demographic covariates, the researchers found that exposure to any PTE before the age of 11 was associated with higher risk for lifetime use of marijuana, cocaine, nonmedical prescription drugs, other drugs, and multiple drugs. There was evidence of a dose-response relationship between the number of PTEs experienced and marijuana, other drug, and polydrug use. The experience of interpersonal violence in childhood was consistently associated with lifetime use of all of the illicit drugs assessed, even after controlling for the confounding effect of parent substance misuse, which attenuated the effect sizes of many of the associations assessed.

“For clinicians, our results combined with other studies imply that drug treatment programs may need to more directly address childhood trauma in their therapeutic approach,” the authors wrote. “Early interventions targeting coping with trauma during this critical period of adolescence could have broad benefits to the health and well-being of adults.”

For related information, see the Psychiatric News article “NIH Seeks Input on Major Study of Adolescent Substance Use.”

(Image: iStock/Cathy Yeulet)

APA President, U.S. Senators Call for Continued Support for Mental Health Reform

A bipartisan group of senators welcomed APA President Maria Oquendo, M.D., and other mental health experts to Capitol Hill yesterday as part of an ongoing effort to pass the Mental Health Reform Act of 2016 (S.2680) before the end of the year.

“As a nation we have failed to meet the needs of Americans with mental illness,” Oquendo told senators and advocates gathered for the event. “We have a fragmented delivery and reimbursement system, we deal with workforce shortages and obsolete regulations, and we face the enduring stigma surrounding mental illness. As a nation we must do better and we can do better.”

The Mental Health Reform Act would improve access to care by increasing the number of providers, disseminating the best scientific research, integrating physical and mental health care, and bolstering coordination among federal mental health agencies, said bill coauthor Sen. Bill Cassidy (R-La.).

His colleague and coauthor from across the aisle, Sen. Chris Murphy (D-Conn.), described the step-by-step process of gathering support among fellow senators, including eight Democratic and eight Republican cosponsors, to move the bill closer to passage.

“The Act is the first attempt in the House and the Senate to take a holistic look at a broken system,” said Murphy. “We assessed the problem as being three-fold: a lack of resources, a lack of coordination, and a lack of focus on this continuing stigma.”

In thanking the senators for their efforts, Oquendo said, “APA is very encouraged that the components of meaningful mental health reform are addressed in the bill.” She also called for more support for research at NIMH, NIDA, and NIAAA, as well as a greater emphasis on preventing mental illness.

Cassidy and Murphy emphasized the importance of grassroots support of mental health reform in the months ahead.

“Even in this election year, we can still pass the Mental Health Reform Act and get it signed by the president,” said Cassidy. 

In a blog post describing the event, Oquendo noted, “APA is committed to ensuring that comprehensive mental health reform becomes a reality, and is engaged in lobbying both the House and Senate as they move toward committee votes on these bills. I urge you to reach out to your representatives in Congress and urge them to support comprehensive mental health reform. If we work together, we can eliminate the shortfalls in our current mental health care system, and achieve better and lasting outcomes for our patients and their families.”

For related information, see the Psychiatric News article “Comprehensive MH Reform Bill Introduced in U.S. Senate.”

(Image: Aaron Levin)

Suicide Attempts Higher Among Army Soldiers With Mental Illness, Never Deployed

The rate of suicide attempts by soldiers in the U.S. Army is elevated among those who were never deployed and those who have a mental illness, according to a study published yesterday in JAMA Psychiatry.

The rate of suicide attempts, similar to that of suicide, has increased in the Army over the past decade, noted lead author Robert Uranso, M.D., chair of the Department of Psychiatry at the Uniformed Services University in Bethesda, Md., and collaborators. However, the researchers added, suicide attempts by Army members have been studied less than completed suicides among this population, despite the potential for a suicide attempt to be a gateway to dying by suicide.

In an effort to shed more light on factors associated with suicide attempts among Army soldiers, Uranaso and colleagues gathered the health information of 163,178 soldiers to examine risk factors and timing of suicide attempts by those who were currently deployed, previously deployed, or never deployed in the period 2004 through 2009. The work is part of the Army Study to Assess Risk and Resilience in Service members (Army STARRS).

The results showed that 9,650 of the study's participants had attempted suicide. The 40.4 percent of soldiers who had never been deployed accounted for 61.1%  of the enlisted soldiers who attempted suicide. Previously deployed soldiers accounted for 29.2% of the suicide attempts, and currently deployed soldiers accounted for about 10%. The risk for suicide attempts among soldiers who never deployed was highest within the second month of service; the risk among soldiers on their first deployment was highest in the sixth month of deployment; and the risk among soldiers who had been deployed was highest five months after their return. 

Regardless of deployment status, suicide attempts were more likely to occur among soldiers who were women, were in the first two years of Army service, or had a mental illness (in accordance with ICD-9 criteria) in the previous month. Soldiers with one previous deployment were at higher risk of attempting suicide if they screened positive for depression or posttraumatic stress disorder after they returned from deployment, especially at a follow-up screening about four to six months later. 

“Deployment context is important in identifying SA [suicide attempt] risk among Army-enlisted soldiers,” wrote the researchers. “Understanding the association between suicide attempts and deployment, as well as method and timing of suicide attempts, can assist in developing interventions.”

For related information, see the Psychiatric News article “Troops Face Complex, but Not Inevitable, Mental Health Issues.”

(iStock.com/Niyazz)

Medicare 'Comparative Billing Report' Letters Go to 4,300 Psychiatrists

This month, 4,300 psychiatrists will receive a “Comparative Billing Report” regarding their billing for psychotherapy and evaluation and management (E/M) services (CBR 201607). These seven-page letters from eGlobalTech on behalf of the Centers for Medicare and Medicaid Services (CMS) have alarmed many APA members, and APA plans to share your concerns with CMS. But first, here are some facts to help you understand why you might receive one of these reports and what to do if you do.

Who should expect to receive these CBR letters?

• Psychiatrists who had Medicare claims for services for psychotherapy (CPT® codes 90832, 90833, 90834, 90836, 90837, 90838) billed concurrently with E/M services (CPT codes 99211-99215) that were provided in 2015 “in the office” (site of service code 11)
and
• were found to have “different billing patterns when compared to their peers.” (“Peers” were apparently defined at both the state and national levels.)

What information is contained in the CBR letter?

Each letter reviews your percentage of psychotherapy visits billed concurrently with E/M services, average minutes of psychotherapy per visit, average psychotherapy services per beneficiary, and total charges per beneficiary for E/M services. A sample CBR letter can be accessed on the eGlobalTech website.

What action should you take? Will you be audited?

The CBR letters and related resources encourage psychiatrists to check with their Medicare administrative contractor (MAC) to ensure they are meeting its billing and documentation standards and to perform a “self-audit.” But the sample CBR letter clearly states that CBRs are only “for educational and comparison purposes and do not indicate the identification of overpayments.” The eGlobalTech “Frequently Asked Questions” (FAQs) also state that the “CBR does not alter, change, or negate any of the documentation and billing requirements established by the MACs.” Above all, the FAQs say that “the CBR team does not conduct any audits.” APA believes a “self-audit” may be helpful for some psychiatrists, as it’s always good practice to check regularly for changes in MAC payment or documentation policies. Medicare audits are extremely unpredictable, but it would be unlikely for all 4,300 psychiatrists receiving CBRs to be audited.

Are psychiatrists being targeted?

No. Since 2010, MACs have released 59 different CBRs that focus on multiple physician specialties and other Medicare providers and services. These include internal medicine, orthopedic and general surgery, ophthalmology, cardiology, and dermatology. According to the sample CBR letter, 28.7 percent of 2014 payments for psychiatry and psychotherapy services were “improper,” as determined by Medicare’s “Comprehensive Error Rate Testing” (CERT) contractor. But “[n]early all the errors were the result of insufficient documentation” regarding the length of session, modalities of treatment, progress to date, and updated treatment plan. The sample CBR letter also cites 2001 and 2010 reports by the Department of Health and Human Services Office of Inspector General that found improper payments for psychiatry and psychotherapy services, but those reports predate the revised CPT® coding structure that was adopted in 2013.

Where can you get more information?

Psychiatrists who receive a CBR letter may want to register for the related CMS webinar on Wednesday, June 8, from 3 p.m. to 4:30 p.m. EDT. There will be an opportunity to ask questions, and a recording will be available in five days. Additional CBR resources include the following:

• CBR Support Help Desk: (800) 771-4430
• CBR Support email: cbrsupport@eglobaltech.com
• eGlobalTech website: www.cbrinfo.net/
• CBR 201607 FAQs: http://www.cbrinfo.net/cbr201607-faqs.html

You may call the Practice Management Helpline at (800) 343-4671 with CBR questions or other queries about coding, reimbursement, or practice management.

Prenatal Exposure to Nicotine May Increase Risk of Schizophrenia, Study Shows

Prenatal exposure to nicotine may be associated with an increased risk of schizophrenia, according to a report published today in AJP in Advance.

The finding, based on a large population-based case control study of all live births in Finland over a 15-year period, suggests that efforts to decrease smoking during pregnancy may help decrease the incidence of schizophrenia.

A team of researchers from several institutions in Finland and New York prospectively analyzed cotinine levels in serum obtained during the pregnancies of women in Finland from 1983 to 1998. Cases of schizophrenia in offspring (N=977) were identified from a national registry and matched 1:1 to control subjects based on date of birth, sex, and residence.

The researchers found that a higher maternal cotinine level was associated with increased odds of schizophrenia in offspring; heavy maternal nicotine exposure (defined as cotinine level greater than 50 ng/ml) was associated with a 38% increased odds of schizophrenia. The association persisted after adjusting for maternal age, maternal or parental psychiatric disorders, and socioeconomic status, and the authors noted that there was no clear evidence of mediation of this relationship by low weight for gestational age.

“To our knowledge, this is the first biomarker-based study to show a relationship between fetal nicotine exposure and schizophrenia,” the authors wrote. “The plausibility of these findings is supported by an extensive literature on prenatal smoking and neurocognition. Offspring of mothers who smoke have delayed psychomotor and mental developmental scores; deficits in sustained attention, verbal learning, and design memory; impaired speech and language; and lower IQ. Low premorbid IQ and other neurocognitive abilities have been related to schizophrenia.”

The authors concluded, “Given the high frequency of smoking during pregnancy, these results, if replicated, may ultimately have important public health implications for decreasing the incidence of schizophrenia.”

(Image: iStock/Baris Muratoglu)

Phone-Based CBT for Insomnia May Improve Symptoms in Menopausal Women

A study published today in JAMA Internal Medicine suggests that phone-based cognitive-behavioral therapy for insomnia (CBT-I) may improve sleep in women experiencing insomnia associated with menopause. The study also found CBT-I reduced the degree to which hot flashes interfered with daily functioning.

The findings suggest CBT-I may offer an alternative therapeutic option for women who are hesitant to use sedatives or hormonal therapies to treat these two menopause-related symptoms, which can adversely affect mood, productivity, and physical health.

The study involved 106 Seattle-area women aged 40 to 65 who reported moderate insomnia and at least two hot flashes a day. All of the women were asked to keep daily logs of their sleep patterns throughout the study and rate the quantity, frequency, and severity of their hot flashes at the beginning of the study, and again at eight weeks and 24 weeks later. Half of the participants received six, 20- to 30-minute CBT-I phone sessions over 8 weeks, which included advice how to identify factors that negatively affect sleep and reduce physiological arousal at bedtime; the other half received phone sessions in menopause education control (MEC), which included general strategies for symptom self-management.

After eight weeks, the authors found that women receiving CBT-I showed greater improvements in both insomnia and sleep quality scores compared with those that received MEC, with 70% of CBT-I participants achieving scores equating to no insomnia (compared with 24% in the control group). The CBT-I group also had greater improvements in their diary-reported sleep latency, wake time, and sleep efficiency. These differences persisted at the 24 week mark, even after the sessions had ended.

While the authors found no between-group differences in self-reported hot flash frequency and severity, women in the CBT-I group reported less hot flash interference with daily functioning at 8 and 24 weeks relative to MEC.

Because the professionals delivering the sessions were not sleep specialists, the authors noted, “Our findings support the potential for training non-sleep specialists to deliver telephone-based CBT-I to women with insomnia and vasomotor symptoms in a variety of primary and women’s health care settings.”

They concluded, “Telephone-based CBT-I allows upscaling to reach large populations of menopausal women seeking treatment for sleep problems. Centralized telephone CBT-I should be tested as a dissemination model, similar to effective telephone-based counseling programs for smoking cessation.”

For related information, see the Psychiatric News article “Older Age at Menopause May Reduce Risk of Depression.”

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Mental Disorders Top List of Most Costly Health Conditions in the United States

A comprehensive analysis of federal spending data published this week in Health Affairs found that mental health disorders accounted for an estimated $201 billion in health care costs in 2013—far exceeding the cost of all other medical conditions in the United States (heart conditions and trauma, which came in second and third, accounted for $147 billion and $143 billion, respectively).

The findings represent a shift in spending from 1996, when annual spending on heart conditions was $105 billion compared with $79 billion for mental disorders.

For years the Agency for Healthcare Research and Quality (AHRQ) has produced estimates of spending by medical condition from its Medical Expenditure Panel Survey (MEPS), but these estimates are limited to the civilian non-institutionalized population. In contrast, Charles Roehrig, Ph.D., the founding director of the Center for Sustainable Health Spending at Altarum Institute in Michigan, pooled data from both civilian non-institutionalized and institutionalized (nursing community residents, psychiatric hospital inpatients, prisoners) and active-duty military to determine health spending estimates.

Roehrig found that mental disorders topped the list of health conditions by spending by a substantial margin, at $201 billion—of which more than 40 percent was spending for institutionalized populations.

“The fact that more than 40 percent is spent on populations in prisons, nursing homes, and other institutional settings demonstrates the need to invest more in preventive care,” APA President Maria Oquendo, M.D., told Psychiatric News. “Insurers should be compelled to follow the law and cover mental illness in the same manner as they cover physical illness. Removing currently existing, though illegal, barriers to access to mental health care can mean treating people earlier and avoiding costlier care later.”

Roehrig did note that the increases in health care spending seen for mental disorders were not due to a rapid rise in costs over the past two decades; since 1996, mental health spending has risen about 5.6% each year, which is right around the average rate for all diseases. Rather, costs for cardiovascular disease have been low, rising approximately 2% each year (suggested to be attributable to factors such as improved smoking habits and lower drug costs with the advent of generic statins).

“A look ahead suggests that reductions in deaths from heart conditions and cerebrovascular disease are likely to drive spending on mental disorders even higher, as more people survive to older ages—when mental disorders, such as dementia, become more prevalent,” Roehrig wrote.

Oquendo added, “While non-institutional mental health care is significantly less expensive, this study should be not misread to mean we need to invest less in mental health care. The reality is that we need to spend wisely.”

For related information, see the Psychiatric News article “The Critical and Evolving Roles for Psychiatry in Health Reform.”

(Image: iStock/MilosJokic)

Study Suggests Marriage May Protect Against Alcohol Use Disorder

Marriage to a spouse without a history of alcohol use disorder appears to be associated with a large reduction in risk for alcohol use disorder (AUD), according to a report published on Monday in AJP in Advance. The findings, which were released during APA’s 2016 Annual Meeting in Atlanta, add to a body of evidence that suggests psychological and social aspects of marriage protect against the development of AUD.

To assess the relationship between first marriage and subsequent record of AUD, Kenneth Kendler, M.D., a professor of psychiatry and human and molecular genetics at Virginia Commonwealth University School of Medicine, and colleagues analyzed data contained in a variety of Swedish national birth, health, and crime registries. Of the 3,220,628 individuals included in the sample, 72,252 met the criteria for alcohol use disorder.

The authors found that married men and women had, respectively, a 60% and 71% lower risk for onset of alcohol use disorder compared with individuals who remained single. 

“While marriage to a spouse without lifetime registration for alcohol use disorder was strongly protective, marriage to an affected spouse significantly increased the risk for future alcohol use disorder,” the authors wrote. Additional analysis revealed that the protective effects of marriage were stronger in those at high familial risk for alcohol use disorder compared with those without.

“The protective effects of marriage on risk for alcohol use disorder are likely to arise largely from direct spousal interactions, and they are stronger in individuals who have an elevated familial risk for alcoholism,” the authors wrote. “While causal effects are difficult to prove in observational data, and we cannot rule out the impact of hidden biases, these results are consistent with the hypothesis that the psychological and social aspects of marriage strongly protect against the development of alcohol use disorder.”

For related information, see the Psychiatric News article “Why Treat Alcohol Use Disorders in Primary Care?”

(Image: iStock/digitalskillet)

Responding to Mental Health Needs of U.S. Service Members and More From Annual Meeting

Highlights from Day Five

Our coverage of APA’s 2016 Annual Meeting continues with a discussion of the mental health needs of members of the U.S. Marine Corps; scenarios consulting psychiatrists in collaborative care networks will likely face; and reflections by patients and clinicians on the effectiveness of ECT.

Marine Commandant Asks APA Members to Join in Care of U.S. Marines The Marine Corps trains its recruits to be tough, resilient, adaptable in overcoming obstacles, and most of all, to be members of a team, Gen. Robert B. Neller, commandant of the U.S. Marine Corps, said yesterday at APA’s Annual Meeting. When something happens, that sense of cohesion usually sustains them. But not always. Read More >

Columbia University Residents Win 2016 MindGames Competition Residents from Columbia University emerged victorious in the MindGames competition at APA’s Annual Meeting last night. The “Jeopardy”-like competition—which challenges psychiatry residents’ knowledge of medicine in general, psychiatry in particular, and patient-care issues—has become a popular attraction at APA’s Annual Meeting. Read More and Watch Video >

Curbside Consultation in Collaborative Care Is All About Education Curbside consultation with primary care is an essential skill for psychiatrists participating in collaborative care networks. During a lecture yesterday at APA’s Annual Meeting, psychiatrists had the chance to practice common scenarios that consulting psychiatrists in a collaborative care network might face. Read More >

Kitty Dukakis, Veterans Share Personal Stories of the Effectiveness of ECT Former first lady of Massachusetts Kitty Dukakis joined with several veterans and clinician scientists on Monday to discuss the effectiveness of electroconvulsive therapy (ECT) and the need for greater access to ECT in Veterans Health Administration facilities. Read More >

ECT May Help Patients With Treatment-Resistant Schizophrenia If you have a patient with schizophrenia who is not responding fully to medication, you may want to consider referring them for ECT, Georgios Petrides, M.D., of the Zucker Hillside Hospital, explains to Psychiatric News. Watch Video >

Glen Gabbard, M.D., on Opportunities for Psychiatrists After Retirement “Retirement is not about leaving something, it’s about going to something” said Glen Gabbard, M.D., a clinical professor of psychiatry at Baylor College of Medicine, on Sunday during the Annual Meeting session “The Aging Physician: Possibilities and Perils of Senior Psychiatrists.” Gabbard explains the ways that psychiatrists nearing retirement can find new opportunities in their post-career life. Watch Video >

Inside the Supreme Court and More From APA’s 2016 Annual Meeting

Highlights from Day Four

Our coverage of APA’s Annual Meeting continues with U.S. Supreme Court Justice Stephen Breyer’s address on the inside workings of the Supreme Court; a report on the results of an APA poll on “phantom” insurance networks; and the continued debate over the ethics of involuntary outpatient commitment laws.

Justice Stephen Breyer Gives Inside Look at Country’s Highest Court U.S. Supreme Court Justice Stephen Breyer spoke today at APA’s 2016 Annual Meeting in Atlanta about his latest book, The Court and the World: American Law and the New Global Realities, and what it’s like to work at the highest court in the land. Read More >

Frieden Calls for Joining Psychiatry, Public Health During Convocation Lecture Thomas Frieden, M.D., M.P.H., director of the Centers for Disease Control and Prevention, told attendees at APA’s Convocation of Distinguished Fellows that depression and severe mental illness, alcoholism, opioid addiction, suicide, HIV/AIDS, and a host of other conditions are amenable to solutions that look at broad societal influences, as well as the factors that influence individual behavior. Read More >

Psychiatry Plays an Important Role in Palliative Care, Experts Say In a session at today’s Annual Meeting, Nathan Fairman, M.D., M.P.H., and Scott A. Irwin, M.D., Ph.D., described the expanding interface between palliative medicine and psychiatry and opportunities for psychiatrists to enhance the care of seriously ill patients and their loved ones. Read More >

APA’s Incoming President-Elect to Emphasize Increasing Access to Care Psychiatric News Editor-in-Chief Jeffrey Borenstein, M.D., interviews Anita Everett, M.D., who becomes president-elect of APA at the conclusion of APA’s 2016 Annual Meeting. Watch Video >

APA Poll Finds Access to Care Stymied by ‘Phantom’ Networks in D.C. Because of frequently heard complaints that patients are unable to find a psychiatrist in their insurance network who is available to see them within a reasonable time or even at all, APA engaged the American Psychiatric Association Foundation to conduct a study to see how pervasive this problem really is. The results were announced yesterday at APA’s 2016 Annual Meeting. Read More >

Dangerousness, Not Mental Illness, Should Guide Gun Restrictions Reducing death and injury by firearms should focus less on people who are mentally ill and more on reducing access to lethal means by individuals who want to harm themselves or others, according to Jeffrey Swanson, Ph.D. There is only a tiny intersection between gun violence and mental illness, he pointed out. Read More >

Debate Persists on Ethics of Involuntary Outpatient Commitment Laws Are involuntary outpatient commitment laws a good thing? Depends on who you ask and how that person is looking at the question, said experts in a symposium yesterday at APA’s 2016 Annual Meeting. Read More >

NIDA Session Offers Scientific Solutions to Address Opioid Crisis Opioid misuse is at epidemic proportions in the United States, with deaths due to opioid overdose quadrupling since 1999. Shedding some light on ways to address this problem through science, the National Institute on Drug Abuse (NIDA) sponsored an Annual Meeting session on therapeutic developments that may one day potentially be used to help reverse this public health crisis. Read More >

Talking With Patients About End of Life and More From APA’s 2016 Annual Meeting

Highlights from Day Three

Our coverage of APA’s Annual Meeting continues with reflections on the role of end-of-life care discussions with patients, a former U.S. surgeon general’s commitment to improving mental health care for all, and how to avoid serious professional boundary violations.

Gawande Urges M.D.s to Talk to Patients About End-of-Life Goals People have goals in life other than living longer, and they should be prompted to talk about them, advised noted surgeon and author Atul Gawande, M.D., M.P.H., at the Opening Session of APA’s 2016 Annual Meeting. Read More >

APA Honors Former U.S. Surgeon General David Satcher, M.D. Former U.S. Surgeon General David Satcher, M.D., received APA’s 2016 Human Rights Award at APA’s Annual Meeting today. He was honored for his work highlighting the importance of mental health when he was the U.S. surgeon general as well as his work as founding director and senior advisor of the Satcher Health Leadership Institute at Morehouse University. Read More >

Incoming APA President Discusses Initiatives for Coming Year Incoming APA President Maria Oquendo, M.D., describes how she would like to strengthen APA’s partnerships with other specialty groups in medicine and build an international psychiatric research network. She is interviewed by Psychiatric News Editor-in-Chief Jeffrey Borenstein, M.D., at APA’s 2106 Annual Meeting. Watch Video >

Clinicians Need to Be Sensitive to Patient-Doctor Boundaries, Says Gabbard Glen Gabbard, M.D., discusses his 30 years of experience in treating, evaluating, and consulting on cases of serious professional boundary violations, both sexual and nonsexual. Read More >

Richard Kogan, M.D., on Scott Joplin and Ragtime Psychiatrist and concert pianist Richard Kogan, M.D., explains the origin of ragtime and the psychiatric hospitalization of Scott Joplin and illustrates his lecture with examples of Joplin’s work. Watch Video >

Treating Depression in Youth Requires Systematic Approach, Says Expert Diagnosis, evaluation, and treatment of children and adolescents with depression require subtle but significant shifts in thinking compared with adults, according to Karen Dineen Wagner, M.D., Ph.D., a professor and chair of psychiatry and behavioral sciences at the University of Texas Medical Branch, Galveston. Read More >

Winners of Assembly Election Announced Assembly members select their next speaker-elect and recorder. Read More >

Stopping Mental Illness Early and More From APA’s 2016 Annual Meeting Day Two

Highlights from Day Two

Day two of APA’s Annual Meeting included discussions of the importance of collaboration across medical disciplines, APA’s work over the past year, and several legal cases raising important questions for the field. From now through May 18, you’ll be receiving daily highlights of the meeting through news articles and multimedia interviews. Whether you are here in Atlanta or at home, these reports will convey the excitement and outstanding scientific program being presented at this year’s meeting.

Binder Highlights Five Areas Where Psychiatrists Must Remain Committed In the Opening Session today at APA’s 2016 Annual Meeting, APA President Renée Binder, M.D., outlined key areas in which psychiatrists must take the lead to ensure that people with mental illness get the high-quality care they deserve. Read More >

Oquendo Emphasizes Collaboration Is Key to Preventing Mental Illness APA President-elect Maria Oquendo, M.D., will become president at the end of the Annual Meeting. In her Opening Session speech today, she explained why she chose the theme “Prevention Through Partnerhips” for her presidency. Read More >

Improving Child Mental Health Care Calls for ‘Big Solutions’ Mental disorders are the most expensive elements of child health care, yet opportunities for major improvements are possible with changes under way in the American health care system. Gregory Fritz, M.D., director of the Division of Child and Adolescent Psychiatry at Brown University’s Warren Alpert School of Medicine, discusses some of them. Read more >

Experts Discuss Legal Cases Raising Important Issues for Psychiatry Marvin Swartz, M.D., Paul Appelbaum, M.D., and Howard Zonana, M.D., discuss three major cases in which APA filed friend-of-the-court briefs. Each case has major repercussions for psychiatry. Read More >

APA CEO and Medical Director Recounts APA’s Successes of Past Year Psychiatric News Editor-in-Chief Jeffrey Borenstein, M.D., interviews APA CEO and Medical Director Saul Levin, M.D., M.P.A., on the many initiatives that APA undertook in the past year and the work that APA is doing to achieve the passage of comprehensive mental health reform. Watch Video >

Winners of Resident/Medical Student Poster Competition Announced Psychiatry residents were honored yesterday at APA’s 2016 Annual Meeting for their outstanding new research posters. Read More >

Clinical/Research News From APA’s 2016 Annual Meeting Day One

Welcome to Atlanta!

APA’s 2016 Annual Meeting began in Atlanta today. From now through May 18, you’ll be receiving daily highlights of the meeting through news articles and multimedia interviews. Whether you are here in Atlanta or at home, these reports will convey the excitement and outstanding scientific program being presented at this year’s meeting.

Dimensional Approach to Diagnosing NPD Leads to More Successful Treatment

A dimensional approach to understanding and diagnosing narcissistic personality disorder (NPD) as outlined in Section III of DSM-5—focusing the patient’s functioning with regard to identity, self-direction, empathy, and intimacy—marks a significant improvement over a strictly trait-based diagnostic system. Read More >

Early Intervention for Psychosis Works, But U.S. Lags Behind Some Other Countries

In a session at today’s Annual Meeting, Stephen Adelsheim, M.D., Lisa Dixon, M.D., M.P.H., and Kenneth Duckworth, M.D., gave a broad overview of early intervention programs for psychosis in the United States and described a growing evidence base for the effectiveness of early intervention. But Adelsheim noted that prevention and early intervention are far more entrenched in Europe and Australia. Read More >

Binder Recounts Her Year as APA President

In this video interview with Psychiatric News Editor-in-Chief Jeffrey Borenstein, M.D., outgoing APA President Renée Binder, M.D., looks back on the past year and describes the gains made by psychiatry and APA through major initiatives. Watch video >

Psychiatrists Urged to Incorporate AA’s 12-Step Program Into Treatment

The 12-step Alcoholics Anonymous program can be an integral part of substance use treatment in a psychiatric setting, according to Marc Galanter, M.D., director of the Division of Alcoholism and Drug Abuse at New York University School of Medicine. He pointed out that AA uses many of the psychosocial features that operate in any charismatic membership group. Read More >

Psychiatrist Gives Inside Look at Fort Hood Shooting

The U.S. Army psychiatrist who killed 13 people at Fort Hood, Texas, on November 5, 2009, eventually revealed to members of a military sanity board the development of the thinking that led to the crime, according to Kaustubh Joshi, M.D., who chaired the group. Now that Hasan had been tried and a verdict rendered, Joshi said that he could finally discuss the case. Read More >

Stronger Bridge Needed Between Judiciary, MH Systems for Youth

An event was held today at Morehouse School of Medicine in conjunction with APA’s 2016 Annual Meeting in Atlanta that brought together community members, mental health professionals, and state and local judiciary leaders to discuss youth, the criminal justice system, and mental health services. Presenters hoped to have a positive impact on the community by addressing mental health issues in youth. Read More >

Ketamine May Reduce Active Suicidal Thoughts in Patients With Treatment-Resistant Depression

Ketamine may be able to rapidly reduce persistent suicidal thoughts in medicated patients with treatment-resistant depression, according to a small study published online in the Journal of Clinical Psychiatry. The findings suggest that ketamine may offer an alternative for stabilizing people in emergency situations.

Previous work has shown that ketamine can provide rapid relief of depressive symptoms and lower suicidal ideation scores in patients with both unipolar and bipolar depression. This study is the first to exclusively enroll patients with active suicidal ideation (a score of 3 or higher on the Columbia Suicide Severity Rating Scale).

Fourteen patients with major depressive disorder recruited for the presence of current, stable (three months or more) suicidal thoughts received open-label ketamine infusions over three weeks (0.5 mg/kg over 45 minutes for the first three infusions; 0.75 mg/kg over 45 minutes for the last three). All the patients were taking antidepressants at a dose that was stable for at least 4 weeks prior to enrollment. Explicit suicidal ideation scores (using scales such as the C-SSRS) and implicit scores (using the Implicit Association Test which measures overall attitudes and beliefs) were assessed four hours after each infusion.

As Dawn Ionescu, M.D., and colleagues reported, there was a consistent decrease in suicidal scores during the three week acute phase, with seven of the 14 patients achieving remission of their ideation (a C-SSRS score of 0) by the final infusion; during a naturalistic follow-up three months later, two of these seven patients were still free of suicidal thoughts. In addition, IAT scores went up, suggesting a more positive outlook on life.

“Given the length (three months or more) of participants’ ongoing suicidal ideation and the lack of currently available antisuicidal agents, this steady decrease in suicidal ideation within three weeks is noteworthy,” the authors wrote.

Because there were no control groups, the authors could not be sure if multiple infusions were providing any more benefit than a single infusion, nor could they rule out that ketamine was only augmenting antidepressant action rather than acting on its own. They concluded, “Larger controlled studies (including more serious/acute patients in the emergency room) are necessary to study ketamine’s antisuicidal effects and the relationship between antisuicidal and antidepressant effects.

For related information, see the American Journal of Psychiatry article “Ketamine and Other NMDA Antagonists: Early Clinical Trials and Possible Mechanisms in Depression” and the Psychiatric News article “APA Task Force to Address ‘What’s Next?’ for Ketamine.”

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Lithium May Reduce Self-Harm, Unintentional Injury in Patients With Bipolar Disorder

Patients with bipolar disorder prescribed lithium appear to have lower rates of self-harm and unintentional injury than those prescribed other common maintenance treatments for the disorder. The findings, which were published yesterday in JAMA Psychiatry, suggest lithium use reduces impulsive aggression in addition to stabilizing mood.

Self-harm is a major cause of illness and injury in patients with bipolar disorder. Randomized clinical trials show maintenance medications such as lithium, valproate sodium, olanzapine, and quetiapine fumarate can stabilize mood, but there has been little research on the link between these medications and self-harm.

Joseph F. Hayes, M.Sc., M.B.Ch.B., of the University College London and coauthors compared rates of self-harm, unintentional injury (for example, falls or car accidents), and suicide deaths in patients diagnosed with bipolar disorder who were prescribed lithium, valproate, olanzapine, or quetiapine as a maintenance mood stabilizer using a large database of primary care electronic health records (EHRs) in the United Kingdom.

The team of researchers analyzed EHR data from 6,671 patients with bipolar disorder (2,148 prescribed lithium, 1,670 prescribed valproate, 1,477 prescribed olanzapine, and 1,376 prescribed quetiapine), collected between 1995 and 2013. They found that self-harm rates were lower in patients prescribed lithium (175-241 per 10,000 person-years at risk [PYAR]) compared with those prescribed valproate (334-460 per 10,000 PYAR), olanzapine (345-483 per 10,000 PYAR), or quetiapine (489-692 per 10,000 PYAR). Rates of unintentional injury were also lower in people taking lithium compared with those taking valproate or quetiapine but not olanzapine. The number of suicides was too low to show differences by the individual medications, the report noted.

“The lower rates of self-harm in those prescribed lithium may be due either to improved mood stabilization compared with other treatments or specific effects on impulsive aggression and risk taking,” the authors wrote. “The similarity of the negative association between lithium use and unintentional injury and that between lithium use and self-harm supports the latter hypothesis because there is little reason to expect that lower rates of depressive symptoms would reduce unintentional injury.”

They concluded, “Self-harm, unintentional injury, and suicide are important morbidity and mortality outcomes in BPD [bipolar disorder] that appear to be amenable to modification through appropriate drug treatment.”

For related information, see the Psychiatric News article “Treating Bipolar Disorder in Primary Care” by Joseph Cerimele, M.D., M.P.H., of the University of Washington.

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FDA Warns of Rare but Serious Skin Reaction Reportedly Linked to Olanzapine

The FDA on Tuesday issued a warning that the antipsychotic olanzapine may cause a rare but serious skin reaction that can progress to other parts of the body. According to the announcement, a warning about this severe condition—known as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)—will now appear on all olanzapine-containing products.

According to the FDA Adverse Event Reporting System database, 23 worldwide cases of olanzapine-related DRESS have been identified since the drug’s approval in 1996.

DRESS causes an abnormally high number of eosinophils (infection-fighting white blood cells), which can lead to inflammation or swelling. DRESS commonly starts as a rash but can also be accompanied by a fever, swollen lymph nodes, and a swollen face. The swelling and inflammation can spread to internal organs, causing organ damage, and can lead to death. While there is no specific treatment for DRESS, the FDA recommends the syndrome is best managed by early recognition, discontinuation of the offending medication, and supportive care.

The FDA advises health care professionals prescribing olanzapine to make patients aware of the risks associated with the medication and stop treating patients with olanzapine if DRESS is suspected. Any side effects involving olanzapine should be reported to the FDA MedWatch program.

For related information, see the Psychiatric News article “Antipsychotics May Contribute to Cases of Acute Pancreatitis.”

Hospitalizations Among Veterans Increase After Reductions in Citalopram, Study Shows

All-cause hospitalizations and deaths among veterans significantly increased following reductions in prescribed doses of the antidepressant citalopram in response to an FDA safety bulletin that warned against prescribing citalopram at doses higher than 40 mg/day, according to a report appearing online today in AJP in Advance.

The August 2011 FDA communication stated that doses of citalopram above 40 mg/day may be associated with risk for arrhythmia related to QT prolongation. But today’s AJP study appears to indicate serious unintended consequences in the form of increased hospitalization for mental disorders.

“Rapidly reducing dosages from [greater than] 60 mg/day to 40 mg/day [or less] may have precipitated worsening symptoms of depression, PTSD, and other mental health disorders,” wrote David Rector, Ph.D., Pharm.D., of the University of Minnesota, and colleagues.

The researchers searched the VA’s national electronic medical records database and found 265,795 veterans who filled at least one outpatient citalopram prescription in the three months before August 2011. At the time the warning was issued, 35,848 veterans had active citalopram prescriptions for 64 mg/day, on average. Within 180 days after the safety communication was issued, 60% had filled prescriptions for 40 mg/day or less.

The researchers used statistical analysis to compare hospitalizations and mortality after citalopram doses were or were not reduced to 40 mg/day or less. They found the unadjusted incidence of all-cause hospitalizations or deaths was more than 2.5 times higher after citalopram dosages were reduced to 40 mg/day or less. Hospitalizations for depression, diagnoses of self-injury, or death were also higher after citalopram dosages were reduced. At the same time, there was no noticeable reduction in hospitalizations for cardiac arrhythmias, according to the researchers.

“In the present study, deaths that were directly or possibly indirectly related to worsening mental health may have offset deaths from cardiac arrhythmias incurred by a continuance of higher prescription dosages,” the researchers wrote. “The safety warning may have prompted electrocardiograms that led to dosage reductions that prevented some hospitalizations for cardiac arrhythmias and deaths. However, the net effect of the large number of citalopram dosage reductions that occurred shortly after the safety communications were issued appeared to manifest as an increase in hospitalizations for mental health disorders.”

In response to a request for comment by Psychiatric News, an FDA spokesperson replied, “The FDA does not typically comment on specific studies, but evaluates them as part of the body of evidence to further our understanding about a particular issue and assist in our mission to protect public health.”

For previous coverage of the FDA’s decision to warn health care providers against prescribing citalopram at doses exceeding 40 mg/day, see the Psychiatric News article “FDA Responds to AJP Manuscript on Citalopram Safety.”

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Magnetic Stimulation Opens Pathways to Depression Treatment

Antidepressant medications achieve their effect by altering the communication between individual neurons, but repetitive transcranial magnetic stimulation (rTMS) appears to work on a broader scale.

rTMS is a neuromodulation technique, like trigeminal nerve stimulation and deep brain stimulation. It works by using electromagnetic induction to depolarize neurons under the magnet and cause them to fire, altering functional neural networks in the brain, according to Andrew Leuchter, M.D., (left). He is a professor of psychiatry and biobehavioral sciences and director of the Neuromodulation Division at the Semel Institute for Neuroscience and Human Behavior at the David Geffen School of Medicine at the University of California, Los Angeles.

The technique stimulates cortical excitation over the surface of the brain.

“At the same time, rTMS administered to the left dorsolateral prefrontal cortex rapidly induces blood flow changes throughout the limbic system in the thalamus, caudate, and other subcortical and cortical areas with connections to the site of stimulation,” said Leuchter.

Researchers are still exploring variations of magnet placement, timing, and patterns of stimulation, as well as other related technologies, to determine their effects on depression symptoms.

“[P]sychiatrists may one day find themselves performing office-based brain stimulation procedures and prescribing devices to be used at home,” concluded Leuchter.

For an in-depth report in Psychiatric News about transcranial magnetic stimulation, see “New TMS Device Reduces Depression Symptoms.”

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Teens Who Regularly Use Marijuana May Be at Greater Risk of Paranoia, Hallucinations

Adolescents who regularly use marijuana may be more likely to experience subclinical paranoia and hallucinations, even after sustained abstinence from the drug, a study published this week in AJP in Advance reports.

Several studies have suggested that marijuana use, particularly during adolescence, is related to acute psychotic episodes and future psychotic disorders, but little is known about whether adolescents who regularly use the drug over several years exhibit a systematic increase in their subclinical psychotic symptoms that persists during periods of sustained abstinence.

Researchers from University of Pittsburgh Medical Center and Arizona State University, Phoenix, analyzed data from a sample of 1,009 adolescent boys from Pittsburgh who self-reported annually on the number of days they used marijuana in the past year and experiences of subclinical psychotic symptoms (e.g., feelings of paranoia, hallucinations, bizarre thinking) from age 13 to 18. The teens also annually reported on the number of days they used alcohol, tobacco, and other illicit drugs.

As expected, substance use increased from age 13 to 18. By the last assessment, 270 participants reported having used marijuana weekly, 325 had used alcohol weekly, 377 had used tobacco daily, and 134 had used other illicit drugs at least once. For each year the participants engaged in weekly marijuana use, their expected level of subsequent subclinical psychotic symptoms rose by 21% and their expected odds of experiencing subsequent subclinical paranoia or hallucinations rose by 133% and 92%, respectively.

Additional analysis revealed that even when adolescents stopped using marijuana for one year, the effect of prior weekly marijuana use on total subclinical psychotic symptoms, paranoia, and hallucinations persisted. For each additional year adolescents engaged in weekly marijuana use, their expected number of total subclinical psychotic symptoms rose by 29% during subsequent periods of year-long abstinence, and their expected odds of experiencing paranoia and hallucinations rose by 112% and 158%, respectively.

“[T]he most concerning finding is that the effect of prior weekly marijuana use persists even after adolescents have stopped using for one year,” the researchers wrote.

While the authors acknowledged future studies are needed to determine whether the findings hold for girls and adults living in geographically diverse locales and whether the effect of regular adolescent marijuana use on subclinical psychotic symptoms persists into adulthood, they concluded, “Given the recent proliferation of marijuana legalization across the country, it will be important to enact preventive policies and programs to keep adolescents from engaging in regular marijuana use, as chronic use seem to increase their risk of developing persistent subclinical psychotic symptoms.”

For related information, see the Psychiatric News article “Research Identifies Gene Linked to Cannabis-Induced Psychosis.”

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