Psychiatrist Joshua Gordon, M.D., Appointed Director of NIMH

The National Institutes of Health (NIH) announced yesterday the selection of Joshua A. Gordon, M.D., Ph.D., an associate professor of psychiatry at Columbia University Medical Center and research psychiatrist at the New York State Psychiatric Institute, to serve as the director of the National Institute of Mental Health (NIMH). 

Gordon is expected to assume his new post in September. He will replace Acting Director Bruce Cuthbert, Ph.D.

“I am personally delighted with Dr. Gordon’s appointment as director of NIMH,” APA President Maria A. Oquendo, M.D., a professor of psychiatry and vice chair for education at Columbia University Medical Center, told Psychiatric News. "Having worked closely with him over the years, I can attest to the fact that in addition to being a scientist of the highest caliber, he has an open-mindedness, fairness, and thoughtfulness that are rare indeed. I look forward to seeing the wonderful things Dr. Gordon will do. For our part, APA will continue to pursue staunch advocacy for mental health research funding, the most effective path toward improving the lives of our patients.

Gordon joins NIMH with an extensive research background that focuses on the analysis of neural activity in genetic mouse models that have mutations of relevance to psychiatric diseases such as schizophrenia, anxiety disorders, and depression. His research involves an integrative neuroscience perspective and is performed across multiple levels of analysis, with an aim to understanding how a given disease mutation leads to a particular behavior.

Gordon’s work has been recognized by several prestigious awards, including the Brain and Behavior Research Foundation–NARSAD Young Investigator Award, Rising Star Award from the International Mental Health Research Organization, A.E. Bennett Research Award from the Society of Biological Psychiatry, and Daniel H. Efron Research Award from the American College of Neuropsychopharmacology. 

(Photo courtesy of NIMH)

No Response to Lurasidone at 2 Weeks? Study Suggests Dose Escalation May Help

Despite the fact that early nonresponse to antipsychotic therapy in patients with schizophrenia is known to predict future poor response, there is limited evidence available to guide clinicians for addressing early nonresponse in this patient population. A study in the Journal of Clinical Psychiatry that examined nonresponse to a standard dose of lurasidone at two weeks suggests that escalating the dose of the medication early may lead to symptom improvements.

Antony Loebel, M.D., of Sunovion Pharmaceuticals Inc., and colleagues randomly assigned patients with acute schizophrenia (Positive and Negative Syndrome Scale [PANSS] total score equal to or greater than 80) to lurasidone 80 mg/d (n=199) or placebo (n=112) for two weeks. After two weeks of treatment with lurasidone 80 mg/d, the researchers classified 98 patients (49.5%) as early nonresponders (less than 20% improvement in PANSS total score) and re-randomized these patients to either continue treatment with lurasidone at 80 mg/d or lurasidone at 160 mg/d. 

In patients classified as early nonresponders at week 2, mean change from week 2 to week 6 in PANSS total score was significantly greater for patients whose lurasidone dose was increased to 160 mg/d compared with that for patients who continued receiving 80 mg/d (-16.6 versus -8.9). While a comparable magnitude of improvement was observed in Clinical Global Impression-Severity (CGI-S) score from week 2 to week 6 for early nonresponders re-randomized to lurasidone 160 mg/d versus 80 mg/d, the difference was not statistically significant. Treatment response (defined as equal or greater than 20% decrease in PANSS total score from study baseline to week 6) was demonstrated by 74.4% and 59.6% of early nonresponders re-randomized to lurasidone 160 mg/d and 80 mg/d, respectively. 

Early nonresponders whose dose was increased to lurasidone 160 mg/d reported a greater incidence of anxiety, abdominal discomfort, akathisia, insomnia, and somnolence compared with patients who continued on lurasidone 80 mg/d.

“[T]he increased probability of response in early nonresponders after dose escalation to lurasidone 160 mg/d should be considered in the context of the risk-versus-benefit findings associated with this strategy,” the authors wrote. “These considerations include a modest increase in the frequency of certain adverse events and the clinical need to enhance the rate of response.”

William Carpenter, M.D., a professor of psychiatry at the University of Maryland School of Medicine and an expert on schizophrenia, told Psychiatric News that “the initial response predicting later outcome has been documented in several datasets, but the dose escalation benefit observed with lurasidone should not be generalized to other antipsychotic medications, where adverse effects may outweigh benefit. It is natural for clinicians to seek new options if you don't see a treatment response at two weeks, but there is scant evidence supporting common practices such as dose increase or addition of another drug.”

Added Carpenter, who was not involved in the study, “Clinicians who prescribe lurasidone should also consider if the real message of these findings is that they should start patients at 160 mg/day. And, if so, should the higher dose be reduced once remission is achieved?” 

This study was sponsored by Sunovion Pharmaceuticals Inc. 

Low Scores on Odor Identification Test May Predict Early-Stage Alzheimer’s Disease

At the 2016 Alzheimer’s Association International Conference yesterday, new evidence was presented suggesting that a low-cost smell identification test may be able to predict cognitive decline and the early onset of dementia in older adults.

Past studies have suggested that decreased ability to identify odors is a predictor of cognitive decline. The current study, led by researchers from the Columbia University Medical Center and New York State Psychiatric Institute, evaluated the usefulness of the 40-item University of Pennsylvania Smell Identification Test (UPSIT) in detecting the transition to dementia and cognitive decline. 

The researchers administered UPSIT to 397 older adults (average age of 80 years) from a multiethnic population in Manhattan, New York, who did not have dementia at the start of the study and were followed for four years. All participants received an MRI scan to measure the thickness of the entorhinal cortex, one of the first regions of the brain known to be affected by Alzheimer’s disease. Composite cognitive domain scores were derived from memory, language, and visual-spatial abilities.  

At the four-year follow-up, 12.6% of the participants had developed dementia, and 19.8% had signs of cognitive decline. Low UPSIT scores—indicative of a decreased ability to identify odors—and entorhinal cortical thinning were significantly associated with the transition to dementia after adjusting for age, education, gender, language of UPSIT administration (English or Spanish), functional status, and intracranial volume. Low UPSIT scores also predicted cognitive decline; entorhinal cortical thinning was not associated with cognitive decline.

“It’s clear that the science around biological measures in the detection of Alzheimer’s continues to gather pace and validation,” said Heather Snyder, Ph.D., director of medical and scientific operations of the Alzheimer’s Association, at a press conference that highlighted the study’s findings. “Using other biomarkers of Alzheimer’s disease to detect the disease at an earlier stage—which have the potential to be lower-cost and non-invasive—could lead to dramatic improvements in early detection and management of the disease.”

For more information, see the Psychiatric News article “Low Physical Activity in Early Adulthood Linked to Worse Midlife Cognition.”

Quetiapine Appears Effective as Monotherapy for PTSD, Study Shows

The atypical antipsychotic quetiapine appears to be effective as a single agent in the treatment of posttraumatic stress disorder (PTSD), according to a report in AJP in Advance.

Not all patients with PTSD respond to first-line antidepressant treatment, and current VA/Department of Defense guidelines recommend quetiapine and other antipsychotic medications as adjunctive treatments. Researchers from several VA centers and research institutions sought to determine the efficacy of quetiapine as monotherapy.

Eighty veterans meeting criteria for chronic PTSD were randomly assigned to treatment with either quetiapine or placebo tablets for 12 weeks. Quetiapine was initiated at a dose of 25 mg at bedtime and gradually titrated up to a minimum of 50 mg and maximum of 800 mg daily. The participants were evaluated at weeks 1, 2, 4, 8, and 12.

The primary outcome measure was the total Clinician-Administered PTSD Scale (CAPS) score. Secondary efficacy measures included the CAPS subscales, the Davidson Trauma Scale, the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impressions (CGI) scales for severity of illness and improvement, the Hamilton Depression Rating Scale (HAM-D), and the Hamilton Anxiety Rating Scale (HAM-A).

Patients in the quetiapine group experienced greater reductions in CAPS total, re-experiencing, and hyperarousal scores than those in the placebo group. (Scores on the CAPS avoidance/numbing subscale and the PANSS negative symptom subscale did not differ from those of the placebo group—a finding that is consistent with previous reviews of antipsychotics in the treatment of PTSD.) Patients taking quetiapine also experienced greater improvements in scores on the David Trauma Scale, CGI severity and improvement ratings, HAM-A, HAM-D, and PANSS positive symptom and general psychopathology subscale scores compared with the placebo group. 

“Our findings suggest that quetiapine as a single agent is effective in the treatment of PTSD and associated depression and anxiety symptoms,” they wrote. “The level of improvement observed with quetiapine suggests it may be superior for the treatment of PTSD over other antipsychotics, such as risperidone, which did not improve global PTSD symptoms in a large study with veterans.”

For related information, see the Psychiatric News article “Military Turns to Collaborative Care to Treat PTSD, Depression” and the Psychiatric Services article “Development and Validation of a Computerized-Adaptive Test for PTSD (P-CAT).”

(Image: iStock/Todd Headington)

Greater Pain Found to Increase Risk of Opioid Use Disorder

Researchers have long suspected that the level of pain experienced by a patient may increase his or her risk of developing an opioid use disorder. A study in AJP in Advance has for the first time taken a prospective look at this link, revealing a significant association between pain and prescription opioid use disorder at baseline and three years later.

Researchers at Columbia University and the National Institute on Drug Abuse analyzed data from a national sample of 34,653 adults who were surveyed three years apart. At each assessment, the participants were asked about their pain levels and prescription opioid use, as well as other substance use disorders, mood or anxiety disorders, and any family history of addiction or behavioral problems.

The researchers found that people with moderate or severe pain had a 41 percent higher risk of developing prescription opioid use disorders than those without, independent of demographics or other potential contributing factors. Males, younger adults (of either gender), and those with a family history of antisocial personality disorder were also found to be more likely to develop opioid use disorder.

There was no correlation for the inverse phenomenon; that is, people with an opioid disorder did not show any increased risk for developing chronic pain.

“Our findings highlight the need to provide evidence-based treatment for individuals in pain and to develop more effective nonopioid alternative treatments for those who do not respond to existing options,” the authors wrote. “From the clinical and preventive perspective, these clinical and demographic characteristics identify subgroups at increased risk who should be screened for pain and prescription opioid abuse.”

To read more about strategies to prevent opioid misuse, see the Psychiatric News column “Be Sure to Check the PDMP Before Prescribing Controlled Medications,” by Anna Lembke, M.D.

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Multiple Steps Are Needed to Reduce U.S. Firearm Suicides

What has proven effective at reducing the number of firearm suicides in other countries and what is possible to achieve in the United States may be quite different things, according to J. John Mann, M.D., a professor of psychiatry at Columbia University.

While studies in other countries have revealed that general restrictions against the ownership of guns lower firearm suicide rates, such legislation has “proven impossible to duplicate in the United States,” Mann and his colleague, Christina Michel, B.A., wrote online today in AJP in Advance. Instead, gun regulation efforts might better focus on restricting firearm access to people deemed at risk of harming themselves or others. 

However, as the authors noted, “[L]ess than 10 percent of the firearms used in suicides are purchased within two weeks of the suicide and the median interval between handgun purchase and suicide by the victim or another family member is 11 years, with the greatest risk in the first year after purchase.”

Mann and Michel described several ways gun violence restraining orders (which allow family members, significant others, and law enforcement personnel to formally request confiscation of firearms belonging to a person who may hurt himself or others), safer storage, smart-gun technology (which limits firearm access to the owner or permitted users), and firearm safety education campaigns for gun owners may help to lower firearm suicide rates. 

“All such initiatives must be accompanied by systematic evaluation of their effectiveness,” wrote Mann and Michel. “Ultimately, such program evaluation and lifting of the ban on federal funding of research on firearm violence will help improve efforts to reduce firearm suicide mortality.”

For related information, see the Psychiatric News column “Psychiatrists Have a Role to Play in Latest Gun Law Debates,” by APA President Maria A. Oquendo, M.D., and the Psychiatric News article “Violence Risk, Not Mental Illness, Should Guide Gun Access.”

(Image: iStock/DmyTo )

Self-Report Symptom Scale May Predict Patients Most Likely to Experience Depressive Relapse

Despite achieving full remission from depression, it is estimated that nearly 15% of formerly depressed patients may relapse within six months. A study published in AJP in Advance now suggests a 12-item symptom-based tool may be able to predict those at greatest risk of depressive relapse.

Lewis Judd, M.D., of the University of California, San Diego, and colleagues examined the records of participants in the National Institute of Mental Health Collaborative Depression Study. (As part of the NIMH study, follow-up evaluations were regularly conducted and patients periodically completed the Symptom Checklist–90 [SCL-90] self-report.) 

The researchers analyzed the records of 188 patients with major depressive disorder who had at least one SCL-90 assessment after at least eight weeks of full remission from a depressive episode (defined as a value of 1 on the weekly psychiatric rating scale for all depressive conditions, recorded on Longitudinal Follow-Up Evaluation interviews). 

In about 1 in 7 occasions when 188 remitted subjects completed the SCL-90 (73 of 514 assessments), relapse followed within the ensuing 6 months. Analysis of these SCL-90 reports revealed a broad range of symptoms present at a moderate or worse level, including dysphoria, sleep disturbances, somatization, and having one’s feelings easily hurt. 

Further analysis revealed a set of 12 symptoms that most accurately predicted relapse within six months. The relapse rate was 5.8% when none of the 12 symptoms were present, 16.4% when one to five symptoms were present, 34.1% when six to nine symptoms were present, and 72.7% when 10 or more symptoms were present.

“A simple count of the number of symptoms (0 to 12) self-reported at a moderate or worse level of severity during the past week created a score that was highly related to the risk of relapse,” Judd and colleagues wrote.

This study demonstrates “it is possible to construct a brief self-report scale that can be used to ascertain an estimated risk of relapse for the individual patient,” the authors continued. “Such a person-level indicator can be used to tailor the follow-up schedule for each remitted patient based on his or her individually identified risk of relapse and potentially to initiate interventions in a more timely fashion when needed.”

For related information, see the Psychiatric News article “Integrating CBT, Pharmacotherapy May Prevent Relapse in MDD.”

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LAI Antipsychotics May Reduce Rehospitalization of Patients With Schizophrenia

Patients with schizophrenia who receive a long-acting injectable (LAI) formulation as the first antipsychotic medication after a serious mental illness–related hospitalization may be less likely to be rehospitalized at 60 days than those who first received oral antipsychotics, according to study in Psychiatric Services in Advance.

Data drawn from the Truven Health MarketScan Multi-State Medicaid Database (2007 to 2012) was used to analyze 1,450 patients with a schizophrenia diagnosis alone and 15,556 patients with a codiagnosis of schizophrenia and bipolar disorder or major depressive disorder.

About 6.3% of the patients were prescribed a long-acting injectable antipsychotic after the index hospitalization, 84.4% of patients were prescribed an oral antipsychotic, and the remaining 9.3% were prescribed a short-acting injectable antipsychotic.

Overall, the all-cause hospital readmission rate at 60 days was 30.8%, but was five percentage points lower for those receiving the long-acting injectable formulation, wrote Joanna MacEwan, Ph.D., of Precision Health Economics in Los Angeles, and colleagues.

“Although the absolute differences may appear relatively small ... they can be of great value to patients and payers alike, considering the critical importance of preventing such events,” the researchers wrote. 

“Additional research comparing cause-specific reasons for rehospitalization (including psychiatric relapse, adverse event, and nonpsychiatric reason) and the ability to track and measure cause-specific rehospitalizations in large national databases will provide further insight on the drivers of rehospitalization rate differences between patients treated with LAIs and those treated with oral antipsychotics,” they concluded.

The study was supported by Otsuka Pharmaceutical Inc. and Lundbeck LLC.

For related information, see the Psychiatric News article “Long-Acting Injectable Reduces Schizophrenia Symptoms.”

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Study Identifies Predictors of Poor Response to Depression Treatment

Less than half of patients receiving depression care in primary care responded to treatment, and poor self-rated health was by far the strongest predictor of remission or response, according to an observational study in Psychiatric Services in Advance.

Other predictors of poor response included unemployment and lower income. Conversely, younger age and milder baseline depression severity predicted better response.

The results point to a subset of patients who might be identified for more intensive services, including collaborative care, which can address general and psychiatric conditions, say researchers at several institutions.

“The take-away message of our study is that six-month rates of depression remission or response were only 47 percent in this large population of primary care patients receiving usual care, and those who self-rated their health as poor to fair or who were unemployed were significantly less likely to see their depression improve,” lead author Rebecca Rossom, M.D. (pictured above) of HealthPartners Institute, told Psychiatric News. “Collaborative care can be effective for depression; however, this model can be cost-prohibitive for some care systems. For those systems it would be more efficient to focus use of this model on patients who are more likely to have poor depression outcomes.”

Outcome data for 792 patients in 83 urban and rural primary care clinics across Minnesota were analyzed. Baseline and six-month data were collected between March 2008 and November 2010, prior to the implementation of collaborative care in these primary care clinics. Patients received usual care for depression in their primary care clinics; all received antidepressants for depression, and some patients were co-managed by psychotherapists or psychiatrists.

The primary outcome was remission or response, with remission defined as achieving a follow-up PHQ-9 score of 5 or less; response was defined as a follow-up PHQ-9 score that was at least 50 percent lower than the patient’s baseline score. A wide range of correlates to treatment response were examined.

At six months, 47% of patients achieved a combined outcome of remission (N=292) or response (N=83). Patients who reported fair or poor health were significantly less likely to experience depression remission or response compared with patients with good, very good, or excellent health. Patients who were unemployed or had lower income were also less likely to respond.

“Ideally, being better able to identify such predictors of poor depression outcomes may help clinics and care systems determine where limited but potentially effective intensive and evidence-based treatment resources for depression may be most helpful,” the researchers stated.

For related information, see the Psychiatric News article "Brain Area Activity Might Predict Depression Treatment Response."

(Image courtesy Rebecca Rossom, M.D.)

Study Shows Value of ECT Combined With Medication in Treating Geriatric Depression

A two-part clinical study of ultrabrief electroconvulsive therapy (ECT) published Friday in AJP in Advance provides more evidence supporting the use of this treatment modality for geriatric depression.

The multicenter Prolonging Remission in Depressed Elderly (PRIDE) study found ultrabrief ECT (which uses shorter pulses than conventional ECT with reduced side effects) was effective in both acute and maintenance treatment of depression when combined with medication. In the long term, the use of both therapies produced more sustained improvement than medication alone.

In the first phase of PRIDE, 240 patients aged 60 and over with depression were enrolled to receive three ultrabrief ECT sessions a week and daily venlafaxine. During this phase, 61.7% of patients met remission criteria, with an average time to remission of about 2.5 weeks (7.3 ECT sessions).


In the second phase, all remitters were randomized to receive either continued ECT as needed along with medication (venlafaxine plus lithium) or medication only. After 24 weeks of treatment, the ECT plus medication group showed significantly lower depression scores on the Hamilton Rating Scale for depression than the medication-only group, with no statistical differences in their cognition scores.

“The clinical implications of these findings are that continuing ECT after remission, rather than abruptly stopping a course of ECT, is likely to be beneficial in sustaining mood improvement for most patients and that clinicians should be willing to prescribe additional ECT if patients begin to show symptom reemergence,” the authors wrote.

To read more about this topic, see the Psychiatric News article “ECT Said to Be Valid Alternative For Elderly Patients With Depression.”

(iStock/AlexRaths)

Senate Passes Addiction Treatment Legislation

Yesterday the U.S. Senate passed, by a vote of 92 to 2, the Comprehensive Addiction and Recovery Act (CARA), a significant first step in addressing the nation’s opioid crisis. The Senate’s action on a conference committee report follows that of the House, which voted to adopt the report last week (407 to 5). The measure now goes to President Obama for his anticipated approval.

“We are encouraged by the bipartisan support for this legislation—it encompasses many critical first steps toward fighting the nationwide opioid use epidemic,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “But we cannot stop here. These programs must be fully funded to be effective. APA looks forward to continuing to work with Congress to curb this epidemic.”

When funded, CARA will provide grants to expand access to opioid overdose reversal drugs (such as naloxone) and support addiction treatment services, including those using buprenorphine and other medication-assisted treatments.

The legislation also will offer grants to community organizations to develop and enhance recovery services and link those services to other recovery support systems. Grants will be available to states for opioid abuse education, treatment, and recovery efforts, prescription drug monitoring programs, and efforts to prevent overdose deaths.

For more in Psychiatric News about Congressional action on opioid abuse, see “House Members Consider Best Options for Treatment, Prevention of Opioid Abuse.”

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Study Highlights Role of Triggers in Short-Term Risk of Violence

Most individuals with mental illness are not violent, but a study published Wednesday in JAMA Psychiatry that examined triggers that increase short-term risk of violence highlights the importance of incorporating a violence risk assessment into psychiatric evaluations.

Seena Fazel, M.D., a professor of forensic psychiatry at the University of Oxford, United Kingdom, and coauthors used nationwide Swedish data for individuals born between 1958 and 1988 to examine a range of triggers for violent crimes in patients with psychotic disorders and individuals without a psychiatric diagnosis. The study sample included 34,903 patients who were diagnosed with schizophrenia spectrum disorders, 29,692 patients with bipolar disorder, and more than 2.7 million people who had never been diagnosed with a psychiatric disorder.

Within each subsample, the authors identified people who had experienced any of the following triggers for violent acts: exposure to violence, parental bereavement, self-harm, traumatic brain injury, unintentional injuries, and substance intoxication. The risk of the individual committing a violent crime in the seven days following exposure to a trigger was then compared with risk in earlier periods when they were not exposed to any trigger. (Violent crime was defined as a conviction for homicide, assault, robbery, threats and violence against an officer, unlawful threats, unlawful coercion, kidnapping, illegal confinement, arson, intimidation, or sexual offenses.)

All three groups showed statistically significant associations between each of the six triggers and the rate of violent crime in the week after exposure compared with earlier control periods. Although the absolute risk of violence was greatest in patients with schizophrenia, the relative risks across the three groups was similar, with the exception of parental bereavement, where the authors found stronger relative risks in the patients with schizophrenia (adjusted odds ratio [aOR], 5.0) than in the controls (aOR, 1.7).

“This study demonstrates that violence risk occurs when there are certain triggers, especially substance intoxication and severe stress. This is true whether or not an individual suffers from a mental disorder,” APA Immediate Past President Renée Binder, M.D., a professor of psychiatry and director of the Psychiatry and Law Program at the University of California, San Francisco School of Medicine, told Psychiatric News.

However, interpreting what the findings say about patients with psychotic disorders is more difficult, due to the fact that the authors of the study looked only at diagnoses, not the effect of treatment on modifying risks, she continued.

“The key point in assessing violence risk is not necessarily the diagnosis. Patients who have been diagnosed with schizophrenia or bipolar disorder and who are in remission and are complying with treatment are not at risk for violence. Thus, it is not the diagnosis per se, but rather the stage of illness (acute versus chronic), the treatment status, and whether or not the person is using substances” that are important when evaluating risk of violence in a psychiatric evaluation, she said. 

“Clinically, these findings imply that patients with schizophrenia or bipolar disorder should receive a psychiatric assessment for the risk of violence if they sustain an experience similar to one of the triggers tested in this study,” Jan Volavka, M.D., Ph.D., of the New York University School of Medicine, wrote in a related editorial. “The need for assessment is particularly pressing for young patients who have been targets of violence. To be useful, the assessment should occur as soon as possible after the event; certainly within the first week. Depending on the results, the patient may need supportive psychotherapy, medication adjustment, or hospitalization. In general, the findings raise the need to treat comorbid substance use disorders in individuals with schizophrenia and bipolar disorder.”

For related information, see the APA resource document “Psychiatric Risk Assessment,” of which Binder is a coauthor, and the Psychiatric Services article “Proximal Risk Factors forShort-Term Community Violence Among Adults With Mental Illnesses.”

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CBT May Reduce Likelihood to Repeat Self-Harm

A meta-analysis published online Tuesday in Lancet Psychiatry suggests that cognitive-behavioral-based psychotherapy (which includes cognitive-behavioral and problem-solving therapy) may reduce the likelihood that a patient who self-harms will repeat the behavior.

Self-harm (intentional acts of nonfatal self-poisoning or self-injury), which is strongly associated with suicide, is a growing problem in many countries, according to the study authors. By some estimates, up to 25% of individuals who present at hospitals with injuries caused by self-harm return because of a repeat episode within a year. 

To determine the effectiveness of psychosocial interventions at preventing patients from repeating self-harm, a team of international researchers conducted a systematic review of randomized, controlled trials of psychosocial interventions that included adults 18 years and older after a recent (within six months) episode of self-harm. 

The researchers included 29 trials in their analysis, comprising 18 trials of cognitive-behavioral therapy, problem-solving therapy, or both; three trials of dialectical behavioral therapy; and four trials each of case management and postcards sent periodically to participants over the course of the 12-month intervention period. The primary outcome analyzed was repetition of self-harm at the conclusion of treatment and at follow-up six, 12, and 24 months later; secondary outcomes included improvements in suicidal ideation and various aspects of mood and cognitive function. 

The analysis revealed that cognitive-behavioral and problem-solving therapy was associated with fewer participants repeating self-harm at six- and 12-month follow-up compared with patients who received usual care. Patients who received cognitive-behavioral and problem-solving therapy also experienced significant improvements in depression, hopelessness, suicidal ideation, and problem solving. 

“In view of the apparent positive benefits of CBT, studies should be conducted to identify which types of patients are most likely to benefit from this approach,” the authors wrote. “Researchers evaluating psychosocial treatments should investigate whether the intervention results in changes in the psychological or social mechanisms that are the targets of treatment (e.g., improved problem solving, regulating emotions, and changes in interpersonal skills) and the extent to which such changes relate to positive outcomes.”

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

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Smoking Reduction May Decrease Suicidality in Patients With Psychosis

People with severe mental illness are at heightened risk for both substance misuse and suicide, and several lines of research have shown a connection between the two. A study published in Psychiatry Research suggests that patients with psychosis who smoke less may also be less likely to experience suicidal ideation or behaviors.

These findings came from a study of 235 smokers aged 18 or over with a psychotic disorder who participated in a healthy lifestyle intervention trial in Newcastle, Sydney, and Melbourne, Australia. The study participants smoked at least 15 cigarettes a day at the start of the trial, were diagnosed with a schizophrenia spectrum or bipolar disorder as confirmed by the Mini International Neuropsychiatric Interview, and were taking antipsychotic medication as prescribed for a period of at least two months. Suicidality was assessed using the Brief Psychiatric Rating Scale (BPRS) at the start of the trial and at follow up 15 weeks and 12 months later.

While there was no association between reduced smoking and suicidality at 15 weeks, significant association was seen at 12 months. This association was reduced, but not eliminated, when depression was factored in, with the authors estimating that depression accounted for around 30% of the connection between smoking and suicidality.

“In addition to physical health impacts, the results of the present study provide a further important reason why clinicians should address smoking in this population,” the authors wrote.

For more information, see the Psychiatric News article “Giving Patients With Serious Mental Illness Mobile Boost to Quit Smoking.”

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Study Suggests Adjunctive Brexpiprazole May Reduce Irritability in Patients With MDD

Although irritability and anger attacks are relatively common in patients with major depressive disorder (MDD), there are limited options for treating irritability associated with a major depressive episode. Findings from a study published in the Journal of Clinical Psychiatry now suggest that adding the atypical antipsychotic brexpiprazole to antidepressants may reduce irritability in patients with MDD.

Brexpiprazole is known to act as a partial agonist at 5-HT1A receptors and D2 receptors, and previous studies suggest this mechanism may help reduce aggression in animals. In the current study, Maurizio Fava, M.D. (pictured left), a professor of psychiatry at Harvard Medical School, and colleagues recruited 54 adult patients aged 18 to 65 with MDD and irritability who failed to respond adequately (as documented by a self-report of a less than 50% response) to their antidepressant treatments for two weeks. The patients received six weeks of open-label treatment with their current antidepressant regimen and adjunctive brexpiprazole (ranging from 1 mg to 3 mg daily). After six weeks, brexpiprazole was discontinued, and patients continued treatment with antidepressants alone for an additional four weeks.

Outcome measures included changes in depression, irritability, and anger from baseline to week 6 and from week 6 to week 10. Multiple rating scales were used to assess outcome measures, including the Montgomery-Asberg Depression Rating Scale, the Sheehan Irritability Scale, and the Kellner Symptom Questionnaire.

At week 6, clinically relevant improvements were observed in irritability, anger, and depressive symptoms. However, no further improvements in irritability, anger, and depressive symptoms were observed after brexpiprazole was discontinued at six weeks. Overall, adjunctive brexpiprazole was well tolerated with no clinically meaningful changes from baseline to endpoint in mean fasting metabolic parameters.

“Adjunctive treatment with brexpiprazole may represent a strategy for the treatment of irritability symptoms in patients with MDD and inadequate response to antidepressant treatment,” the authors wrote. “[W]hether these effects are reproducible in a placebo-controlled study needs to be confirmed,” they concluded.

For related information, see the Psychiatric News article “Brexpiprazole Found Safe for Patients With Schizophrenia.”

(Photo Courtesy of Harvard Medical School)

CMS Announces Medicare Coverage of Psychiatric Consultations in Collaborative Care

Medicare will begin reimbursement next year for collaborative care services, according to an announcement by the Centers for Medicare and Medicaid Services (CMS).

CMS, in its proposed Medicare Physician Fee Schedule rule, has included coverage for “Psychiatric Collaborative Care Management Services.” The coding for those services will support payments to psychiatrists for consultative services they provide to primary care physicians in the collaborative care model (CoCM). The model was developed by the late Wayne Katon, M.D., and Jürgen Unützer, M.D., M.P.H., at the AIMS Center of the University of Washington. It is the only evidence-based model of its kind and has been proven effective in more than 80 randomized, controlled trials.

“This is a huge win for APA, psychiatrists, as well as patients with mental health and substance use disorders,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “The APA administration is in the process of reviewing the rule for more specifics regarding these new codes and other provisions of the proposed rule.” 

After conducting its review, which will include an analysis of work values associated with the coding, APA will submit comments to CMS.

In the CoCM, the primary health care provider employs a behavioral health care manager to provide ongoing care management for a caseload of patients with diagnosed mental health or substance use disorders. The psychiatrist provides the primary care practice with expert advice and consultation through regular case review and recommendations for treatment and medication adjustments; in especially difficult cases, the psychiatrist may also provide direct treatment.

The codes included in the CMS announcement for adoption in 2017 are similar to the “Psychiatric Collaborative Care Management” codes that the CPT® Editorial Panel approved for use starting in 2018. The CPT coding proposal was brought by APA, with the assistance and participation of several other medical specialty societies, including the American Academy of Child and Adolescent Psychiatry, the American Academy of Family Physicians, and the American College of Physicians, among others.

Importantly, APA received a grant from CMS through its Transforming Clinical Practice Initiative to train psychiatrists and primary care physicians in the CoCM and to encourage systems to implement this evidence-based model. Training will be provided online an at APA meetings, including the upcoming IPS: The Mental Health Services Conference in Washington, D.C., in October. Read more about the TCPI on APA's website.

For detailed coverage of the CMS proposed rule and additional information about the collaborative care model, see an upcoming edition of Psychiatric News.

RAISE Study Suggests Shared Decision Making May Influence Antipsychotic Prescribing Patterns

Most individuals experiencing a first episode of psychosis who participated in the RAISE (Recovery After Initial Schizophrenia Episode) Connection Program were prescribed first-line antipsychotic agents within recommended dosage ranges, according to a report in Psychiatric Services in Advance. The findings suggest the benefits of training and clinical supervision sessions for psychiatrists led by experts in these approaches.

The RAISE CP Implementation and Evaluation Study is part of a landmark National Institute of Mental Health study looking at treatments for first-episode psychosis. For this report, researchers developed the RAISE CP Schedule of Recommended First and Second Line Antipsychotic Medications to guide the selection of antipsychotic treatment within a shared decision-making framework. They then conducted a longitudinal, observational study to evaluate the adherence of psychiatrists to the schedule.

Sixty-five individuals with a first episode of psychosis were enrolled in the two RAISE CP clinics. Two psychiatrists received training and ongoing consultation with experts in the psychopharmacological management of psychosis, treatment of adolescents with psychotic disorders, and shared decision making. The authors then analyzed the extent to which patterns of antipsychotic prescribing and side-effect monitoring were consistent with the Antipsychotic Schedule.

Ninety-two percent of participants were prescribed an antipsychotic medication and received the medication on an average of 76% of the days they were in treatment—a percentage the authors suggested may be due to the use of a shared decision-making approach, in which participants were able to continue to receive services and meet with the psychiatrist, even if they did not receive antipsychotic treatment. 

“These ongoing psychiatrist visits provided the opportunity for close monitoring of symptoms and a restart of antipsychotic medication if symptoms worsened, and they also facilitated the use of nonpharmacological approaches to symptom management, all of which were jointly agreed upon by the treatment team and the participant,” the authors wrote.

Although all study participants prescribed an antipsychotic received at least one medication side-effect evaluation (over the course of the study, 92% of participants had at least one weight recorded, 72% had at least one blood glucose measure recorded, and 62% had at least one lipid profile recorded), the authors noted that these measurements occurred less frequently than is recommended. “This demonstrates that even specialized services may have difficulty attaining recommended antipsychotic side effect–monitoring goals,” they wrote.

The authors concluded, “The implementation of shared decision making was enhanced by training and clinical supervision sessions for psychiatrists led by experts in these approaches. … The extent to which these components of the approach to the pharmacological treatment of this population can be feasibly disseminated and implemented in regular clinical practice requires additional investigation.”

For more about the RAISE study, see the Psychiatric News article “Psychosocial Treatments Found Effective for Early Psychosis.”

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HHS Announces Series of Actions to Expand Opioid Treatment, Reduce Misuse

Expanded access to buprenorphine treatment, proposed elimination of a possible financial incentive to overprescribe opioids, and a requirement for Indian Health Service practitioners to check state Prescription Drug Monitoring Program (PDMP) databases were among the actions taken today by the U.S. Department of Health and Human Services (HHS) to address the opioid epidemic in this country.

The department also announced the start of “more than a dozen” new research studies on pain treatment and opioid misuse. Additionally, it will compile an inventory of the research being conducted or funded by HHS agencies.

Also issued today was a final rule that will expand access to buprenorphine treatment by increasing from 100 to 275 the number of patients a qualified physician can treat. Addiction specialists and those who practice in a qualified health setting will be eligible for the higher patient limit.

“We welcome the final rule raising the cap on buprenorphine patients because it balances the needs for access to quality care and safety,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “APA had provided feedback to SAMHSA, and we are encouraged that the agency followed the spirit of our recommendations.”

The American Academy of Addiction Medicine and the American Osteopathic Academy of Addiction Medicine also contributed to the feedback given to SAMHSA.

The government will also eliminate use of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions on pain as a criterion for Medicare payment. Hospitals will still ask patients about pain management but the answers won’t affect payments.

“We will continue to work with our members and partner medical societies to curb the opioid epidemic, and we applaud the steps taken by the administration,” said Levin.

Detailed coverage of the HHS actions and the final rule will appear in a future issue of Psychiatric News. A summary of federal opioid research by the Department of Health and Human Services is posted here. 

Calculator Shows Promise in Predicting Risk for Conversion to Psychosis

Although considerable progress has been made in determining risk factors for psychosis in recent decades, mental health professionals currently lack a widely available tool for calculating a precise estimate of risk for patients seeking help. Two studies published today in AJP in Advance suggest researchers have developed a risk calculator for the individualized prediction of a psychotic disorder over a two-year period.

In the first study, researchers led by Tyrone Cannon, Ph.D., a professor of psychology and psychiatry at Yale University, described how they examined eight criteria to evaluate the prediction of psychotic disorder in 596 participants (mean age 18.5 years) over a two-year period in the North American Prodrome Longitudinal Study (NAPLS-2).

“Higher levels of unusual thought content and suspiciousness, greater decline in social functioning, lower verbal learning and memory performance, slower speed of processing, and younger age at baseline each contributed to individual risk for psychosis,” Cannon and colleagues wrote. However, other variables—stressful life events, trauma, or a family history of schizophrenia—did not predict conversion to psychosis, they said. The overall model accuracy rate was 71%—which the authors noted is “in the range of values for established calculators currently in use for cardiovascular disease and cancer recurrence risk, which range from 0.58 to 0.81.”

“This prediction tool represents a potential breakthrough for early intervention in psychiatry. However, as with any predictive analytic model, its performance must be validated in samples of clinical high-risk patients collected independently of NAPLS-2,” Ricardo Carrión, Ph.D., an assistant professor of psychiatry at Hofstra Northwell School of Medicine in Hempstead, N.Y., and colleagues wrote in a companion article.

Carrión’s team evaluated the performance of the NAPLS-2 risk calculator in an external, independent sample of individuals (aged 12 to 25) at clinical high risk for psychosis collected as part of the Early Detection, Intervention, and Prevention of Psychosis Program (EDIPPP). The overall model accuracy rate was 79% in the EDIPPP sample. 

“Although further replication is needed, at present the risk calculator appears to have considerable potential for determining the probability that an individual will develop psychosis, and it may provide a foundation for the personalized treatment of clinical high-risk individuals,” Carrión and colleagues wrote.

For more in Psychiatric News about the Early Detection and Intervention for the Prevention of Psychosis Program, see “Early Intervention Trial in Youth at Risk for Psychosis Shows Improved Symptoms.”

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