Higher Heart Rate in Late Adolescence May Predict Future Psychiatric Disorders

A study of more than one million Swedish military draftees published last week in JAMA Psychiatry suggests heightened heart rate and blood pressure at age 18 may be associated with higher levels of psychiatric disorders later in life.

The highest risk from an elevated resting heart rate in late adolescence was found for obsessive-compulsive disorder (OCD); men with resting heart rates above 82 beats per minute had a 69 percent increased risk for OCD compared with those with heart rates below 62 beats per minute, wrote Antti Latvala, Ph.D., of the Karolinska Institutet and the Department of Public Health at the University of Helsinki and colleagues.

Linking several Swedish national registers with longitudinal data available through the end of 2013, Latvala and colleagues compared psychiatric disorder diagnoses in men drafted from 1969 to 2010. (Men with registered diagnoses before drafting were excluded from the study.)

In addition to being at a higher risk of developing OCD later in life, men with resting heart rates above 82 beats per minute had a 21 percent higher risk for schizophrenia and an 18 percent higher risk for anxiety. Analysis of blood pressure measurements from the group revealed an association between higher diastolic blood pressure and increased risk of anxiety, OCD, and schizophrenia. The study also found that a lower resting heart rate was associated with substance use disorders and convictions for violent crimes.

“Increased heart rate is seen in many psychiatric disorders, but showing that increased heart rate predicts obsessive-compulsive disorder, anxiety disorders, and schizophrenia is very original,” Ranga Krishnan, M.B., Ch.B., dean of Rush Medical College in Chicago, and who was not involved in the study, told Psychiatric News.

“[The study] raises the possibility that autonomic changes can predict later development of these disorders and raises intriguing questions about how this could happen,” said Krishnan. “More research is needed.”

For related information, see the Psychiatric News article “Depression Increases Stroke Risk, Even After Symptoms Remit.”

(Image: iStock/Sebastian Kaulitzki)

White House Task Force Issues Report on Improving Parity Implementation, Compliance

The White House Mental Health and Substance Use Disorder Parity Task Force issued a “Final Report to the President” yesterday outlining recommendations to better enable states and the federal government to monitor compliance by health plans with the Mental Health Parity and Addictions Equity Act and to assist individuals in finding help with parity complaints and appeals.

“Parity is only meaningful if health plans are implementing it well, consumers and providers understand how it works, and the government provides clear guidance and appropriate oversight,” stated Task Force Chair Cecilia Munoz in a summary accompanying the report. She is assistant to President Obama and director of the Domestic Policy Council.

The task force developed its recommendations through a series of “listening sessions” with stakeholders held between March and October. APA provided input through written comments, and members were invited to do so at a session held in May at APA’s 2016 Annual Meeting in Atlanta.

Recommendations for short-term action include providing $9.3 million to states to help implement parity protections; development of a beta version of a new parity website to help consumers find the appropriate federal or state agency to assist with their parity complaints, appeals, and other actions; a “Consumer Guide to Disclosure Rights” to help consumers and providers understand what type of information to ask for when inquiring about a plan’s compliance with parity; and providing guidance on the application of parity to opioid use disorder treatment.

Longer-term recommendations include increasing federal agencies’ capacity to audit health plans for parity compliance and allowing the Department of Labor to assess civil monetary penalties for parity violations, among others.

“APA welcomes this much-needed report to strengthen implementation and enforcement of existing mental health parity laws,” said APA President Maria A. Oquendo, M.D., Ph.D. “Full implementation and stronger enforcement will help ensure that psychiatric conditions are treated the same as other illnesses and individuals can access the treatment they need.”

She added, “APA stands ready to work with Congress and the White House in monitoring implementation. We will also work with our members to insure parity.”

Ketamine Clinics Attract Patients Despite Unknowns

Even as researchers continue to investigate how a single dose of the anesthetic ketamine reduces symptoms of treatment-resistant depression within hours and what the risks of long-term, repeated ketamine infusions might be, a growing number of patients are turning to ketamine clinics in the United States.

The most recent issue of Psychiatric News PsychoPharm features an article exploring the off-label use of this medication in special clinics. The piece describes what patients can expect at ketamine centers, including the physicians running them and the course and cost of standard treatment regimens.

The majority of the ketamine clinics in the United States are run by anesthesiologists, who tend to have firsthand experience with using ketamine and managing side effects. Psychiatric News spoke with anesthesiologists at ketamine clinics in New York and Arizona, where patients are initially given four infusions of ketamine within about two weeks.

Such procedures can be expensive, with most clinics charging $400 to $800 for a single infusion of ketamine, Dennis Hartman of the Ketamine Advocacy Network told Psychiatric News. (The Ketamine Advocacy Network is a website whose mission is to spread awareness about ketamine therapy for treatment-resistant depression.)

Although ketamine works for many patients, an estimated one-third of all patients in clinical trials do not respond to the medication.

“We need to find particular characteristics that can predict response,” APA President Maria A. Oquendo, M.D., Ph.D., told Psychiatric News. Oquendo is involved with a clinical trial evaluating the safety and effectiveness of ketamine in patients with refractory depression.

Anesthesiologists Glen Brooks, M.D., medical director of the New York Ketamine Infusions LLC, and Mark Murphy, M.D., the medical director of the Ketamine Wellness Centers in Mesa, Ariz., noted that patients at their clinics undergo mental health screening before receiving ketamine infusion, and they recommend that patients receive ongoing psychiatric or psychological care during treatment. Additionally, staff at the clinics routinely communicate with referring psychiatrists.

For related information, see “APA Task Force to Address ‘What’s Next?’ for Ketamine.”

(Image: iStock/teetuey)

Psychiatrists Should Be Alert to Testosterone Abuse

The Food and Drug Administration on Tuesday announced that a new warning of the serious adverse outcomes associated with testosterone and other anabolic androgenic steroids (AAS), including those related to heart and mental health, will now appear on all prescription testosterone products.

The use of prescription testosterone products as hormone replacement therapy is FDA approved for men who have low testosterone due to certain medical conditions. Additionally, there is evidence to suggest that men with depression who use testosterone gel may experience improvements in mood. However, it is well known that testosterone and other AAS are abused by adults and adolescents, including athletes and body builders.

“Abuse of testosterone, usually at doses higher than those typically prescribed and usually in conjunction with other AAS, is associated with serious safety risks affecting the heart, brain, liver, mental health, and endocrine system,” according to an FDA statement. “Reported serious adverse outcomes include heart attack, heart failure, stroke, depression, hostility, aggression, liver toxicity, and male infertility. Individuals abusing high doses of testosterone have also reported withdrawal symptoms, such as depression, fatigue, irritability, loss of appetite, decreased libido, and insomnia.”

According to the FDA, the classwide labeling changes will include additional information about other adverse outcomes associated with abuse and dependence of testosterone/AAS as well as advice to prescribers on the importance of measuring serum testosterone concentration if abuse is suspected.

For related information, see “Large Trial Suggests Testosterone Offers Moderate Benefits.”

Early Identification Programs Show Urban Poor More Likely to Meet Psychosis Criteria

Individuals from deprived and urban communities appear most likely to meet criteria for first-episode psychosis (FEP) among those referred to early identification programs in the eastern region of England, according to an epidemiological analysis in AJP in Advance.

The findings could be used to inform the provision of effective early intervention services for psychosis in the United States and other areas where early identification is less established but gaining traction, according to researchers from several English institutions and agencies.

The researchers identified all new first-episode psychosis cases of individuals aged 16 to 35 years old presenting to early intervention psychosis services in the East of England. Importantly, they found that those most likely to meet criteria for FEP were poorer, younger males from deprived and densely populated neighborhoods. For instance, 68.7% of those between the ages of 16 and 25 met the criteria, compared with 31.3% of those over age 25. Additionally, 55.6% of referrals who met the criteria for FEP were either long-term unemployed or “long-term sick or disabled,” compared with 22.4% of those who were employed. And 52.1% resided in the neighborhoods with the highest population density.

The findings point to possible environmental factors that may influence the incidence of schizophrenia, but the researchers said it is difficult to rule out other possibly confounding influences, relevant to psychosis, that may aggregate among lower sociodemographic populations.

“Further longitudinal studies are required to disentangle the potential role of social causation from [other confounding factors],” the researchers wrote. “Although we could not establish causation directly, our results demonstrate that our most deprived and urban communities shoulder a disproportionate burden of psychosis morbidity at the population level. This should be used to inform the provision of effective early intervention services for psychosis.”

For related information see the Psychiatric News article “Psychosocial Treatments Found Effective for Early Psychosis.”

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Some Patients May Develop Adjustment Disorder Up to Year After Trauma

Although adjustment disorders—characterized by the development of emotional or behavioral symptoms within three months of a stressor—are considered to be relatively common, much remains unknown about the course of the disorder, its phenomenology, or its relationship to other disorders. A study published today in AJP in Advance suggests that some people may continue to develop adjustment disorder up to one year after a traumatic event.

The findings came from an analysis of over 800 injury survivors (aged 16 to 70) who had been hospitalized in trauma centers in Australia. Baseline data were collected prior to discharge from the hospital, which was on average seven days after injury, and follow-up data were collected at three months and 12 months after injury.

The authors found that the overall prevalence of adjustment disorder was 19% at three months and 16% at 12 months. While one-third of the patients with adjustment disorder at three months continued to experience symptoms at 12 months, the majority of patients with the disorder at 12 months were not diagnosed as having adjustment disorder at three months. Injury survivors that were diagnosed with adjustment disorder at three months were significantly more likely to meet criteria for another psychiatric condition at 12 months compared with those with no psychiatric disorder.

The most common symptoms reported among those with adjustment disorder were PTSD-associated symptoms including poor concentration, disturbed sleep, and irritability. 

“This study adds to the limited research evidence on adjustment disorder by demonstrating that the diagnosis identifies people who following a stressor experience distress/functioning impairment and who are at risk for developing more severe disorders,” Meaghan O’Donnell, Ph.D., and colleagues at the Phoenix Australia Centre for Posttraumatic Mental Health in Australia, wrote. “However, it challenges the current diagnosis by finding that (1) many people develop the disorder beyond the initial three months after the stressor and (2) it does not present with distinct anxiety or depressive symptoms but rather mixed features, with PTSD symptoms playing an important role. Considering the frequency with which this diagnosis is used by clinicians, it is imperative that more structured research is conducted so that robust diagnostic criteria can be established.”

To read more about this topic, see the Psychiatric News article “When Somebody Has an Adjustment Disorder” by Patricia Casey, M.D., and James Strain, M.D.

(Image: hxdbzxy/Shutterstock)

Brief CBT Element Encourages Trauma Patients to Seek Psychotherapy

Therapeutic homework assignments derived from cognitive-behavior therapy (CBT) and delivered in routine care seem helpful in drawing trauma patients into psychotherapy or counseling, as well as reducing PTSD symptoms, said Doyanne Darnell, Ph.D., an acting assistant professor of psychiatry and behavioral sciences at the University of Washington, Seattle, and colleagues.

The researchers randomized 115 patients from a hospital trauma center to receive the CBT assignments (n=56) or usual care, Darnell reported in Psychiatric Services in Advance.

Patients also received some psychoeducation about symptoms and posttraumatic recovery, as well as anxiety and stress-reduction techniques. These were brief and could be rendered during routine care in the emergency department, hospital, or in outpatient medical follow-up appointments, or even by telephone.

“The elements were designed to help patients overcome behavioral avoidance patterns consequent to anxious avoidance, withdrawal, or functional impairments related to the injury,” wrote the researchers.

The researchers found that trauma patients who received the intervention were more likely (93%) than usual-care controls (10%) to get psychotherapy or counseling.

Furthermore, the analysis showed “a statistically significant and clinically meaningful association between CBT element homework completion and PTSD symptom reduction for intervention patients.”

Darnell and colleagues concluded that with further study, “readily deliverable CBT elements targeting PTSD and comorbidity” could be incorporated into American College of Surgeons guidelines in acute medical settings, just as universal screening for alcohol use disorder is today.

For more in Psychiatric News about early intervention for trauma victims, see “Early Intervention Offers Hope For Preventing PTSD.”

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Why Isn't Naltrexone Used More Often for Alcohol Use Disorder?

Naltrexone, first approved for treatment of opioid addiction, is known to help some patients with alcohol use disorder (AUD) drink less. For instance, a 2014 meta-analysis in JAMA found it was associated with reduction in return to drinking and number of heavy drinking days. But clinicians who spoke with Psychiatric News say the medication is vastly underutilized in treatment of AUD. 

Charles O’Brien, M.D., Ph.D. (pictured at left), one of the original researchers on naltrexone for alcohol use disorder and chair of the DSM-5 Work Group on Substance Related Disorders, said there are several reasons naltrexone is underutilized: for example, many physicians are unfamiliar with the medication, and alcohol rehabilitation centers are not typically staffed by medical professionals. But the most important reason, he and others say, is the longstanding conviction—widely held among physicians as well as the general public—that alcoholism can be treated only by the 12-step recovery model.

“When I send a patient to a rehabilitation center, they follow the 12-step program," he said, adding that many counselors at such centers are likely to advise patients not to use medication.

John Renner, M.D., co-chair of APA’s Council on Addiction Psychiatry, agreed. “There is very good evidence showing that if you compare naltrexone to placebo you get much better sobriety,” he said. “But the general attitude in the recovery community is a very strong preference for a very early version of AA that is uncomfortable with medication.

“Doctors just aren’t used to thinking about pharmacotherapy for alcohol use disorder, and we have had difficulty getting buy-in from general physicians," he continued.

O’Brien and Renner both emphasized that there is no reason that clinicians can’t use naltrexone in conjunction with AA or any other psychosocial treatment, and that in fact it is always encouraged. “We always recommend cognitive-behavioral therapy and/or 12 step,” O’Brien told Psychiatric News.

For more in-depth coverage on this subject, see tomorrow’s issue of Psychiatric News PsychoPharm. For related information, see O’Brien’s 2015 article in the American Journal of Psychiatry titled “In Treating Alcohol Use Disorders, Why Not Use Evidence-Based Treatment?” An archive of webinars and other information about the Providers’ Clinical Support System for Medication Assisted Treatment is available on the APA website.

Folinic Acid May Improve Verbal Skills in Children With Autism Spectrum Disorder

High-dose folinic acid (a form of folate) may improve communication skills in children with autism spectrum disorder (ASD), reports a study published yesterday in Molecular Psychiatry.

For the study, Richard Frye, M.D., Ph.D., of the Arkansas Children’s Hospital and colleagues randomly assigned 48 children (aged 3 to 14 years) diagnosed with ASD and language impairment to receive either daily folinic acid (2 mg/kg, capped at 50 mg) or placebo for 12 weeks. Researchers used the CELF-preschool-2, CELF-4, and the Preschool Language Scale-5 instruments to measure changes in verbal communication.

At the end of the 12-week period, the children taking folinic acid showed significantly greater improvements in verbal communication than placebo (an average of 5.7 standardized points better). Several secondary measures such as daily living skills, stereotypic behaviors, and internalizing problems also improved more in the folinic acid groups.

Frye and colleagues also screened the children for the presence of antibodies to the folate receptor alpha (FRAAs) in the blood, which would indicate a dysfunction in the transport of folate from the blood to the brain. They found that children with positive FRAA results showed a particularly strong improvements in verbal communication when given folinic acid (about 7.3 standardized test points).

“This study suggests that FRAAs predict response to high-dose folinic acid treatment,” the authors wrote. “[F]uture studies will be needed to define factors that predict response to treatment, investigate optimal dosing and help understand whether other compounds could work synergistically with folinic acid.”

While no serious adverse events were reported by children in the folinic acid group, the authors did caution that “[s]ince ASD is likely a lifelong disorder the long-term adverse effect of any treatment is a concern. As folinic acid may increasingly become used to treat ASD in the future, short-term and long-term adverse effects should be studied in more detail to ensure safety.”

For related information, see the Psychiatric News article “Program Teaches Social Skills to Adolescents With Autism” and the American Journal of Psychiatry article “Neurometabolic Disorders: Potentially Treatable Abnormalities in Patients With Treatment-Refractory Depression and Suicidal Behavior.”

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People With OCD May Prefer Psychotherapy to Medications

Although it is well known that patient preferences for treatment can influence outcomes, few studies have explored treatment preferences among individuals with anxiety disorders such as obsessive-compulsive disorder (OCD). A study published yesterday in Psychiatric Services in Advance suggests that people with OCD may prefer psychotherapy to medications, both as a first-line therapy and augmenting agent.

A total of 216 adults who self-reported at least moderate OCD symptoms completed an online survey developed by researchers at Columbia University. The survey asked participants to choose their preferred evidence-based treatments, rate acceptability of novel treatments, and answer questions regarding their treatment history, current OCD symptoms and severity, and more.

The study participants reported a slightly higher preference for exposure and response prevention (EX/RP) therapy (55%) than serotonin reuptake inhibitors (SRIs, 45%) as a first-line treatment. Additional analysis revealed that those who preferred SRIs were in treatment at the time of the survey, were receiving SRIs as their treatment, and reported a positive experience with treatment overall and with medications.

Participants significantly preferred EX/RP (68%) to antipsychotic medications (31%) when used to augment SRI response. Compared with those who preferred antipsychotics, those who preferred EX/RP were younger, more likely to be female, and more likely to be taking benzodiazepines. 

Among novel OCD treatments, behavioral interventions (such as acceptance and commitment therapy and Kundalini yoga) were rated as more acceptable than medical procedures (deep brain stimulation and gamma knife surgery).

“Our findings highlight the importance of patient-level characteristics, beliefs about treatment, and past experience as factors that influence preferences for OCD treatment,” the authors wrote. “Given EX/RP’s efficacy, both as monotherapy and as a strategy to augment SRI response, and our finding that individuals preferred EX/RP whether or not they were taking SRIs, efforts to increase access to this treatment are warranted.

To read more on the topic of OCD treatments, see the Psychiatric News article “Antidepressants May Inhibit D-Cycloserine From Improving Symptoms in People With OCD.”

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Study Suggests Association Between SSRIs in Pregnancy, Speech Disorders in Offspring

A study published last week in JAMA Psychiatry suggests that children born to women who took selective serotonin reuptake inhibitors (SSRIs) during pregnancy may be at an elevated risk of speech and language disorders. While experts say the study raises important questions, more research is needed to determine whether exposure to SSRIs confers greater risk than untreated depression during pregnancy over the long term.

For the study, Alan S. Brown, M.D., M.P.H., director of the Unit in Birth Cohort Studies at the New York State Psychiatric Institute, tracked the incidence of speech/language, scholastic, and motor disorders from birth to 14 years in 56,000 children born in Finland between 1996 and 2010. 

The offspring were divided into three groups: 15,596 were in the SSRI-exposed group (mothers diagnosed as having depression-related psychiatric disorders with a history of purchasing SSRIs during pregnancy); 9,537 were in the unmedicated group (mothers diagnosed as having depression-related psychiatric disorders without a history of purchasing SSRIs during pregnancy); and 31,207 were in the unexposed group (mothers without a psychiatric diagnosis or a history of purchasing SSRIs). 

Over the study period, there was a total of 829, 187, and 285 instances of speech/language, scholastic, and motor disorders, respectively. The authors found that children in the SSRI-exposed group and the unmedicated group were at a significantly increased risk of speech/language disorders compared with those in the unexposed group.

Additional analysis revealed that children of mothers who purchased SSRIs at least twice during pregnancy had a 37% increased risk of speech/language disorders compared with offspring in the unmedicated group and a 63% increased risk compared with children in the unexposed group. There were no significant differences in the risk of the other disorders between offspring in the SSRI-exposed group and the unmedicated group.

“Overall the study is reassuring because there were no scholastic or motor associations, and the risk of language delay, if real, is very small,” Jennifer Payne, M.D., the director of the Women's Mood Disorders Center at Johns Hopkins School of Medicine, told Psychiatric News.

However, Payne noted that because the study did not control for severity of depression or postpartum depression, there is no way of knowing whether antidepressant exposure is actually associated with speech and language delays.

“Postpartum depression has long been known to affect language development and IQ in children,” she added.

“Brown et al have identified a very important research question, … but the current report does not answer whether exposure to SSRIs or untreated depression during pregnancy are in equipoise with respect to neurodevelopmental toxicity or if, over the long-term, one confers greater risk,” Lee Cohen, M.D., and Ruta Nonacs, M.D., Ph.D., of Massachusetts General Hospital wrote in a related editorial.

“Given the extent to which depression during pregnancy predicts risk for postpartum depression with its attendant morbidity, and in light of the robust data describing the adverse effects of maternal psychiatric morbidity on long-term child development, clinicians will need to broaden the conceptual framework used to evaluate relative risk of SSRI use during pregnancy as they navigate this clinical arena with patients making individual decisions to match patient wishes,” Cohen and Nonacs concluded.

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CMS Issues Final Rule on MACRA; APA Is Here to Help Members Know Their Options

The Centers for Medicare and Medicaid Services (CMS) today issued its final rule implementing payment reforms—including the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions—in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

MACRA, which replaces the flawed Sustainable Growth Rate (SGR), establishes new quality reporting programs aimed at encouraging value-based care.

APA staff will be analyzing the final rule and its implications for APA members. Right now, psychiatrists should be aware of the following:

• Psychiatrists with up to $30,000 in Medicare billings or 100 Medicare patients will be exempt from quality reporting and payment adjustments under the MIPS program.
• Psychiatrists can ease into MIPS reporting in 2017 due to relaxed “Pick Your Pace” reporting for that year. Reporting just one measure for Quality, one Clinical Practice Improvement Activity, or all measures for electronic health record (EHR) use will avoid 2019 penalties. Reporting complete MIPS data for part (or all) of 2017 can earn modest (or slightly higher) bonuses in 2019.
• Psychiatrists who do MIPS reporting for 2017 will not be penalized for seeing sicker, lower income patients. Their Medicare patients’ resource use will not be counted in their MIPS score.
• Psychiatrists will only have to report four medium-weight or two high-weight Clinical Practice Improvement Activities and only five Advancing Care Information measures (for EHR use) to get credit in those categories—a significant drop from the proposed rule. 

Importantly, APA staff want to help educate members about their options. For that reason, staff are in the process of developing a variety of tools, including a web-based toolkit and webinar series among others, to make this transition as easy as possible. Psychiatric News and other APA communications will alert members as new items become available.

The downloadable APA MACRA Toolkit may include resources such as:

• MACRA 101 Primer
• Decision tree to help psychiatrists choose their payment pathway   
• Checklist and timelines to get ready for MIPS
• Additional APA and other resources to help members prepare

APA will also be launching a webinar series to walk members through the nuts and bolts of these Medicare changes, show them how they can be successful quality reporters, and demonstrate how to use the data to inform clinical practice. The webinar series can be viewed live and will be available later On-Demand on the APA Learning Center. The tentative schedule for webinars is as follows:

• Quality 101 Reporting—This will be available in late October
• Final Rule Overview—November 16, 2016
• MIPS Quality Category—November 30, 2016
• MIPS Advancing Care Information Category—December 7, 2016
• MIPS Clinical Practice Improvement Activities Category—December 14, 2016
• Alternative Payment Models—January 18, 2017

“The Medicare payment reforms in MACRA are upon us, including significant changes, and members may feel understandably apprehensive," said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “That’s why APA exists—to help its members. Our expert staff are here to guide members in navigating these reforms and making this transition as smooth and simple as possible. I urge you to go to our website at www.psychiatry.org/MACRA and see the resources we have created for you.”

For more information, see upcoming issues of Psychiatric News and the series of Psychiatric News articles on MACRA and value-based care.

Transcranial Magnetic Stimulation May Reduce Cravings in People With Nicotine Use Disorder

Previous studies have found that repetitive transcranial magnetic stimulation (rTMS)—a noninvasive technique that stimulates targeted brain regions using magnetic pulses—reduces cravings in some patients with substance use disorder. A meta-analysis in the Journal of Neuropsychiatry and Clinical Neurosciences now suggests that the neuromodulatory tool may be particularly effective at cutting cravings in people with nicotine use disorder.

Researchers first performed a literature search of the MEDLINE and Cochrane databases for randomized, controlled trials and controlled clinical trials on transcranial magnetic stimulation (TMS) in patients with substance use disorder published up until 2015. Ten studies met the authors’ criteria for inclusion in the meta-analysis, including six on alcohol use disorder and four on nicotine use disorder that involved TMS stimulation to regions of the prefrontal cortex.

The meta-analysis revealed a significant effect size favoring active rTMS stimulation over sham stimulation in reducing craving in substance dependence. Active rTMS stimulation was found to be highly effective for nicotine use disorder in subgroup analysis, but it showed no favorable effect for alcohol use disorder.

“Stimulating DLPFC [dorsolateral prefrontal cortex] by rTMS has been postulated to reduce substance craving possibly by two mechanisms. ... [I]nterconnections of the DLPFC with the ventral tegmental area (VTA) increase dopamine excretion from the VTA to the ventral striatum, an area implicated in reward processing. ... [S]timulation of the DLPFC stimulates glutamate containing corticofugal fibers, which end on dopamine containing terminals in the ventral striatum, potentially increasing dopamine excretion and reducing craving,” wrote Rituparna Maiti, M.D., and colleagues at the All India Institute of Medical Sciences (AIIMS) in Bhubaneswar, India.

Based on the results of the meta-analysis, Maiti and colleagues recommended the adoption of a uniform rTMS treatment protocol for patients with nicotine use disorder. They also called for additional trials to examine the effectiveness of rTMS in patients with alcohol use disorder. “There is a need for further clinical trials with robust rTMS protocols and a greater number of treatment sessions to make a final conclusion on the anti-craving effects of rTMS in alcohol use disorder,” they concluded.

For related information, see the Psychiatric News article “Neuromodulation May Benefit Patients With Varying Psychiatric Illnesses,” by Andrew Leuchter, M.D., 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.

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Candidates Announced for APA's 2017 Election

The APA Nominating Committee, chaired by APA Immediate Past President Renée Binder, M.D., today announced the candidates for the Association's 2017 election.

PRESIDENT-ELECT
Rahn K. Bailey, M.D.
Altha J. Stewart, M.D.

SECRETARY
Philip R. Muskin, M.D.
Gail E. Robinson, M.D.
Robert P. Roca, M.D., M.P.H.

MINORITY/UNDERREPRESENTED REPRESENTATIVE TRUSTEE
David L. Scasta, M.D.
Ramaswamy Viswanathan, M.D., D.Sc.

AREA 2 TRUSTEE
Vivian B. Pender, M.D.
Ravi N. Shah, M.D., M.B.A.

AREA 5 TRUSTEE
R. Scott Benson, M.D.
Jenny L. Boyer, M.D.

RESIDENT-FELLOW MEMBER TRUSTEE-ELECT
Tanuja Gandhi, M.D.
Sarah Kauffman, M.D.
Benjamin Solomon, M.D., M.B.A.

The deadline for candidates who wish to run by petition is November 15. All candidates and their supporters are encouraged to review APA's Election Guidelines. For more election information, please visit the Election section on APA's website or email election@psych.org.

The slate of candidates who have been nominated is public but not official until approved by the APA Board of Trustees at its December meeting. Voting for the 2017 election will be open from January 3 to January 31, 2017.

Identifying, Engaging Patients With First-Episode Psychosis Remains Public Health Challenge

Early identification and appropriate engagement of patients experiencing first-episode symptoms of schizophrenia remains a major public health challenge, said John Kane, M.D. (left), winner of the APA Foundation's 2016 Alexander Gralnick, M.D., Award for Research in Schizophrenia. He received the award on Saturday in Washington, D.C., at APA's fall conference, IPS: The Mental Health Services Conference. 

During his award lecture, Kane outlined the importance of duration-of-untreated psychosis as a moderator of response to treatment for first-episode psychosis, the impact of nonadherence to medication on the course of psychosis, and the unrealized potential of long-acting injectable (LAI) antipsychotics.

Kane said he believes that LAI antipsychotics are an effective but underutilized answer to nonadherence. “I think we have enough data to show that this is a very effective option we are not taking advantage of,” he told meeting attendees.

Emerging technologies can also be used to improve treatment adherence, he explained. He and colleagues at Zucker Hillside Hospital and Massachusetts General Hospital have studied the use of an “an ingestible event marker”—a pill embedded with a tiny sensing device that emits a signal when it comes into contact with gastric contents after being swallowed; the signal is picked up by a receiver in a patch worn by the patient, which in turns transmits the signal to caregivers and clinicians indicating that the medication has been ingested. 

“New technologies, such as smartphones and other monitoring tools, should be systematically developed, tested, and applied,” Kane said.

Kane also addressed how pharmacogenetics can help individualize treatment, the importance of managing metabolic symptoms in patients treated with second-generation antipsychotics, the unique value of clozapine for refractory schizophrenia, and the findings from the Recovery After an Initial Schizophrenia Episode (RAISE) project, on which Kane was a principal investigator.

Complete coverage of the Gralnick lecture will appear in an upcoming issue of Psychiatric News. For related information, see the Psychiatric News article “Long-Acting Injectable Increases MedicationAdherence in Patients With Schizophrenia.”

(Image: Ellen Dallagher)

Refugees’ Mental Stresses Similar Regardless of Country of Origin, Say Experts

Refugees—no matter where they’re from or how old they are or what drove them from their homes—have faced stresses serious enough to threaten their mental well-being, said speakers at APA’s fall meeting, IPS: The Mental Health Services Conference, being held in Washington, D.C., through Sunday. They face a higher risk of depression, anxiety, PTSD, and other mental health problems.

Children are an especially high-risk group, said Gaurav Mishra, M.D., M.B.B.S., a child psychiatrist with the Imperial County (California) Behavioral Health Services, near the border with Mexico. He sees people who have come from Nicaragua, Honduras, and El Salvador, as well as from Haiti and Africa. Many faced violence back home, separation from their parents, and exploitation or abuse on the way to the United States, said Mishra.

The county provides age-graded services for children, adolescents, and young people up to age 25 who have behavioral problems or diagnosed mental illnesses. Funding comes from California’s 1 percent tax on incomes over $1 million.

In Syria, “refugees are affected by loss of home, money, jobs, family, and friends,” said Ashley Nemiro, Ph.D. (above), the technical advisor for mental health for the International Rescue Committee (IRC). Nemiro helps them to resettle in the United States. “They experience stress from the conflicts in their home country, from their displacement, and from daily life in the places where they have resettled.”

IRC screens its clients, nearly all of whom have had some experience of trauma. They have developed a variety of support systems for them. In Baltimore, community health workers visit the refugees; in Dallas, they connect with clients through a local mosque; and in Phoenix, they use high school and adult group therapy.

“It’s difficult in practice,” said Nemiro. “We need to let people tell us their stories and then help them to do the tasks of daily living themselves.”

For related information, see the Psychiatric Services article “Mental Health Service Use Among Immigrants in the United States: A Systematic Review.”

(Image: Aaron Levin)

NYC First Lady Describes ThriveNYC, Urges Psychiatrists to Be Advocates

“Our mental health moment is now,” said New York City First Lady Chirlane McCray in a passionate Opening Session address at APA’s fall meeting, IPS: The Mental Health Services Conference, being held today through Sunday in Washington, D.C.
   
She said support for improving access to mental health care has never been stronger. “Across the country, communities large and small are coming together to shatter the stigma of mental illness and develop real solutions.” 
   
McCray, who received the APA Patient Advocacy Award from APA President Maria A. Oquendo, M.D., described ThriveNYC: Mental Health Roadmap, an ambitious program in New York City to improve access to mental health care there. The program, a signature achievement of McCray’s, is founded on six principles as described on the ThriveNYC website: 

• Change the culture: It’s time for New Yorkers to have an open conversation about mental health.
• Act early: New Yorkers need more tools to weather challenges and capitalize on opportunities. That can happen through investment in prevention and early intervention.
• Close treatment gaps: Disparities in care can be addressed by providing New Yorkers in every neighborhood with care in their own communities. “We will address not only gaps in access and availability,” states the website, “but in effectiveness and impact.”
• Partner with communities: By embracing the wisdom and strength of local communities, effective and culturally competent solutions can be created through collaboration.
• Use better data: Better data mean better treatment, better policies, and better interventions.
• Strengthen government’s ability to lead: New York’s government has a responsibility to support mental health. “We’re taking that seriously by serving as the clearinghouse to drive change,” states the website.

McCray also spoke of her own family’s experience with mental illness when her 18-year-old daughter required treatment for depression, anxiety, and addiction.

“Here was our child, in terrible pain. And I wished I could love her into wellness. But I didn’t know where to turn. ... Thankfully, our family got lucky. We connected with wonderfully caring professionals and found enough of what we were looking for. I’m proud to say that our daughter is doing well and recently graduated from college. But even after our own family’s crisis subsided, I could not forget how difficult her journey was and how difficult it must be for other families. ... And that is how ThriveNYC was born.”

In comments to Psychiatric News following her remarks, McCray said the single most important role psychiatrists can plan in assisting the goals of ThriveNYC is advocacy through APA. “APA has so much power.”

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Methylphenidate Monotherapy May Increase Risk of Mania in Patients With Bipolar Disorder, ADHD

Determining the best medications for patients with co-occurring bipolar disorder and attention-deficit/hyperactivity disorder (ADHD) can be challenging, as evidence suggests that pharmacotherapies for ADHD can worsen symptoms of bipolar disorder and vice-versa.

A study appearing this week in AJP in Advance now suggests methylphenidate may increase the risk of treatment-emergent mania in patients with bipolar disorder when it is used without a concomitant mood-stabilizing treatment.

Using Swedish national registries, the authors identified 2,307 adults with bipolar disorder who initiated therapy with methylphenidate between 2006 and 2014. The patients were divided into two cohorts—those with and those without concomitant mood-stabilizing treatment. The authors then compared the rate of mania during a six-month period before the start of methylphenidate treatment with a six-month period following the start of methylphenidate treatment.

The authors found that the relative risk of mania following methylphenidate treatment among patients treated with methylphenidate monotherapy was increased in both the initial three months after treatment and in the subsequent three months. By contrast, among patients treated with a concurrent mood stabilizer, the risk of mania was reduced in the initial three months and slightly reduced in the subsequent three months.

“On the basis of this finding, we recommend careful assessment to rule out bipolar disorder before initiating methylphenidate as a monotherapy,” Alexander Viktorin, Ph.D., of the Karolinska Institutet and colleagues wrote. “As no association with treatment-emergent mania was observed among bipolar patients who were concomitantly receiving a mood-stabilizing medication, it would appear that concomitant therapy of ADHD is both safe and feasible in the context of ongoing preventive therapy.”

For related information, see the Psychiatric News article “Mania Risk Seen in Treating Bipolar Patients With Antidepressants Alone.”

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Pentagon Expands Mental Health Care for Troops, Families

The Department of Defense yesterday issued a final rule broadly expanding access to mental health and substance use disorder treatment for military service members. The rule covers services for 9.4 million active and retired military service members and their families under TRICARE.

The rule eliminates quantitative and nonquantitative limitations on mental health and substance use disorder care. All inpatient mental health day limits were eliminated, as were annual and lifetime limitations on outpatient services and substance use disorder treatment.

Copayments for mental health visits were cut from the current $25 to $12, the existing standard for general medical and surgical care.

Also, substance use disorder treatment will now include outpatient medication-assisted protocols, enabling qualified TRICARE contract providers to use buprenorphine and other medications.

The rule also now permits coverage of all non-surgical care in treatment of gender dysphoria, a development arising from the decision to permit transgender people to serve openly in the armed forces.

Overall, the new rule represents a step forward for service members and their families, but their effects need to be documented better, said former U.S. Army psychiatrist Charles Engel, M.D., a senior scientist at the RAND Corporation in Boston.

“What works for those in uniform may be in tension with what is best for non-uniformed military health system beneficiaries,” said Engel. “There are lots of complex pieces to these changes, but there has been little large, independent health care services analysis of the system.”

More information on this topic can be found in the book Care of Military Service Members, Veterans, and Their Families from APA Publishing. APA members may purchase the book at a discount here.

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Report Highlights Challenges People Face When Seeking Care for Borderline Personality Disorder

While people seeking resources for borderline personality disorder (BPD) appear to be aware of evidence-based therapies to treat BPD, stigma associated with the disorder and the cost of treatment remain significant hurdles to care, according to a report published today in Psychiatric Services in Advance. The authors of the report qualitatively examined BPD service needs from the perspective of those seeking care information or services related to BPD—including patients, family members and friends, and health professionals.

“This study provided a broad overview of the experiences and preferences of BPD care seekers and highlights important focal areas for improving BPD services,” wrote the study authors. “These insights offer targets for future efforts to improve BPD services and outcomes.”

Researchers at the Dartmouth Centers for Health and Aging analyzed the transcripts from more than 6,000 resource requests made to the Borderline Personality Disorder Resource Center (BPDRC) at New York Presbyterian Hospital between 2008 and 2015. From these transcripts, the authors were able to determine the frequency of the type of service requested, the distribution of requests by state, and the caller’s relationship to a BPD patient.

Afterwards, 500 transcripts were randomly chosen and assessed in more detail to identify themes, challenges, and common experiences reported by BPD care seekers. More than half (256) of the 500 requests were for outpatient services, and almost all of these were requests were for dialectical behavioral therapy (DBT) or related behavioral therapies. Few callers seeking outpatient services for BPD requested pharmacotherapy or referrals to psychiatrists who could prescribe medications for BPD.

Among the areas that those requesting resources for BPD thought needed improvement were family services, crisis intervention, and mental health literacy. In addition, they cited stigmatization, financial concerns, and medical comorbidities as barriers to finding and obtaining appropriate treatment.

“Overall, these findings underscore challenges in obtaining appropriate care for BPD and opportunities for improving the coverage and scope of current resources,” the authors wrote.

To read more about BPD, see the Psychiatric News article “Shared Elements Across Therapies for Suicidal Patients With BPD.”

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