Suicide Risk Remains Elevated for Years After Discharge From Psychiatric Hospital

Patients admitted into psychiatric hospitals because of suicidal thoughts and behaviors are known to be at a particularly heightened risk of suicide upon discharge. A report published today in JAMA Psychiatry suggests that suicide risk is markedly elevated in all patients after psychiatric hospital discharge, even those with no reported history of suicidal thoughts. 

“It has been argued that a way of combating post-discharge suicide is to focus on individual patients with clinical characteristics that signify a high suicide risk. However, the very high suicide rates calculated in this study and the known limitations of suicide risk assessment suggest that a focus on clinical risk assessment might mislead clinicians into thinking that some patients can be regarded as having low risk after discharge,” Matthew Michael Large, B.Sc., M.B.B.S., D.Med.Sci., of the University of New South Wales, Australia, and colleagues wrote.  

The findings were based on a meta-analysis of 100 studies of post-discharge suicide rates carried out over the past 50 years. The pooled estimate discharge suicide rate was 484 per 100,000 person-years—a figure the authors noted is “44 times the global suicide rate of 11.4 per 100,000 patients per year in 2012.” 

The suicide rate was highest within three months after discharge (1,132 per 100,000) and among patients admitted with suicidal ideas or behaviors (2,078 per 100,000). Pooled suicide rates per 100,000 patient-years were 654 for studies with follow-up periods of three months to one year, 494 for studies with follow-up periods of one to five years, 366 for studies with follow-up periods of five to 10 years, and 277 for studies with follow-up periods longer than 10 years.

“The clinical message of these findings is clear: universal and continuing suicide prevention interventions are needed for patients after psychiatric hospital discharge, with a higher level of clinical monitoring and support for patients during the first few months after hospital discharge and for patients with a history of suicidal behavior,” Mark Olfson, M.D., M.P.H., of the Columbia University College of Physicians and Surgeons and New York State Psychiatric Institute wrote in a related editorial. “A greater appreciation of the enduring elevated risk of psychiatric inpatients after discharge might help build support for the clinical resources to reduce the unacceptably large number of individuals who die by suicide each year.”

For related information, see the Psychiatric News article “Emergency Department Intervention May Reduce Suicide Attempts in At-Risk Patients.”

(Image: iStock/robypangy)

Psychodynamic Therapy Is Equivalent to CBT, Meta-Analysis Finds

Psychodynamic therapy appears to be as effective at treating mental illness as other techniques with established efficacy, including cognitive-behavioral therapy (CBT), according to a meta-analysis in AJP in Advance. 

“This meta-analysis is the first in psychotherapy research to systematically investigate equivalence of a specific form of psychotherapy to established treatments by formally applying the logic of equivalence testing,” wrote Christiane Steinert, Ph.D., of the University of Giessen in Germany and colleagues. 

The meta-analysis included 23 randomized, controlled trials with 2,751 patients. Twenty-one of the trials compared psychodynamic therapy to other forms of psychotherapy, in most cases CBT. Two studies compared psychodynamic therapy with a selective serotonin reuptake inhibitor or with a serotonin-norepinephrine reuptake inhibitor in the treatment of depression. The majority of studies investigated participants with a depressive disorder (n=8), followed by anxiety disorders (n=4), eating disorders (n=4), personality disorders (n=4), substance dependence (n=2), and posttraumatic stress disorder (n=1).

The primary outcome was “target symptoms,” which included measures specific to the mental disorder under study (for example, measures of depressive symptoms in depressive disorders or of social anxiety in social anxiety disorder). General psychiatric symptoms and psychosocial functioning—including social, occupational, and personality functioning—were also examined.

Regardless of whether efficacy results in the individual trials favored psychodynamic therapy or the comparator treatment, the pooled between-group difference in outcome for target symptoms at post-treatment for all studies was statistically small, suggesting psychodynamic therapy is as efficacious as the other treatments. 

The authors noted that “therapist effects”—which refers to the effects of the skills or experience a therapist brings to treatment, as well as to the “fit” between patient and therapist—are known to be a determinant in the effectiveness of psychotherapy. “Because therapist effects seem to have a stronger impact on outcome than the treatments being compared and need to be taken into account, one promising strategy for improving treatments is enhancing therapist training and eventually therapist outcome,” they concluded. “Furthermore, different patients may benefit from different approaches, which is why a shift from one empirically supported treatment to another may be helpful in case of nonresponse.”

For related information, see the Psychiatric News article “Cost-Effectiveness and the Role of Psychodynamic Psychotherapies,” by Susan G. Lazar, M.D., a clinical professor of psychiatry at Georgetown University School of Medicine.

(Image: iStock/sturti)

Psychotic Experiences Found to Be Higher Among Adolescent City Dwellers

Adolescents raised in urban neighborhoods may be significantly more likely to have psychotic experiences than their rural counterparts, according to a study published this week in Schizophrenia Bulletin. The association remained significant after adjusting for other factors, including family socioeconomic status, family psychiatric history, and adolescent cannabis use.

“These findings highlight the importance of early, preventative strategies for reducing psychosis risk and suggest that adolescents living in threatening neighborhoods within cities should be made a priority,” said senior author Helen Fisher, Ph.D., of King’s College London in a press release. 

Fisher, together with colleagues at King’s College London and Duke University, found that neighborhood social conditions and personal victimization by violent crime were strong contributing factors to adolescent psychotic expressions. Adolescents who had grown up in the most adverse neighborhoods and had been victim to a violent crime had nearly five times the chances of experiencing psychotic phenomena compared with those without such history, according to the study.

As part of the Environmental Risk (E-Risk) Longitudinal Twin Study, the researchers asked 2,063 18-year-olds in England and Wales about whether they had had any psychotic experiences since the age of 12. Participants were deemed to have these experiences if they reported during an interview at least one out of 13 potential psychotic experiences, such as believing they were being followed, hearing voices others could not hear, or thinking their food was poisoned. Just over 30% of the study’s total participants said they had at least one psychotic experience.

Researchers measured neighborhood social factors, such as trust and support between neighbors, and signs of threats such as assaults and vandalism through postal code surveys of neighbors living alongside participants. Personal victimization by violent crime was assessed through interviews with the participants themselves.

Of adolescents who had lived in the most socially adverse neighborhoods (neighborhoods that were simultaneously characterized by lower levels of social cohesion and higher levels of neighborhood disorder), 24% reported to have been personally victimized, compared with 15% who lived in better neighborhoods. Adolescents who had been victimized by violent crime had over three times greater odds of having psychotic experiences, the study found. 

Early intervention offers the best hope for improving outcomes in psychosis, the authors concluded. “It is crucial to understand how the wider structural and social environment may influence psychotic experiences among young people in order to design and effectively target preventive interventions,” they wrote. 

For related information, see the Psychiatric News article “Hallucinations Can Be Marker For Variety of Psychiatric Disorders in Youth.”

(Image: iStock/LeoPatrizi)

APA to U.S. Senate: Reject the American Health Care Act in Favor of Bipartisan Solutions

If the Affordable Care Act (ACA) replacement bill that narrowly passed the U.S. House of Representatives earlier this month becomes law, it will leave some 14 million more people uninsured next year than under the current law and 23 million more in 2026, the Congressional Budget Office (CBO) announced Wednesday. APA responded promptly to the news, renewing its call for the U.S. Senate to reject the ACA replacement bill, the American Health Care Act (AHCA), in favor of a bipartisan solution. 

“We are deeply troubled that 23 million Americans could lose access to health care,” past APA President Maria A. Oquendo, M.D., Ph.D., said in a press release. “Taking away their coverage is unconscionable.” (Oquendo recently took this message to Capitol Hill, where she and leaders from several other medical associations met with Republican senators to discuss their opposition to the AHCA.)

Among other things, APA is concerned about what changes proposed in the AHCA would mean for people with mental illness and substance use disorders; an estimated 1.3 million Americans with serious mental illness and 2.8 million Americans with substance use disorders gained coverage for the first time under the expansion of Medicaid in the ACA.

The AHCA, which passed the House on May 4 by a margin of 217-213, is currently under consideration in the Senate, where it is expected to undergo significant changes before it comes up for a vote.

“Congress made much progress over the past three years, culminating in the passage last year of the bipartisan, bicameral 21st Century Cures Act,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “This current bill reverses those gains. We stand ready to work with both parties to ensure adequate health care for all Americans.”

APA has previously offered the following recommendations to lawmakers:

• Maintain the current level of coverage for mental health and substance use disorders in health insurance plans. 
• Maintain safeguards in private insurance by specifically prohibiting the following: 
• Denying coverage based upon a pre-existing condition; 
• Establishing lifetime and annual dollar limits on essential health benefits; and
• Discrimination based upon health status, including a history of mental illness or substance abuse. 
• Any efforts to restructure Medicaid must ensure sufficient funding for mental health and substance use issues and not shift the cost to states in a way that forces them to tighten eligibility requirements, provider reimbursement, or benefits.  
• Ensure full implementation and enforcement of the bipartisan Mental Health Parity and Addiction Equity Act, which calls on insurers to offer coverage for mental health care on par with coverage for any other ailment.

“As the Senate debates reforms to the health system, services for people with mental health and substance use disorders—and their families—must be maintained. The APA urges the Senate to reject the American Health Care Act in favor of bipartisan legislation,” the release noted.

Write Your Senators and Urge Them to Start Over on AHCA

APA members are urged to contact their senators to express opposition to the AHCA and instruct the Senate to set aside the House bill and start over on new legislation that does not put at risk health care for people with mental health/substance use disorders. To make such communication quick and easy, visit the APA Advocacy Center.

(Image: Mikhail Kolesnikov/Shutterstock)

Involuntary Psychiatric Care, Malingering, and More From APA’s 2017 Annual Meeting

Highlights of day five coverage from APA’s Annual Meeting include a tribute to the late psychiatrist Chester Pierce, M.D., discussion of involuntary psychiatric care, and tips on how to work with patients who distort or withhold key information.

Look for future coverage of APA’s 2017 Annual Meeting in upcoming issues of Psychiatric News.

Pernicious Effects of Racism Discussed in Session Honoring Chester Pierce, M.D.

The late Harvard psychiatrist Chester Pierce, M.D., left a legacy that continues to inspire his successors in the study of the connection between race and mental health in America. Read More >

Columbia Residents Win 2017 MindGames Competition for Second Straight Year

The team from Columbia emerged victorious during the 11th annual MindGames competition at APA’s Annual Meeting. The competition that pits residents from psychiatry programs across the country against each other to test their knowledge of psychiatry. Read More >

The Battle Over Involuntary Psychiatric Care

Involuntary psychiatric treatment is regarded by many as essential in some settings, and there is evidence from some states that when appropriately administered, it is effective. But it is not without controversy and some ardent critics. Read More >

Determining Whether Service Members Are Malingering Poses Dilemma for Military M.D.s

American military personnel who are discharged because of a service-related disability may be eligible for a lifetime of monthly payments of between 30 percent and 100 percent of their salary and health benefits. That may be a temptation to a few who might choose to stretch the truth about an injury or psychiatric disorder. Read More >

Expert Shares Guidance on Prescribing Medicinal Marijuana to Avoid Legal Snags

Twenty-nine states and the District of Columbia have legalized medical cannabis, so psychiatrists throughout the country are or could be involved in prescribing marijuana to patients. Read More >

Confronting Non-Disclosure Can Engage Patients in New Ways

Physicians rely on patients to tell them what is wrong, but patients who distort or withhold critical facts can be challenging, especially for trainees, requiring advanced interviewing skills. Read More >

Toronto Psychiatrist Brings ECHO Model to Mental Health

The telehealth-based mental health initiative is helping to connect local physicians with specialists at an academic medical center for a short didactic lecture on rotating medical topics followed by intensive case discussions. Read More >

Pediatric Integrated Care Is Key to Meeting Needs of Young Patient

Since becoming president of the American Academy of Child and Adolescent Psychiatry in 2015, Gregory K. Fritz, M.D., has made it his mission to educate child and adolescent psychiatrists about how best to collaborate with others in primary or specialty medical care. Read More >

Winners of the Resident/Medical Student Poster Competition Announced

The Resident/Medical Student Poster Competition is an APA Annual Meeting tradition that allows residents and medical students to attend the meeting, present their research, and be recognized for quality work. Read More >

Overcoming Addiction, Googling Patients, and More From APA’s 2017 Annual Meeting

Highlights of day four coverage from APA’s Annual Meeting include two tales of patient recovery, the ethical and clinical questions you should consider before Googling your patients, and debates over the value of genetic tests in psychiatric practice.

Through tomorrow, Psychiatric News is delivering an evening digest of some of the day’s highlights—from the lecture halls to the exhibit floor. Whether you are here in San Diego or at home, these reports will convey the excitement and outstanding scientific program being presented at this year’s meeting.

From Depths of Addiction to Triumph of Recovery: ABC Journalist Shares Story of Strength and Inspiration

During the 2017 William C. Menninger Memorial Award Lecture Monday, Elizabeth Vargas delivered a candid address, describing the evolution of her alcoholism and its roots in a gripping anxiety she experienced since childhood. Read More >

Author Cahalan Tells a Tale of the Art and Science of Clinical Care

“I know what it is like to lose your grip,” author Susannah Cahalan said during the Opening Session on Sunday. “I have come back intact, and I hope I can share with you the perspective of a patient. I want to offer you a view from the inside of psychosis, hallucinations, and delusions.” Read More >

Rep. Tim Murphy Wins Javits Award

Rep. Tim Murphy (R-Pa.), who spearheaded the effort for mental health reform in Congress, received APA’s 2017 Jacob K. Javits Award for Public Service. Read More >

To Google or Not to Google: How Much Do You Want to Know About Your Patient?

The practice of Googling a patient’s name may be too easy to resist and may seem innocuous. But a panel of experts said that Googling and other forms of collecting collateral information about a patient online raise a host of questions, ethical and clinical, about how that information may affect the physician-patient relationship and clinical care. Read More >

Pediatric Psychosomatic Physician Talks About Special Considerations for Young, Medically Ill

While most people think of psychosomatic medicine as a field that treats adult patients with cancer, HIV/AIDS, or other serious illnesses, there is a vibrant and emerging community of pediatric psychosomatic doctors. Read More >

Expert Panel Debates Benefits, Harms of Pharmacogenetic Testing

Over the course of a Learning Lab session, experts fielded a range of questions on genetic testing—including scientific, ethical, judicial, and financial considerations. Read More >

Lessons Learned From Studying Mental Health Outcomes of U.S., U.K. Soldiers

The president of the Royal College of Psychiatrists describes the similarities and differences between the mental health outcomes of U.S. and U.K. military members. Read More >

APA Raises $16,000 for Free Clinic Project

The proceeds from the annual APA Gives Back program went to the UCSD Student-Run Free Clinic Project. The project operates four clinics in the San Diego area, providing free medical and preventive care, health education, and access to social services. Read More >

Future of NIMH, Goldwater Rule, and More From APA's 2017 Annual Meeting

Highlights of day three coverage from APA’s Annual Meeting include an address by the NIMH director on the future of the institute, the naming of the winners of APA’s Psychiatry Innovation Lab, the importance of partnerships when caring for the military, and how mental illness played a major role in the musical genius of Robert Schumann.

From now through May 24, Psychiatric News will deliver an evening digest of some of the day’s highlights—from the lecture halls to the exhibit floor. Whether you are here in San Diego or at home, these reports will convey the excitement and outstanding scientific program being presented at this year’s meeting.

NIMH Director Discusses His Vision for Institute

As part of his Year 1 listening tour, Joshua Gordon, M.D., Ph.D., the new director of the National Institute of Mental Health (NIMH), presented a special lecture in which he discussed the institute’s future funding outlook as well as his vision for its future—and what that might mean for psychiatry. Read More >

Session on Goldwater Rule Elicits Diverse Reactions From Participants

Ethics experts and session participants share their views on the Goldwater Rule. Read More >

Partnerships Are Key to Caring for Members of the Military, Says Vice Admiral

Military and civilian health care providers share a common overarching mission and have much to offer each other. Read More >

APA’s New Mental Health Registry Will Help You Improve Care, Meet Reporting Requirements

PsychPRO, the mental health registry being developed by APA to help members more easily meet quality reporting and maintenance of certification (MOC) requirements, has gotten off to a fast start since the launch of its preliminary phases last October. Read More >

Experts Describe Ongoing Efforts to Shift Conversation on Psychiatric Medications

At a Presidential Symposium, members of the neuroscience-based nomenclature (NbN) task force discussed the history and future of their nearly decade-long effort to change psychotropic medicine descriptions to reflect their molecular targets or mode of action instead of an arbitrary indication. Read More >

Your Patients May Want You to Incorporate Spirituality Into Treatment

While most hospitals rely on chaplain services to address the spiritual needs of patients, a hospital-wide initiative at McLean Hospital aims to “empower, encourage, and train clinicians around the hospital to attend to patient’s spirituality and religion rather than ignoring or outsourcing this area of life.” Read More >

APA Congratulates Winners of the Psychiatry Innovation Lab

APA held its third Psychiatry Innovation Lab competition at this year’s Annual Meeting on Sunday. The goal of the competition is to accelerate innovative ideas and ventures that aim to improve the delivery of mental health care. Read More >

Richard Kogan, M.D., Explores Genius of Composer Robert Schumann

Psychiatrist and concert pianist Richard Kogan, M.D., describes the mind of 19th century German composer Robert Schumann and how Schumann’s mental illness played a major role in his musical genius. Watch >

Partnering With Community Groups May Improve Outcomes in Older Adults Who Hoard

A thorough psychiatric evaluation that identifies psychiatric, medical, and cognitive comorbidities is essential to the effective management of hoarding in the elderly, but most individuals will require additional hands-on assistance. Read More >

Workshop Attendees Debate Best Options for Treating Perinatal Depression

The cases discussed included guidance on how to monitor medications and adjust dose as needed during pregnancy, as well as some of the different treatment options available. Read More >




In tomorrow’s Psychiatric News Alert: A report on ABC News journalist Elizabeth Vargas’s lecture and discussion with NIDA Director Nora Volkow, M.D., at the Convocation of Distinguished Fellows.

Innovative Solutions for Expanding MH Care and More From APA’s 2017 Annual Meeting Day Two

Day two of APA’s Annual Meeting included an announcement of the results of a national poll on Americans’ views on access to mental health care, an address by the director of NIAAA, and discussion about ways to strengthen the therapeutic alliance with a patient after a suicide attempt.

From now through May 24, Psychiatric News will deliver an evening digest of some of the day’s highlights—from the lecture halls to the exhibit floor. Whether you are here in San Diego or at home, these reports will convey the excitement and outstanding scientific program being presented at this year’s meeting.

Oquendo Recounts Victory of 21st Cures Act, APA’s Ongoing Efforts on AHCA

“We are at the threshold of a wonderful era for psychiatry,” said APA President Maria A. Oquendo, M.D., Ph.D., recapping an eventful presidential year highlighted by her presence at the White House for the signing of the 21st Century Cures Act.
Read More >

Everett to Center Presidency on Innovative Solutions to Expanding Care, Increasing Support to Members

During the Opening Session, APA President-elect Anita Everett, M.D., said the development of innovative systems for improving access to care, team-based care for first-episode psychosis, and initiatives regarding physician wellness and burnout would be key goals for her presidency. Read More >

Large Majority of Americans Say MH Care Should Be Covered by Insurance

Mental health is important to Americans, and they think it should be important to their elected representatives as well, according to the results of a national poll released today by APA. Read More >

NIAAA Director Describes ‘Dark Side of Addiction,’ Hope for Future Treatments

The negative emotional states experienced by people with substance use disorders are an integral part of the addictive process, according to George F. Koob, Ph.D. Read More >

Winners of Assembly Election Announced

At their meeting held yesterday in conjunction with the Annual Meeting, members of the APA Assembly chose James R. Batterson, M.D., of Kansas City, Mo. (right), as the group’s next speaker-elect. He is the Area 4 representative and is concluding his term as recorder. Steven Daviss, M.D., a representative from the Maryland Psychiatric Society, was elected recorder. The new officers begin their terms at the close of the Annual Meeting, at which time Theresa Miskimen, M.D., of Piscataway, N.J., will become the speaker of the Assembly.

Asking Patients About Suicide Narrative May Improve Long-Term Outcomes

Placing greater emphasis on a patient’s narrative of the feelings leading up to a suicide attempt may not only strengthen the therapeutic alliance, but create a foundation from which safety planning and long-term outreach can be maintained. Read More >

What Can Children’s Books Teach You About Your Patients?

All literature is born from the human need to tell stories that help us understand ourselves and others. Children’s books—which allow young readers to experience love, loss, and betrayal through the lives of characters—can lead to cognitive and emotional growth in young people. Read More >

Psychiatrists Have Tools Needed to Help Patients in Pain

Physicians today appreciate that chronic pain involves vicious cycles of both physical and psychological feedback. Read More >

Historical Survival Traits May Be to Blame for Some Mental Health Disorders

Depression and anxiety are, paradoxically, directly linked to the same genetic traits that evolved to help our ancestors survive, said Lee Goldman, M.D., author of Too Much of a Good Thing: How Four Key Survival Traits Are Now Killing Us. Read More >

Clinical/Research News From APA’s 2017 Annual Meeting Day One

Welcome to San Diego!

APA’s 2017 Annual Meeting began in San Diego today. From now through May 24, Psychiatric News will deliver an evening digest of some of the day’s highlights—from the lecture halls to the exhibit floor. Whether you are here in San Diego or at home, these reports will convey the excitement and outstanding scientific program being presented at this year’s meeting.

Strengthening Sense of Identity Can Promote Mental Health of Students of Color

Identity can be a source of both emotional adversity and strength for ethnic minority college students, said speakers at a panel today at APA’s Annual Meeting.
Read More >

When Should Psychiatrists Disclose Mental Health Problems?

Psychiatrists have been at the forefront of encouraging patients to adopt ideas like recovery, resilience, and engagement, yet when confronting their own mental health issues, psychiatrists lean toward privacy. Read More >

Experts Describe Recent Advances in Psychodynamic Psychotherapy

Interpretation of transference, treatment of narcissistic personality disorder, and the evolution of psychodynamic treatments for borderline personality disorder and posttraumatic stress disorder were among topics discussed. Read More >

Volkow Honored for Addiction Research

Nora Volkow, M.D., director of the National Institute on Drug Abuse, was presented the Presidential Award for 2017 today by the American Association of Chairs of Departments of Psychiatry. The organization presents the award each year to a psychiatrist for distinguished scientific achievement and leadership in the field of psychiatry. Volkow was honored for her groundbreaking psychiatric research demonstrating drug addiction is a brain disease. She is flanked by Ondria Gleason, M.D., chair of the Department of Psychiatry at the University of Oklahoma School of Community Medicine, and Britta Ostermeyer, M.D., chair of the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center.

Panel Discusses the Role of Mobile Technology in Mental Health Care

As interest in digital technologies like smartphones and telemedicine continues to expand in psychiatry, psychiatrists should be aware of the promise and the pitfalls of this digital evolution. Read More >

Scopolamine May Offer Clues About Fast-Acting Antidepressants

Ketamine’s ability to relieve symptoms of treatment-resistant depression in a matter of hours has captured the attention of clinicians and patients alike. However, it’s not the only medication on the market capable of exerting rapid antidepressant effects. Read More >

Dual-Gait Testing May Predict Dementia Risk for Patients With MCI

Dual-task gait testing—walking while simultaneously performing a cognitive test—can identify patients with mild cognitive impairment (MCI) who are at heightened risk of progression to dementia, according to a study published this week in JAMA Neurology.

Manuel M. Montero-Odasso, M.D., Ph.D., of the University of Western Ontario and colleagues found that low performance in dual-gait testing was significantly linked to a two- to three-fold increased risk of dementia, independent of age, sex, education, comorbidities, and baseline cognition.

As part of the Gait and Brain Study—an ongoing prospective cohort study of community-dwelling older adults—the researchers assessed cognitive changes in 112 patients with MCI (mean age 76 years; 55 women). Data were collected from July 2007 to March 2016, and participants were followed up to six years with biannual visits.

Researchers used a neuropsychological test battery to assess cognition, and recorded gait velocity under single-task and three separate dual-task conditions. Dual-gait cost was defined as the percentage change between single- and dual-task gait velocities, using an electronic walkway. For the dual tests, participants moved at their usual pace on the walkway, while doing the following cognitive tasks aloud: 1) counting backwards from 100 by ones, 2) subtracting serial sevens from 100, and 3) naming animals. 

Of the 112 participants in the study, 27 (24%) progressed to dementia. Of those 27 participants, 23 progressed to Alzheimer’s disease (85%), two to Lewy body dementia (7%), one to frontotemporal dementia (4%), and one to vascular dementia (4%). Those who progressed to dementia had a significantly lower dual-task gait velocity and a higher dual-task gait cost in the three test conditions. High dual-task cost in gait velocity while counting backward and naming animals was associated with dementia progression. Single-task velocity was not associated with dementia progression.

The dual-task gait testing served as a kind of “brain stress test” to detect impending cognitive decline in patients with subclinical damage, according to the authors, because brain circuits shared by both cognition and motor-gait performance can be impacted by aging and neurogenerative mechanisms.

MCI is known to increase risk of dementia. However, almost one-third of individuals with MCI remain clinically stable after the initial diagnosis or even revert to normal cognitive functioning—making it difficult to accurately predict those most likely to develop dementia, including Alzheimer’s disease. 

“Dual-task gait testing is easy to administer and may be used by clinicians to decide further biomarker testing, preventive strategies, and follow-up planning in patients with MCI,” the authors wrote. 

For related information, see the Psychiatric News article “Neuropsychiatric Symptoms Implicated in Conversion From MCI to Dementia.”

(Image: iStock/AzmanJaka)

GAO Report Raises Questions About Mental Health of Discharged U.S. Servicemembers

More than 60% of U.S. servicemembers separated for misconduct from fiscal years 2011 through 2015 were diagnosed with mental illness or substance use disorders within two years before their separation, according to a report released yesterday by the Government Accountability Office (GAO).

GAO's analysis of Department of Defense (DOD) data found that of the 57,141 servicemembers separated for misconduct between 2011 and 2015, 16% (9,142) had been diagnosed with posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI), and 23% (13,283) received an “other than honorable” characterization for their service, leaving them “potentially ineligible” for health benefits from the Department of Veterans Affairs (VA), the analysis said.

“As a result of policy inconsistencies and limited monitoring, DOD has little assurance that certain servicemembers diagnosed with PTSD or TBI receive the required screening and counseling prior to being separated for misconduct and that all servicemembers, including officers, have been trained on how to identify symptoms of mild TBI in the deployed setting,” the report stated.

To ensure PTSD and TBI are appropriately considered prior to separating servicemembers from the military for misconduct, GAO recommended the Secretary of Defense take several actions, including directing the Air Force and Navy to address inconsistencies with DOD policy related to PTSD and TBI screening; training servicemembers, including officers, on how to identify mild TBI in the deployed setting; and ensuring that the military services monitor adherence to their screening, training, and counseling policies.

“PTSD and TBI can be difficult entities to diagnose because they are based on self-report and history,” said psychiatrist Elspeth Cameron Ritchie, M.D., M.P.H., a retired Army colonel, in response to the analysis. As psychiatry consultant to the Army Surgeon General from 2004 through 2008, she helped developed policies regarding PTSD and TBI. “Sorting through whether misconduct is actually related to PTSD and TBI can be challenging.”

For related information, see the Psychiatric Services article “Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System.”

(Image: iStock/MTMCOINS)

Depression in Early Adolescence May Alter Normal Brain Development

The brains of youth experiencing elevated depressive symptoms early in adolescence appear to develop differently from those experiencing depression in late adolescence, reports a study in the Journal of the American Academy of Child and Adolescent Psychiatry. Specifically, the MRI study found that cortical surface area was lower in youth with early depressive symptoms compared with those in the other groups.

“Our findings suggest that early adolescence is a particularly sensitive period for depressive symptoms to affect cortical surface area development and may provide a critical window for treatment of (subthreshold) depressive symptoms,” Lianne Schmaal, Ph.D., and colleagues wrote.

The study is part of the Orygen Adolescent Development Study, which is being conducted by Orygen, the National Centre of Excellence in Youth Mental Health based in Melbourne, Australia.

Cortical surface area is known to expand during adolescence, remain relatively stable in adulthood, and decrease with older age. The researchers collected structural MRI data from 149 adolescents from age 12 through 19. At each MRI visit, participants were asked about depressive symptoms, using the Center for Epidemiologic Studies Depression Scale (CES-D).

Three depressive symptom trajectories were identified among the participants: “low-stable” (n=97), a group with stable low levels of depression throughout the trial; “early-decreasing” (n=33), a group with moderate initial depressive symptoms that declined over time; and “late-increasing” (n=19), a group with increasing symptoms at each follow-up.

Females with early-decreasing symptoms showed lower anterior cingulate cortex (ACC) and orbitofrontal cortex (OFC) surface area compared with females with stable low levels of depression and with increasing symptoms across adolescence. Males with low stable and late increasing symptoms showed an increase of right OFC surface area, whereas males with early decreasing symptoms showed no such surface area expansion over time. 

The authors noted that because the trial did not include data beyond age 19, there is no way to know “whether the observed lower ACC and OFC surface area findings represent a delay in maturation, i.e., catching up when transitioning into adulthood, or whether these lower surface areas persist into adulthood.” Still, they added, “These findings may indicate that the experience of depressive symptoms early in adolescence, a critical period for surface area expansion, interrupts normal brain maturation of surface area.”

For related information, see the Psychiatric News article “Researchers Develop Composite Image of Brains of Youth With MDD.”

(Image: iStock/Hirkophoto)

NY State Initiative Helps Patients Move Toward Recovery With Less Intensive Services

A New York state initiative to identify and transition some patients in assertive community treatment (ACT) programs to less intensive services so that others in need of such care can access it appears to be working: even as median time spent in ACT fell and turnover rates accelerated over a six-year period, the outcomes of those transitioned remained stable.

Those are among the findings of a report appearing in Psychiatric Services. Journal Editor Lisa Dixon, M.D. (pictured left), a co-author of the report, told Psychiatric News that the findings show the ways that statewide data can be used to influence care.

“ACT should be seen as one treatment in the care continuum, a step on the road to recovery,” she said. A vast literature since the 1980s has shown ACT to be effective in the care of individuals with serious mental illness. Originally, Dixon explained, it was believed that ACT needed to be sustained indefinitely; otherwise, patients would relapse. But, more recent evidence indicates that a subgroup of patients can successfully transition to less intensive care.

The New York State Office of Mental Health (NYSOMH) first implemented ACT statewide in the early 1990s. By 2008, 79 ACT teams were operating, with the capacity to serve about 5,000 people. By 2014, the ACT system had grown to 82 teams to meet the needs of approximately 5,200 people. During this period, as the waiting list grew, the state began to focus on transitioning participants through ACT so that additional patients could receive this service.

Strategies were developed to shift the ACT model from one in which patients would receive ACT care indefinitely to a model that routinely promotes participant transition to less intensive services. These included the development of an ACT Transition Readiness Scale (TRS) to monitor participants’ readiness for the transition from ACT, a learning collaborative focused on transition practices, and a biannual report for monitoring the flow of participants through ACT.

Between 2008 and 2014 the median time spent by individuals in the ACT program dropped by one year, from 44.4 months to 32.4 months. The percentage of participants who met ACT treatment objectives and transitioned from ACT rose from 13% in 2008 to 25% in 2014.

In addition, the percentage of Medicaid-eligible individuals with an ambulatory follow-up within 90 days of leaving ACT increased from 50% in 2008 to 61% in 2014, whereas the percentage with a psychiatric hospitalization within 90 days of disengagement from ACT decreased from 14% to 13%.

Dixon said that the effort is designed to allow ACT teams to use aggregated state-level data to inform decisions about individual patients. “Data are used as ‘touch points’ for looking at individual ACT participants,” she said. “This prompts a review of clinical opportunities to refocus the ACT team to recovery-oriented practices and to problem solve around barriers to transition to less intensive services.”

For related information, see the Psychiatric News article “What Role Can Technology Play in Assertive Community Treatment?”