CMS Releases Proposed 2019 Medicare Fee Schedule, Collapses Some E/M Codes Into Single Rate

The Centers for Medicare and Medicaid Services (CMS) has released the proposed 2019 Physician Fee Schedule, including proposals to reduce documentation burdens associated with evaluation and management (E/M) services and to substitute a single “flat rate” payment for some E/M services. The proposed changes apply only to those E/M codes billed in an office setting for new and established patients (99202-99205 and 99212-99215).

The proposed changes to documentation requirements would allow physicians to choose between documenting on the basis of current guidelines for a level 2 service, documenting by time only, or documenting by medical decision making only. This would simplify documentation for billing purposes.

The proposed single flat rate would take the place of the different levels of complexity (2 through 5) currently reportable by clinicians. That means physicians would be paid the same rate for E/M services regardless of the complexity of the work a patient requires.

Overall, psychiatry would see a small increase in payment for E/M services if the proposed flat rate is made final, according to an estimate by the AMA. However, certain subspecialists and physicians who treat more complex patients would likely see a decrease in overall payment. For example, payments to addiction medicine physicians and geriatric psychiatrists for E/M services are estimated to drop by 2 and 3 percent, respectively. Rates may or may not be offset by payments for other billed services.

APA staff are analyzing the proposal and are working with member experts as well as other physician specialty and subspecialty groups in crafting a response.

“We are pleased to see the administration is taking steps to ease the administrative burdens facing physicians in their daily practice,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We are carefully analyzing the administration’s proposed fee schedule and especially the proposal for a single, flat-rate for office-based E/M services. Based on that analysis, we will send our comments to the administration and work with our affiliate organizations to secure appropriate payment for all psychiatrists and ensure access to care for all patients.”

The deadline to submit comments on the proposed rule is Monday, September 10. 

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Midlife Orthostatic Hypotension May Increase Risk of Dementia, Stroke

People with orthostatic hypotension (an excessive drop in blood pressure when standing up that can lead to dizziness and fainting) in midlife may be more likely than those without the condition to develop stroke and dementia later in life, according to a study in Neurology.

“The presence of orthostasis, especially in midlife, might identify individuals in whom more careful monitoring or risk factor management might be warranted,” wrote lead author Andreea Rawlings, Ph.D., of the Johns Hopkins Bloomberg School of Public Health and colleagues.

These findings come from an analysis of data from 11,709 participants without a history of heart disease or stroke who participated in the Atherosclerosis Risk in Communities study. At baseline, 552 (4.7%) of these participants had orthostatic hypotension, defined as at least a 20 mm Hg drop in systolic blood pressure or 10 mm Hg drop in diastolic blood pressure upon transitioning from lying down to standing up.

During an average follow-up of 24 years, 1,068 of the total participants developed dementia and 842 had an ischemic stroke. Compared with people without orthostatic hypotension, those with orthostatic hypotension were about 1.54 times more likely to develop dementia, and 2.08 times more likely to have a stroke. Since strokes are themselves dementia risk factors, Rawlings and colleagues did a second analysis that excluded 145 participants who developed a dementia after having a stroke. Even after this exclusion, orthostatic hypotension was associated with 1.45 times the risk of dementia.

Further analysis also found that people with both orthostatic hypotension and high blood pressure or diabetes at baseline had even greater risks of dementia than those with orthostatic hypotension alone.

“For dementia, our finding that OH [orthostatic hypotension] may be particularly detrimental in persons with hypertension and diabetes mellitus adds support to the idea that OH operates primarily via vascular processes, perhaps through microinfarcts or other manifestations of small vessel disease,” Rawlings and colleagues wrote.

For related information, see the American Journal of Psychiatry article “Modifiable Predictors of Dementia in Mild Cognitive Impairment: A Systematic Review and Meta-Analysis.”

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Maternal Prenatal Depression, Anxiety Affects Child Development, Particularly in Poorer Families

Children of mothers who experienced depression and/or anxiety during pregnancy are more likely to have behavioral difficulties throughout childhood, according to a meta-analysis in the Journal of the American Academy of Child and Adolescent Psychiatry. The association between prenatal depression and the children’s behavioral problems was found to be higher in economically disadvantaged families.

“Preventive interventions in pregnancy may be particularly appropriate for mothers presenting with depression and/or those burdened by demographic risk,” wrote Sheri Madigan, Ph.D., of the University of Calgary and colleagues.

Madigan and colleagues searched the English-language literature for studies in which maternal depression and/or anxiety was measured during pregnancy and offspring outcomes were collected prior to the age of 18 years. For the purposes of the analysis, child socio-emotional development was defined to include social and emotional competence (such as understanding and selecting appropriate social or emotional responses), temperament (including fussiness or negative affectivity), behavioral problems, and crying or colic. The researchers analyzed 73 studies.

They found that for mothers experiencing prenatal depression and anxiety, the odds of having children with behavioral difficulties were almost 1.5 to 2 times greater than those not experiencing prenatal depression or anxiety. Additional analysis revealed that children born to mothers with prenatal depression had a higher risk of behavioral problems than those born to mothers with prenatal anxiety (odds ratio 1.79 and 1.50, respectively).

“This research adds support to the increasing body of literature suggesting that prenatal depression and anxiety are potential fetal programming factors, affecting biological, cognitive, and behavioural development in offspring,” the authors wrote.

For related information, see the Psychiatric News article “Maternal Mental Health: Moving Mental Health Care Upstream” and the American Journal of Psychiatry article “Fetal Origins of Mental Health: The Developmental Origins of Health and Disease Hypothesis.”

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Escitalopram May Improve Long-Term Outcomes After Heart Attack

Treating patients who have depression following a recent heart attack or unstable angina with escitalopram may reduce their risk of future cardiac events, according to a study published this week in JAMA.

The findings come from a long-term follow-up study of 300 patients who were diagnosed with depression two to 12 weeks after acute coronary syndrome (ACS), which includes heart attacks and unstable angina. The study participants had received 24 weeks of escitalopram (flexibly dosed from 5 mg/day to 20 mg/day) or placebo. As was previously reported, 24 weeks of escitalopram was found to be superior to placebo at reducing depressive symptoms in these patients.

During the eight-year follow-up of these patients, 61 (40.9%) in the escitalopram group and 81 (53.6%) in the placebo group experienced a major cardiac event, which was a statistically significant difference. The difference remained significant after the researchers excluded eight patients (five in the escitalopram group and three in the placebo group) who reported taking antidepressants for at least one year after ACS.

When looking at individual cardiac events, the researchers also found a significant difference in heart attack incidence between the groups: 8.7% of patients in the escitalopram group had a heart attack compared with 15.2% in the placebo group. There were no significant differences in mortality between the groups, nor was there a difference in the occurrence of percutaneous coronary interventions (a procedure to open narrow arteries).

“[E]scitalopram may have modifying effects on disease prognosis in ACS-associated depressive disorder through reduction of depressive symptoms,” wrote Jae Min-Kim, M.D., Ph.D., of Chonnam National University Medical School in Korea and colleagues. “In addition, escitalopram may positively affect common mediators of ACS and depression including brain-derived neurotrophic factor and proinflammatory cytokines and may normalize autonomic and platelet dysfunction, which have adverse effects on cardiac outcomes.”

To read more on this topic, see the Psychiatric News PsychoPharm article “Which Antidepressant Is Best for Patients With Coronary Artery Disease, Depression?” by Peter Shapiro, M.D.

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APA Awarded $7.1M for Fellowship Aimed at Improving Mental Health Care for Underserved Populations

APA has been awarded a five-year, $7.1 million grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to expand the reach of APA’s Minority Fellowship Program. The amount of the grant is almost double that of the grant awarded to APA to support the fellowships in the previous five-year cycle.

SAMHSA’s Minority Fellowship Program (MFP) grants support organizations committed to achieving the following goals: (1) reduce health disparities and improve behavioral health care outcomes for underserved populations and (2) encourage more racial and ethnic minorities to join the behavioral health workforce. While racial and ethnic minorities make up more than 28% of the nation’s population, less than 20% of America’s mental health workforce consists of members of racial or ethnic minorities, according to SAMHSA.

MFP fellows must be a racial/ethnic minority or have an interest in reducing mental health disparities. Each fellowship is for one to two years, and each fellow is awarded $25,000 for a research project in addressing mental health disparities.

The grant will allow APA to expand and deploy robust programs that enable SAMHSA to continue its MFP mission and help APA with its goal of ensuring mental health equity for all. Leveraging APA technology and resources, MFP fellows will be provided individualized support for their projects on mental health disparities as well as mentorship from fellow MFP recipients, MFP alumni, and APA leaders.

“Addressing racial disparities in health care is a core part of the APA strategic plan and a specific focus in my presidential term,” said APA President Altha Stewart, M.D. “The increased funding will allow us to expand the work of the fellows and support training that will impact the ability of all our members to provide culturally appropriate care and improve outcomes for all patients, especially those in minority and underserved communities. The fact that SAMHSA nearly doubled the annual funding shows the importance and value of this effort, and we look forward to this APA program supporting our work to achieve mental health equity.”

Since 1974, APA has supported more than 500 MFP fellows, many of whom continue to support underserved communities and remain leaders in the field of psychiatry. To find out more about the program, click here.

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APA Joins in Urging House, Senate to Investigate Treatment of Immigrant Children

APA and 13 other medical organizations today called on members of the House and Senate oversight committees to hold hearings as soon as possible with officials of the Department of Homeland Security (DHS) and Department of Health and Human Services (HHS) regarding the treatment of immigrant children forcibly separated from their parents at the U.S. border.

In letters addressed to key committee members in the House and Senate, the groups reaffirmed their strong opposition to the separation of migrant children from their parents and prolonged detention of families. “Studies of detained immigrants have shown that children and parents may suffer negative physical and emotional symptoms from detention, including anxiety, depression, and posttraumatic stress disorder,” they wrote.

“Most recently,” they continued, “two physicians within DHS’s Office of Civil Rights and Civil Liberties, an office that has investigated DHS-run facilities and found serious compliance issues resulting in harm to children, stated in a letter to Congress that there is no amount of programming that can ameliorate the harms created by the very act of confining children to detention centers. The troubling observations described in the doctors’ report show possible medical neglect and child endangerment and merit congressional inquiry and oversight.”

The Trump administration is scrambling to return about 3,000 separated children to their parents by a July 26 deadline imposed by a federal judge, but it is not yet known whether that deadline will be met. HHS returned only about half of the approximately 100 separated children under the age of 5 by a July 10 deadline.

“We know that separating children from their parent causes undue harm and stress, which can have lifelong health and mental health consequences,” said APA President Altha Stewart, M.D., in a statement released by APA today. “We call upon Congress to step in and fully examine this harmful practice so that it doesn’t occur again and that the children who remain in custody are returned to their parents and receive the care they need.”

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How can you help?

APA has partnered with Lutheran Family Services and Catholic Charities to facilitate psychiatric help for the parents and children who have been separated in recent months while attempting to enter the United States at the Southwest border. APA has written a blog post detailing how psychiatrists can get involved to help these families.

Psychiatrists may also register with the Physicians for Human Rights and sign up for its Asylum Network to be connected with advocacy organizations that are looking for evaluators. Mental health professionals can also volunteer by submitting their names to Stand With Immigrants.

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Low-Dose Ketamine Offers Effective Alternative to Opioids in Treatment of Acute Pain, Meta-Analysis Suggests

Low-dose intravenous ketamine (≤0.5 mg/kg) is as effective as opioids at reducing acute pain in adults who present to an emergency department (ED), suggests a meta-analysis published in the journal Academic Emergency Medicine.

“For patients with opioid use disorders or substance use disorders that require a potent analgesic in the ED such as a narcotic, ketamine may be a favorable option compared to an opioid,” wrote Nicholas Karlow, M.P.H.S., of the Washington University School of Medicine and colleagues.

According to the authors, acute pain is one of the most common causes of ED presentations, with up to 78% of visits including pain as a presenting complaint. While previous reviews have examined the effects of low-dose ketamine on acute pain in an emergency setting, the inclusion of trials where ketamine was administered with other analgesics or ketamine was administered for sedation have made it difficult to draw conclusions about the independent effect of ketamine on acute pain control, Karlow and colleagues wrote.

For the current meta-analysis, the authors included only randomized, controlled trials that compared the analgesic effect of I.V. low-dose ketamine with I.V. opioids in patients 18 and older presenting to an ED with acute pain; their final pooled sample included three trials and 261 patients. The researchers compared the difference in pain scores after the administration of ketamine or an opioid from baseline to within 60 minutes of the intervention. (I.V. opioids were converted to morphine equivalent dosing for analysis.) They found no statistical difference in pain scale reduction between morphine and ketamine.

“While alternative analgesics such as ketamine continue to grow in popularity, the purpose of this article is not to argue that ketamine should replace opioids in the ED,” Karlow and colleagues wrote. “In fact, there is most definitely a role for opioids in the treatment of pain in the ED. However, we do believe that it is important to establish that alternatives such as ketamine are comparable to opioids so that if a clinician decides to order it instead, they can be confident that the patient obtains appropriate analgesia in a comparable time frame. We feel this is important as physicians continue to face pressure to reduce their opioid use.”

For related information, see the Focus article “Ketamine: A Review for Clinicians.”

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APA Joins With Research!America to Offer Scientists Grants to Engage Candidates During Midterm Elections

Calling all student science policy groups: APA is supporting an initiative by Research!America and the National Science Policy Network to offer grants to scientists who can increase engagement between scientists and candidates in the upcoming midterm elections.

The idea behind the Bipartisan Candidate Engagement Initiative is for science graduate students and trainees to find ways to elevate the importance of scientific research, innovation, and public health—including mental health—in the national conversation among candidates during the midterm elections. According to the results of a survey commissioned by Research!America and released earlier this year, some 80% of American adults believe candidates running for Congress should have a basic understanding of scientific issues, and 68% believe candidates should have a science advisor.

APA is one of the donors to the initiative, which is part of the National Science Policy Network’s microgrant program. The initiative will support innovative, collaborative proposals that engage a diverse group of young scientists for activities such as lab tours, roundtable discussions with candidates, community science events, social media engagement, media outreach, and webinars.

Science policy groups managed by graduate students and postdocs are eligible to apply; awards range from $1,000 to $3,000, with the potential for up to $5,000 for high-impact proposals. Proposals are due by August 10; click here for an application.

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Reducing EMR Default Settings for Opioids Prescribed After Surgery May Help Address Opioid Epidemic

Lowering the default number of opioid pills prescribed through an electronic medical record system to patients undergoing outpatient operations can significantly reduce the mean amount of opioid analgesia prescriptions, reports a study published today in JAMA Surgery. The findings point to a low-cost and potentially scalable intervention to continue to decrease the overprescribing of opioids.

On May 18, 2017, the Yale New Haven Health System, which uses a unified electronic medical record (EMR) system, lowered the default number of pills on all electronic opioid prescriptions from 30 to 12. To evaluate the impact of this change on the amount of opioid prescribed to patients, Alexander S. Chiu, M.D., of Yale School of Medicine and colleagues compared postprocedural prescribing patterns during the three months before the default change with the three months after the default change. The study specifically focused on opioid prescribing to patients aged 18 and older undergoing the 10 most common outpatient operations.

Overall, the median number of opioid pills prescribed per operation decreased from 30 before the default was changed to 20 afterward. “When evaluating the association over our entire hospital system, the decrease in the amount of opioid prescribed during three months was the equivalent of almost 25,000 fewer pills of 5 mg of oxycodone distributed,” Chiu and colleagues wrote.

To address concerns that reducing default opioid prescriptions might have negatively impacted patients with pain, the authors examined whether additional opioid prescriptions were written for pain-related reasons within 30 days of the operation. There was no statistical difference in opioid refill rates before and after the default change.

“The success of this intervention is a prime example of a ‘nudge,’ a concept in behavioral sciences that describes an intervention that ‘alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives,’ ” David D. Q. Zhang, M.D., C.M., and colleagues of University of Toronto wrote in an accompanying editorial.

“The usual ‘default’ postoperative prescription of 30 pills is in most circumstances excessive. Because appropriate disposal of unused opioids is uncommon, excess prescribing creates the potential for drug diversion and misuse,” they continued. “Although Chiu et al. do not evaluate if the change in physician prescribing practice was sustained, given the simplicity of the intervention and rapid change in practice, the potential of nudges to improve opioid prescribing needs to be harnessed.”

For information on ways to address opioid use disorder, see the Psychiatric News article “Group of Six Releases Principles for Addressing Opioid Crisis.”

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Study Finds 60% of Privately Insured Youth With PTSD Receive Psychotherapy

Although the majority of privately insured youth diagnosed with a new episode of posttraumatic stress disorder (PTSD) receive psychotherapy—considered the first-line treatment for pediatric PTSD—treatment gaps remain, according to a report in Psychiatric Services.

The report found while about 6% of youth with PTSD were prescribed pharmacotherapy, more than a third received neither psychotherapy nor psychopharmacology.

Rene Soria-Saucedo, M.D., Ph.D., of the Boston University School of Public Health and colleagues analyzed data from the MarketScan Commercial Claims and Encounter database for children and adolescents aged 6 to 18 who received a new diagnosis of PTSD in 2012. A total of 7,726 youth were included in the analysis.

Overall, 59% of youth received psychotherapy alone, 2.7% received combination treatment (psychotherapy and pharmacology), and 5.9% received pharmacotherapy. Of the youth prescribed medications for PTSD, most (71.3%) received antidepressants, followed by antipsychotics (21.6%) and benzodiazepines (7.1%). Youth who received pharmacotherapy were more likely to be older, to be female, to have been previously hospitalized, and to have a larger number of comorbidities.

“There is a strong and consistent empirical support for the safety and effectiveness of psychotherapy, particularly TF-CBT [trauma-focused cognitive-behavioral therapy], for PTSD,” Soria-Saucedo and colleagues wrote. “Further research is needed to understand the rationale behind the prescription of pharmacotherapy for PTSD among children and develop initiatives to expand psychotherapy access, especially in the primary care setting,” the researchers wrote.

For related information, see the Psychiatric News article “SAMHSA Child Mental Health Event Promotes Trauma-Informed Approach.”

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Report Reveals Patterns of Potentially Unsafe Use of Zolpidem

Despite FDA recommendations that the hypnotic zolpidem be used for short-term treatment of insomnia, most patients report sustained use, according to a report published today in JAMA Internal Medicine. The report also found evidence that women may be taking zolpidem above the recommended dose.

In 2013 the FDA recommended that manufacturers of some zolpidem products update their medication labels to lower the recommended initial dose of the medication for women after evidence at the time suggested that women eliminate zolpidem more slowly from their bodies than men. The FDA informed manufacturers that the recommended dose of zolpidem for women should be lowered from 10 mg to 5 mg for immediate-release products (Ambien, Edluar, and Zolpimist) and from 12.5 mg to 6.25 mg for extended-release products (Ambien CR); the FDA recommended that health care professionals also consider prescribing the lower doses for men, according to the 2013 safety announcement.

“These precautions were intended to reduce the risks of next-day impairment, abnormal behavioral changes, and dependency,” study authors Thomas J. Moore, A.B., of the Institute for Safe Medication Practices and Donald R. Mattison, M.D., M.S., of Risk Sciences International in Ottawa, Canada, explained in the JAMA Internal Medicine report. Moore and Mattison used the U.S. Medical Expenditure Panel Survey for 2015 to examine how patterns of reported use compared with the FDA recommendations.

Overall, 3.8 million adults aged 18 to 85 years reported filling one or more prescriptions for zolpidem in 2015. Women were nearly twice as likely as men to report taking zolpidem, they noted. Additional analysis revealed that 68% of women were taking 10 mg immediate release or 12.5 mg extended-release products—above the recommended initial dose of 5 mg and 6.25 mg, respectively. More than 68% of those exposed to zolpidem reported sustained use (defined as three or more prescriptions or use over 61 days or more); the sustained-use zolpidem group reported a median of 192 days’ supply.

“Although efficacy declines substantially after 14 days of continuous administration, most zolpidem patients reported sustained use, with increased risk of dependence, given that zolpidem is a class IV-controlled substance,” the authors wrote.

For more on hypnotics, see the Psychiatric News article “Study Finds Rising Long-Term Use of Hypnotics.”

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Avatar-Guided Virtual Reality Therapy Found to Reduce Fear of Heights

A brief psychological therapy using virtual reality (VR) can help people overcome their fear of heights, reports a randomized, clinical study published this week in The Lancet Psychiatry. The VR therapy used a digital avatar as the coach; there was no human therapist involved.

“Immersive virtual reality therapies that do not need a therapist have the potential to dramatically increase access to psychological interventions,” said lead author Daniel Freeman, Ph.D., of the University of Oxford in a press release. “We need a greater number of skilled therapists, not fewer, but to meet the large demand for mental health treatment, we also require powerful technological solutions.”

For this study, 100 people with clinically diagnosed fear of heights, or acrophobia, using DSM-5 criteria were divided into two groups: one participated in the VR coaching program; the other received no treatment. All participants scored higher than 29 on the Heights Interpretation Questionnaire (HIQ), which the researchers considered as the threshold indicating a moderate fear of heights.

The VR therapy involved six 30-minute sessions over two weeks. In the first session, the virtual coach provided background information about acrophobia and how to treat it from a cognitive perspective to develop memories of safety that counteract fear associations.

The remaining sessions had the participants tour a virtual 10-story office complex and take part in activities to break down their fears while the coach provided empathic encouragement, repeated key learning points, and sought feedback on whether the participant felt safer than before. As the program progressed, the activities became more challenging, starting with simple tasks like watching a safety barrier gradually lower over the edge of a drop and then moving on to more difficult tasks like walking out on a high platform.

At the end of the study, the VR participants had an average reduction of 24.5 points on their HIQ scores compared with a 1.2-point reduction among the controls. At the two-week follow-up, 34 of the 49 VR participants had HIQ scores of 29 or lower. No adverse side effects were reported, and 44 of the 49 participants completed all six sessions.

To read more about VR, see the Psychiatric News article “Virtual Reality May Soon Become Clinical Reality in Psychosis Care.”

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APA Awarded $14.2 Million Grant to Improve Treatment for Serious Mental Illness

APA has been awarded a five-year, $14.2 million grant to create an educational and support system to expand access to care for the 11 million adults in this country who have serious mental illness.

The funding for the project, known as the Clinical Support System for Serious Mental Illness (CSS-SMI), was awarded by the Substance Abuse and Mental Health Services Administration. Serious mental illnesses are those that substantially interfere with major life activities and include schizophrenia, bipolar disorder, and major depressive disorder. At least one-third of people with these diagnoses do not receive treatment.

“This grant will allow APA to take a leading role in addressing serious mental illness in this country,” said APA President Altha Stewart, M.D., in a statement. “The CSS-SMI project will help us disseminate best practices for treating people who have serious mental illness and increase their access to care. I am excited to see the project unfold over the next five years.”

The project will offer expert consultation services and learning opportunities nationwide to enable clinicians—such as physicians, nurses, recovery specialists, peer-to-peer specialists, and others—to provide evidence-based care using state-of-the-art technology to treat or assist people with serious mental illness. Components include sophisticated internet- and app-based technologies to promote best practices in caring for these individuals, including the use of APA’s PsychPRO mental health registry.

In addition to APA, 29 partner organizations and individuals will provide expertise on clinical content, educational resources, and strategic guidance. Partners include the Academy of Consultation-Liaison Psychiatry, American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, and the American Association of Community Psychiatrists.

Detailed information will appear in a future issue of Psychiatric News.

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Highlights From APA’s 2018 Annual Meeting: Issue #3

As ECT Marks 80th Birthday, Experts Reflect on Its Future
Researchers are using neuroimaging to determine additional ways to make this proven treatment for treatment-resistant depression even safer and more effective.

Read More >


Assembly Seeks Help for Members Appealing Insurance Denials
At its meeting in May, the APA Assembly took action on a number of issues important to the Association, the field of psychiatry, and its patients. Among them was a proposal to help members appeal denied insurance claims.

Read More >


Equine Therapy Helps Patients Overcome Range of Psychiatric Disorders
In this millennia-old practice, equine-assisted therapy promotes patients’ physical, occupational, and emotional growth.

Read More >


Identities Should Be Additive, Not ‘Either/Or,’ Say Speakers
Self-reflections shared by three speakers highlight how women of color face unique discrimination and biases.

Read More >


Taking Some Antipsychotics During Pregnancy May Raise Risk of Gestational Diabetes
Women who continue use of the antipsychotic drugs olanzapine and quetiapine during pregnancy have an increased risk of gestational diabetes, according to a study in AJP in Advance that was released at the APA Annual Meeting.

Read More >

ED-Administered Safety Planning Intervention Reduces Suicidal Behaviors

A brief clinical intervention in the emergency department (ED) along with structured follow-up phone calls can reduce suicidal behaviors in patients and  encourage them to use mental health services, according to a study published today in JAMA Psychiatry.

Barbara Stanley, Ph.D., of Columbia University and colleagues enrolled 1,640 adults who had been admitted to one of nine Veterans Administration EDs who had had a suicidal crisis (but who did not subsequently require inpatient hospitalization) between 2010 and 2015. Four of the EDs continued to provide their usual care for the patients, while the other five implemented a safety-planning intervention combined with telephone follow-up. 

Safety planning provides patients with a written safety plan that includes coping skills, strategies to make their environment safer, and a list of people who can provide support. The telephone follow-up consisted of at least two postdischarge contacts with a patient to monitor suicide risk, review the safety plan, and encourage continued treatment.

Six months after ED discharge, fewer patients in the safety planning group engaged in suicidal behavior compared with the usual care group (3.03% vs. 5.29%, respectively). Recipients receiving the safety-plan intervention and follow-up also had more than double the odds of attending at least one outpatient mental health visit after discharge. 

The increased visits with outpatient mental health services were not solely responsible for the reduced suicidal behaviors, the authors noted; other components of the safety-planning intervention were also contributing to patient improvements.

“Our findings are promising and indicate that safety planning and active outreach—a set of low-burden strategies—are useful components of effective suicide prevention,” Stanley and colleagues wrote. “Importantly, using the low-burden intervention in this project and others was associated with about the same reduction in suicidal behavior as more intensive and costly psychosocial interventions. If implemented broadly, [this intervention] has the potential to reduce suicidal behavior and enhance behavioral health treatment engagement, particularly during high-risk periods following ED discharge.”

To read more on this topic, see the Psychiatric News article “Emergency Department Intervention May Reduce Suicide Attempts in At-Risk Patients.” 

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Opioid Prescribing for Teens Exceeded CDC 2016 Guidelines for Adults

Between 2005 and 2016, opioid prescriptions for adolescents generally were written for longer than three days, and the number of prescriptions filled for four and five day supplies increased, according to a report in Psychiatric Services in Advance.

These trends occurred prior to the issuance of guidelines for opioid prescribing by the Centers for Disease Control and Prevention (CDC) in 2016 but during a period of increasing national awareness of the opioid epidemic, according to lead author Mir M. Ali, Ph.D., of the Center for Behavioral Health Statistics and Quality at the Substance Abuse and Mental Health Services Administration and colleagues. The CDC did not provide explicit opioid-prescribing guidance for individuals under age 18 in 2016 but did recommend that opioids be prescribed even more cautiously for adolescents than for adults.

Ali and colleagues measured the number of days for which opioids were prescribed for adolescents aged 12 to 17 covered by Medicaid or commercial insurance by using the 2005-2016 IBM MarketScan commercial and Medicaid databases. They identified all oral prescriptions filled by adolescents for the most commonly prescribed opioids: hydrocodone, hydromorphone, oxycodone, codeine, methadone, tramadol, and morphine. They measured average days’ supply per prescription using the following categories: one, two or three, four or five, six or seven, eight to 15, 16 to 30, and greater than 30 days.

For adolescents with Medicaid insurance, a supply of two or three days was the most common prescription range until 2016, decreasing from 50.5% of prescriptions filled in 2005 to 36.7% in 2016. Over the same period, the percentage of prescriptions with a supply of four or five days increased from 30.2% to 37.7%; even in 2016, the percentage of prescriptions written for between four days and more than 30 days exceeded 50 percent. The pattern for adolescents with commercial insurance followed similar patterns for adolescents with Medicaid, according to the report.

The rate of prescriptions written for a one-day supply remained at 1.0% to 2.0% until 2016, when the CDC guidelines were issued. In that year, they increased to 3.6%, according to the report.

The latter trend is hopeful. “The uptick in one-day opioid prescriptions in 2016 … may indicate that some prescribers are increasingly trying to minimize prescribing to adolescents,” the researchers stated. “As states increasingly impose days’ supply restrictions for adolescents that are often more restrictive than those for adults and as those restrictions are strictly enforced, it is possible that the increasing trend of prescribing a supply of four or five days of opioids for adolescents might reverse.”

For related information, see the Psychiatric News article “Psychiatrists Can Play Vital Role in Stemming Opioid Crisis.”

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Rates of Routine Depression Screening on Rise but Still Low

Rates of routine depression screening among U.S. adults have increased since 2009 but remain low overall, reports a study published today in Psychiatric Services in Advance. In 2009, the U.S. Preventive Services Task Force (USPSTF) first recommended that routine depression screening be carried out in any clinical practice that has adequate depression care support in place.

The USPSTF is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. Its members are appointed by the director of the Agency for Healthcare Research and Quality, the lead federal agency charged with improving the safety and quality of the U.S. health care system.

Sandipan Bhattacharjee, Ph.D., of the University of Arizona and colleagues used data from the National Ambulatory Medical Care Survey to assess screening rates among adults 18 and older without a depression diagnosis who made an outpatient visit to a health care professional other than a psychiatrist. Of the 298,896 records of doctor visits between 2005 and 2015 that met the researchers’ criteria, 3,986 visits (1.4%) included a depression screening.

During the study period, screening rates fell from about 1.5 percent in 2005 to a low of .65 percent in 2008 and then steadily rose from 2009 to a high of 3 percent in 2015.

In addition to the 2009 USPSTF recommendation, Bhattacharjee and colleagues noted that the rise in screening rates could have been influenced by the Affordable Care Act of 2010, which mandated depression screening and other preventive care be offered at no cost. They also noted that their study period ended before USPSTF updated its recommendation in 2016 to reflect that routine depression screening should occur even in clinical practices without on-site mental health services. 

“This study observed that more time spent by the patient in the physician’s office led to higher screening rates,” wrote the researchers. “Since increasing the length of time of the actual visit to the physician may be difficult, it is recommended that other health care providers in these settings be trained to provide screening.”

To read more on this topic, see the Psychiatric News article “New Primary Care Guidelines Recommend Routine Screening for Depression in Adolescents.”

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Active Participation in Health Care Governance Said to Combat Physician Burnout

The loss of autonomy for physicians—as many have begun working in large health systems rather than as solo or small group practitioners—has been a key driver of physician burnout, according to the authors of a Viewpoint article in the July issue of JAMA Psychiatry.

While efforts to improve self-care have been moderately effective in addressing burnout, they fail to address its underlying cause—namely, the lack of physician autonomy in today’s large health care systems, write Frederick S. Southwick, M.D., a professor of medicine at the University of Florida College of Medicine, and Steven M. Southwick, M.D., the Glenn H. Greenberg Professor of Psychiatry at Yale University School of Medicine. In small group and solo practices, physicians were largely free to dictate how they practiced medicine, but large health care systems, by contrast, tend to be impersonal and controlling, leaving little room for physicians to decide what tests to perform, what treatments to administer, and how much time to spend with patients. 

Physicians often feel frustrated by today’s broad array of mandated regulations, required use of electronic health records, and performance expectations imposed by insurance companies, government agencies, and hospital administrators. These conditions leave many physicians feeling overwhelmed and relatively powerless. In animal and human studies, chronic stress that is experienced as uncontrollable can have highly toxic effects, the authors write. “The degree of control that an animal or human can exert over a stressor has a substantial impact on the emotional, behavioral, neurobiological, and physiological effects of that stressor.”

How can physicians take control of their work lives and prevent or reduce burnout and at the same time contribute to improvements in every process that affects patient care? The authors recommend that “health care organizations adopt a distributive leadership model that encourages physicians to actively participate in governing and improving the systems in which they work. Modern health care is highly complex and interdependent, and it is crucial to effective service provision that physicians share administrative and policy leadership positions with nonphysician health care administrators.” Also needed are “the allocation of sufficient administrative time, resources, training, and administrative support to empower physicians to lead the adaptive changes needed to fix health care delivery.” 

The authors conclude that high rates of burnout among physicians will persist until health care systems find ways to increase doctors’ sense of control and autonomy.

For related information, see APA’s Well-being and Burnout Resources, including an online well-being self-assessment tool.

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Prenatal Exposure to Folic Acid Appears to Promote Healthy Brain Development

Increased prenatal exposure to folic acid, which is known to reduce the risk of neural tube defects, may also promote healthy brain development through adolescence, reports a study published in JAMA Psychiatry. According to the study authors, prenatal exposure to folic acid may protect against psychosis through altered postnatal cortical development. 

Some studies suggest poor maternal nutrition during pregnancy increases subsequent risks for conditions like schizophrenia in offspring; other studies have suggested that prenatal exposure to folic acid may lower the risk of language delay and autism in children. In 1996, the U.S. government mandated that all food manufacturers fortify enriched grain products with folic acid by January 1, 1998. To examine whether prenatal exposure to folic acid is associated with changes in brain development later in life, Hamdi Eryilmaz, Ph.D., of Massachusetts General Hospital and colleagues compared cortical brain development in youth who were born before, during, and after the full implementation of folic acid fortification of U.S. grain products.

Eryilmaz and colleagues analyzed multiple sets of magnetic resonance imaging (MRI) scans taken when children and adolescents born from 1993 to 2001 were ages 8 to 18: one set consisted of normal brain images taken from 292 patients seen at Massachusetts General Hospital; another set included images from 861 participants in the Philadelphia Neurodevelopmental Cohort, a study that assessed psychiatric symptoms in the study participants; and a third included scans collected of youth in an NIH study, who were born prior to folic acid fortification. 

The researchers found that cortical thickness was greatest in youth born after the implementation of folic acid fortification, intermediate in those partially exposed to folic acid fortification, and lowest in those born before fortification. Data from the Philadelphia cohort suggested delayed cortical thinning in the group exposed to full folic acid fortification was associated with a reduced risk of psychosis symptoms. “Collectively, these data suggest an association of prenatal exposure to folic acid fortification with increased cortical thickness through early adolescence, accompanied by delayed onset of cortical thinning and reduced risk of psychosis,” the authors wrote.

“While our results link prenatal exposure to folic acid fortification with changes in cortical development and with a reduced risk of psychotic spectrum symptoms, they cannot directly link folic acid exposure to reduced schizophrenia risk, since the typical age of onset for that disorder is in the early 20s,” senior author Joshua Roffman, M.D., M.M.Sc., of Massachusetts General said in a press release. “But since such symptoms in youth are on the same continuum as schizophrenia, the results hold some promise for schizophrenia prevention.” 

For related news, see the American Journal of Psychiatry review article “Prenatal Primary Prevention of Mental Illness by Micronutrient Supplements in Pregnancy.”

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Retinal Nerve Fiber Thickness May Offer Clues to Predict Cognitive Decline

Identifying people at greatest risk for cognitive decline as early as possible is important for developing treatments that can prevent or slow dementia. A study in JAMA Neurology suggests assessing the thickness of the retinal nerve fiber layer (RNFL)—the inner most layer of the retina—may offer some clues about those at greatest risk of future cognitive decline.

Fang Ko, M.D., of the University College of London Institute of Ophthalmology and colleagues analyzed data from UK Biobank, a large epidemiological study of UK residents aged 40 to 69. As part of this study, between September 2009 and June 2010 67,321 people underwent optical coherence testing (OCT)—a noninvasive imaging tool that can produce 3-D cross-sectional images of the retina. Study participants received cognitive tests, which measured prospective memory, pairs matching, numeric and verbal reasoning, and reaction time, at the start of the study and again during 2012-2013. The researchers focused their analysis on 1,251 people with high-quality OCT scans, who had complete baseline and follow-up cognitive evaluations, reported no neurological or ocular disease, and did not have diabetes.

The researchers found that a thinner baseline RNFL measurement was associated with worse performance on baseline cognitive tests. Moreover, a thinner baseline RNFL was significantly associated with a future decline in a greater number of cognitive tests, even after controlling for potential confounders.

“Our study strengthens the argument of an association between neurodegenerative processes that affect the brain and the eye and indicates that ... measurement of the RNFL is a potential noninvasive, relatively low-cost, and time-efficient screening test for early cognitive changes,” Ko and colleagues wrote.

For related information, see the Psychiatric News article “Dual-Task Gait Testing Identifies MCI Patients Likely to Develop Dementia.”

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FDA Approves Aristada Initio to Allow Immediate Initiation of the Long-Acting Atypical Antipsychotic

Clinicians will soon be able to offer patients with schizophrenia who are initiating the long-acting injectable atypical antipsychotic Aristada (aripiprazole lauroxil) the option of an alternative to three weeks of oral aripiprazole supplementation following the first injection. The Food and Drug Administration (FDA) has approved Aristada Initio for the initiation of Aristada, manufacturer Alkermes announced today.

This approval now makes it possible for patients to receive Aristada Initio, in combination with a single 30 mg dose of oral aripiprazole, along with their first dose of Aristada (441 mg, 662 mg, or 882 mg monthly; 882 mg once every six weeks; and 1064 mg once every two months) in a single day.

“Previously, the standard initiation regimen for Aristada included 21 consecutive days of oral aripiprazole starting with the first Aristada dose,” according to a press release issued by Alkermes. “The Aristada Initio regimen provides patients with relevant levels of aripiprazole within four days of initiation.”

Aristada was first approved by the FDA in October 2015, with dosages for use every four to six weeks, and in June 2017, the agency approved a two-month dose of the medication.

“Long-acting injectable atypical antipsychotics have an increasingly recognized role in the treatment of schizophrenia. The ability to initiate Aristada on day one may be particularly useful in the hospital setting, where more than one-third of patients initiate on long-acting therapies,” Craig Hopkinson, M.D., chief medical officer and senior vice president of Medicines Development and Medical Affairs at Alkermes, said in the Alkermes release.

According to Alkermes, Aristada Initio is expected to be available later this month.

For related information, see the Psychiatric News PsychoPharm article “Clinicians Can Also Benefit From Using Long-Acting Formulations,” by John Kane, M.D.

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