Psychiatrists Can Do More to Help Patients Quit Smoking, Addiction Experts Say

Several medications are proven to help people stop smoking, but few patients with tobacco use disorder are being offered them, according to addiction experts at APA’s IPS: The Mental Health Services Conference in New York.

Despite the higher rates of smoking by people with mental illness compared with those without mental illness, only a quarter of facilities that treat patients with substance use disorders in the United States offer nicotine replacement therapy or medication treatment, and two-thirds allow tobacco use on their grounds, explained session chair Michael Brus, M.D., a clinical instructor of psychiatry at Icahn School of Medicine at Mount Sinai, during the session “The Deadliest Drug Epidemic: How Psychiatrists and the Media Miss the Boat on Tobacco Addiction, and What to Do About It.” Brus called for psychiatrists to do more to address tobacco use in this population.

To help patients successfully quit tobacco, Jill Williams, M.D., director of the Division of Addiction Psychiatry at the Rutgers University-Robert Wood Johnson Medical School, said psychiatrists should regularly ask patients about their tobacco use, and if they do use tobacco, advise patients on the risks of such use and refer them to treatment such as behavioral counseling.

Psychiatrists should also strongly consider prescribing smoking cessation medications, including varenicline, which is underused despite strong evidence of safety and efficacy.

Brus highlighted a 2016 study known as EAGLES that found varenicline to be superior to bupropion and the nicotine patch in helping smokers achieve abstinence (the study did not show a significant increase in adverse psychiatric events in patients taking varenicline compared with those with nicotine patch or placebo). Yet in the three years since that study, prescription rates of varenicline have ticked up only marginally, Brus said.

Williams highlighted another study that found that varenicline could promote smoking abstinence even in patients whose initial goal was only to reduce their smoking levels. “There’s also evidence that varenicline can lessen dependence and reduce withdrawal symptoms, so prescribing this medication can be a useful harm-reduction strategy even in people not looking to quit,” she said.

For psychiatrists who may still have concerns with varenicline, Brus and Williams pointed out that combination nicotine replacement (combining a long-acting patch with rapid-acting lozenges or gum) has been shown to be as effective as varenicline when combined with counseling. The current data are inconclusive about whether a combination of varenicline plus nicotine replacement therapy promotes better abstinence than either treatment alone. There is emerging evidence that varenicline plus bupropion may elevate quit rates, but more research is needed.

For related information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco” and the Psychiatric Services article “Low-Burden Strategies to Promote Smoking Cessation Treatment Among Patients With Serious Mental Illness.”

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Early Psychosis Treatment Succeeding but Challenges Remain for Sustainability

Early treatment of psychosis has moved out of the research arena into on-the-ground community practice, said Lisa Dixon, M.D., a professor of psychiatry at Columbia University and editor of the APA journal Psychiatric Services. She spoke yesterday at the “Early Psychosis Preconference” held in conjunction with APA’s IPS: The Mental Health Services Conference in New York.

There has been success reaching patients in need and improvements in the course of their illness and treatment outcomes, but achieving long-term sustainability is a challenge for early psychosis programs, requiring advocates to pay attention to public health policy, funding, and reimbursement. “In order to be successful, we must of course focus on patient care. But we need to do more,” Dixon said.

The preconference brought together some 350 mental health professionals involved in the identification and treatment of individuals with psychosis and included a rich variety of presenters.

Dixon presented an overview and evaluation of OnTrackNY, a program of the Center for Practice Innovations at Columbia University/New York State Psychiatric Institute and the New York State Office of Mental Health. Established in 2013, it now includes 23 sites in New York state and serves individuals aged 16 to 30 who have experienced nonaffective psychosis for less than two years.

OnTrackNY is one of the most well-established early psychosis programs in the United States, according to Dixon. Using a framework developed by health services researchers to evaluate program implementation known as RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), Dixon noted some of the lessons learned from the program to date:

Reach: OnTrackNY has served over 1,600 patients since 2013; the program has the capacity to care for 900 patients at a time. “While the growth of OnTrackNY has been remarkable, the actual need may be closer to 2,000 slots based on assumptions about the incidence of schizophrenia and nonaffective psychosis,” Dixon said.

Effectiveness: Rates of participation in treatment, data on rehospitalization, work and school status, and overall functioning are positive, but there is substantial variability across clinics. Also, more needs to be done to identify and help patients with poorer outcomes.

Adoption: The program has thrived in a diversity of sites and locations across the state, but the ability to serve individuals in rural areas remains a challenge.

Implementation: OnTrackNY developed training models to ensure “fidelity,” or the ability of clinics to abide by a model of treatment standardized across sites. Most teams within OnTrackNY have met that standard; the most common unmet domains are metabolic screening of patients and use of peer supports.

Maintenance: OnTrackNY has been fortunate in having the financial support of the state, but long-term funding remains a challenge. There is a need for a more systematic approach to discharge patients, step-down to less intensive services, and long-term follow-up.

“Progress in the implementation of early intervention programs for individuals experiencing early psychosis is palpable,” Dixon said. “The lessons learned inspire strategies for ongoing improvement.”

More coverage of the early psychosis conference and IPS will appear in future issues of Psychiatric News.

For related information, see the Psychiatric Services article “Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes.”

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Women’s Psychiatry Expert Discusses Importance of Addressing Patients’ Sexual Harassment

Asking patients about their history with sexual harassment and abuse should be a routine part of psychiatric care, said APA Past President Nada Stotland, M.D., during her presentation at this year’s IPS: The Mental Health Services Conference. The comments were part of a wide-ranging lecture about important social issues facing women psychiatrists today.

Stotland, who is an expert on reproductive psychiatry and women’s issues, told the audience that psychiatrists can play key roles in helping people deal with and recover from their experiences of sexual harassment and/or sexual abuse. While she noted that identifying a patient’s sexual harassment history is important, she emphasized that such questions must be asked with empathy and sensitivity. If a patient has had such an experience, the psychiatrist’s focus should be on helping the patient deal with her reactions to her experience, such as self-recrimination, shame, guilt, and/or rage. “We need to validate their reactions,” she said.

Stotland recommended that psychiatrists should primarily use psychotherapy during the early stages of therapy and prescribe medications to patients with severe, acute symptoms. Once a good rapport has been reached, medications can be given on a case-by-case basis.

Risk of sexual harassment is not limited to patients, and Stotland also provided some suggestions for women psychiatrists to help protect themselves.

“Before accepting any job, get as much information as possible about the power structure of the employer and its sexual harassment history,” she stressed. Stotland added that women should also be aware of what support services are available at the institution or in the surrounding area should any problems arise.

To read more about sexual harassment in psychiatry, see the Psychiatric News article “Sexual Harassment Still Occurs in Psychiatry, Says Women’s Caucus Leader” and the Psychiatric Services article “Gold Award: Integrated Psychiatric Treatment for Survivors of Intimate Partner Violence at the Bronx Family Justice Center.”

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Psychiatrist Describes Recent Trends in Drug Abuse and Medications to Treat Addiction

Both recent trends in illicit drug use in the United States and pharmacotherapies that clinicians can use to treat certain substance use disorders, such as opioid dependence, were the focus of a symposium at APA's Institute on Psychiatric Services in San Francisco, which ended Sunday. 

“For a while, until 2000, the United States was seeing a marked decrease in heroin use" that spanned a period of nearly 10 years, Petros Levounis, M.D., M.A. (shown in photo), chair of the Department of Psychiatry at Rutgers New Jersey Medical School, said at the session. “Then we had the explosion of prescription opioid use, which became an epidemic.” In an interview with Psychiatric News, Levounis said that because heroin has become less expensive, and sometimes easier to acquire, than prescription opiates, heroin has become the drug of choice for some addicts and accounts for the rapid spread of its use throughout the country in the last few years, along with more people showing up in emergency rooms suffering from heroin overdoses and needing addiction treatment.

Levounis explained that there are currently three FDA-approved pharmacotherapies to treat opiate dependence: methadone, buprenorphine, and naltrexone/naloxone. "There is no 'one-size fits-all' treatment… [and] efficacy of the treatments may vary from person to person," he said. Levounis noted in a later interview with Psychiatric News that there are no "new" medications in the drug-development pipeline to treat opioid addiction, but there are newer formulations of FDA-approved drugs, such as probuphine, which is an implantable, long-injection version of buprenorphine that helps patients adhere to their addiction-treatment regimen.

For more information about opioid dependence, see the Psychiatric News article "Caution Urged for Clinicians Who Prescribe Opioids." Levounis is co-author of The Addiction Casebook, available from American Psychiatric Publishing, which describes strategies for diagnosing and treating patients with various types of addictions.

Improve Your Treatment Skills for Military Patients

In observance of Veterans Day, APA is cosponsoring a webinar that will help APA members and other health care professionals provide more effective care to members of the military and veterans. The free webinar, "Military Culture Counts: Assisting Service Members and Veterans," will be held Monday, November 10, from noon to 1 p.m. The organizations partnering with APA are the Association of American Medical Colleges and Joining Forces, a public-private partnership created by First Lady Michelle Obama and Jill Biden, Ed.D. Register now.

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Addiction Specialist Sounds 'Wake-Up Call' to Psychiatrists About Smoking

Psychiatrists should be providing smoking cessation treatment to all tobacco users, said psychiatrist Jill Williams, M.D., at APA’s  2014 Institute on Psychiatric Services.

Williams, a professor of psychiatry and director of the Division of Addiction Psychiatry at the Robert Wood Johnson School of Medicine, told attendees that the broad public health success that has been achieved with regard to decreasing smoking in the general population has not been extended to those with mental illness—especially serious mental illness. “Smoking is the leading cause of death in people with mental illness or addiction,” she said, citing statistics showing that 50 percent of deaths among people with schizophrenia, bipolar disorder, and depression are attributable to smoking, and that persons with mental illness or addiction purchase and consume up to 44 percent of all cigarettes in the United States.

Moreover, tobacco use disorder is a diagnosable condition in DSM-5. Yet psychiatrists have largely not treated their patients for smoking for a variety of reasons—including a prevalent belief that quitting smoking may actually interfere with treatment of mental illness. But Williams presented evidence showing that smoking cessation has no negative impact on treatment and does not jeopardize recovery from addiction to other substances. And she cited her own 2012 study in the Journal of Clinical Psychiatry demonstrating the safety and efficacy of varenicline in patients with schizophrenia and schizoaffective disorder.

“We as psychiatrists should provide treatment to all smokers,” Williams said. “We should intervene more during periods of temporary abstinence—we detox for other substances; we should detox for this substance. We should promote education and provide leadership to change [smoking] policies at treatment centers. And we should provide national leadership and advocate as physicians.”  

For more information, see the Psychiatric News article "Smoking Cessation for Patients Called an Urgent Priority."

Don't Miss Your Chance to Hear Lectures From National Experts

There is still time to make plans to attend the APA Institute on Psychiatric Services (IPS) October 30 to November 2 in San Francisco and take advantage of a program that will explore in depth critical topics in mental health care today. One of the highlights will be a forum on Thursday, October 30 from 6 p.m. to 8:30 p.m., devoted to issues affecting the mental well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals.

Titled "Achieving Wellness in the LGBT Community: Mind, Body, and Spirit," the free forum will be open to the community and features a keynote address by Darlene Nipper, deputy executive director to the National Gay and Lesbian Task Force. Among the roster of speakers and panelists are Annelle Primm, M.D., M.P.H., deputy medical director of APA; Dan Karasic, M.D., a clinical professor in the Department of Psychiatry at the University of California, San Francisco (UCSF); Robert Cabaj, M.D., medical director of San Mateo Behavioral Health and Recovery Services; Dr. Jei Africa, health equity initiatives director of San Mateo Behavioral Health and Recovery Services; Jamison Green, Ph.D., president of the World Professional Association for Transgender Health; and Lori Thoemmes, L.M.F.T., director of the UCSF Alliance Health Project. The forum is being organized by the APA Division of Diversity and Health Equity.

The IPS program will also feature lectures by some of the mental health field's nationally recognized experts who will address critical issues in patient care and psychiatric practice. The impressive lineup includes Howard Goldman, M.D., Ph.D., on "Implementing First-Episode Psychosis Services: Policy Issues," Tanya Luhrmann, Ph.D., on "Hearing Voices in Three Cultures: A Comparison With Implications for Recovery," Charles Marmar, M.D., on "How Biomarkers for PTSD Will Advance Diagnosis and Treatment," David Pollack, M.D., on "Doin' the Community Waltz: A Saging and Raging Trip With the Walts: i.e., Whitman to White (With Visits to Kelly and Cronkite on the Way)," and Altha Stewart, M.D., on "Blacks and American Psychiatry: After 170 Years of APA and 50 Years of Civil Rights, What's Next?"

Click here to learn more about IPS program highlights and registration information.