In a video interview today, APA CEO and Medical Director Saul Levin, M.D., M.P.A., pays tribute to Nelson Mandela, who died last night in his home in Johannesburg, South Africa. Levin, who was born in South Africa and was a staunch opponent of apartheid, is a former president and chief executive officer of Medical Education for South African Blacks, the largest private sponsor of medical education for blacks in South Africa. Levin discusses how Mandela's battle against apartheid serves as an inspiration to APA as it continues to fight against discrimination toward mentally ill people and for their right to have access to the care they need.
A randomized controlled trial of therapies for treating bulimia nervosa finds that cognitive-behavioral therapy (CBT) is more likely than psychoanalytic psychotherapy to produce marked symptom improvement.
In a study reported online in AJP in Advance, researchers in the Oxford University Department of Psychiatry and University of Copenhagen Department of Psychology randomized bulimia patients to either two years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over five months. Both therapies used versions designed specifically for bulimia treatment. The researchers found that while both treatments produced results, "a marked difference was observed" between the two. At the five-month evaluation, 42% of CBT patients and 6% of psychoanalytic psychotherapy patients had stopped binging and purging. At the two-year follow-up, 44% of CBT patients and 15% of psychoanalytic psychotherapy patients were no longer binging and purging. When improvement occurred, it was usually faster in patients receiving CBT. Study patients had eating-disorder symptoms for a mean of 12.3 years.
The researchers concluded that in light of the fact that substantial numbers of patients in each group still had bulimia symptoms after the therapy, "further treatment developments are needed. One could be the continued development and extension of CBT. Another could be the development of a more structured and symptom-focused version of psychoanalytic psychotherapy, possibly augmented with cognitive and behavioral strategies."
Optimism is known to benefit physical health, emotional health, and longevity. And one way in which it does so may be by reducing the brain's reactions to negative information. This is a key finding of a study of the neural correlates of emotion processing related to optimism conducted by Dilip Jeste, M.D., chair in aging and a distinguished professor of psychiatry at the University of California, San Diego, and colleagues. Their results are published in the Journal of Neuropsychiatry and Clinical Sciences. Jeste is also APA's immediate past president.
Jeste and colleagues had older individuals without a history of psychiatric disorders complete multiple standardized self-report measures to assess how optimistic they were. The researchers then used fMRI imaging to examine the brains of the individuals while they viewed faces whose expression indicated fear—that is, processed negative information. They found that greater optimism was associated with reduced activation in the fusiform gyrus and frontal regions, even after taking potential confounding variables, such as cortical thickness and amygdala volume, into consideration. These "findings have potential implications for the promotion of successful aging," Jeste and his colleagues stated in their study report. In brief, "Optimists may be relatively less fearful, particularly about the likelihood of negative events." Strategies for remaining optimistic and engaged as one ages and the neuroscience of healthy aging are detailed in the American Psychiatric Publishing bookSuccessful Cognitive and Emotional Aging, which was coauthored by Jeste.
Dangerousness and an increased risk of violence, rather that mental illness per se, should guide development of evidence-based policies regarding access to firearms, said a report issued Monday at the University of Virginia. The Consortium for Risk-Based Firearm Policy offered three recommendations to guide state policymakers.
First, strengthen state laws to temporarily prohibit individuals from buying or possessing guns after a short-term involuntary psychiatric hospitalization, when there is a higher risk of violence.
Second, similar limits should be placed on people likely to be dangerous, such as those convicted of a violent misdemeanor, those under a temporary domestic-violence restraining order, and anyone convicted at least twice in five years of either misdemeanors involving a controlled substance or of driving while intoxicated.
Third, permit law-enforcement officers to remove firearms when identifying someone who poses an immediate or credible threat to self or others, with appropriate due-process protections.
“Importantly, successful implementation of our recommendations depends on all firearms transfers requiring a background check under federal law,” concluded the report.
“This is an important effort to refocus the discussion about gun violence on groups that represent high risks for violence, rather than continuing with a misdirected focus on people with mental illness,” said forensic psychiatrist and past APA President Paul Appelbaum, M.D., a member of the consortium and a professor of psychiatry, medicine, and law at Columbia University College of Physicians and Surgeons, in an interview with Psychiatric News.
A two-year study of patients with schizophrenia, schizoaffective disorder, bipolar disorder, or affective psychosis reveals four recovery trajectories and the factors that affect those outcomes. All too often, serious mental illness is seen as incurable, permanent, and progressively deteriorating, but 60% to 70% of patients can achieve some level of recovery, said Carla Green Ph.D., M.P.H., of the Center for Health Research at Kaiser Permanente Northwest, in Portland, Ore.
Green and colleagues used extended interviews with 92 women and 85 men, asking about psychiatric symptoms, quality of life, general health, and the mental health care they were receiving, they explained in their report,"Recovery From Serious Mental Illness: Trajectories, Characteristics, and the Role of Mental Health Care"in the December Psychiatric Services. They also used self-reports and health-plan data in their analysis. The scores on the various measures pointed to four patterns of recovery: high and stable levels of recovery; moderately high but fluctuating; moderately low but fluctuating; and consistently low and stable.
“Few demographic or diagnostic factors differentiated clusters at baseline,” the researchers said. “Consistent predictors of trajectories included psychiatric symptoms, physical health, resources and strains, and use of psychiatric medications.” The most consistent predictors of recovery were psychiatric symptoms and changes in those symptoms, they said. Those in turn are dependent on good-quality care, which includes satisfaction with their clinicians and with the medications they are taking. "Providing such care has the potential to change recovery trajectories over time,” they concluded.
While there is no screening tool proven to identify people at risk of suicide, a new study examining medical records of more than 84,000 patients who completed the Patient Health Questionnaire (PHQ-9) at every depression-care visit over several years suggests that the commonly used depression-assessment instrument may be a useful screening tool for detecting suicide risk.
Among outpatients completing PHQ-9 depression questionnaires, a response to item 9 predicted increased risk of suicide attempt or completed suicide over the following several months. That item reads: "Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way.” Response options are "not at all," "several days," more than half the days," or "nearly every day." How patients answered was a strong predictor of suicide attempt and suicide death over the following year.
Researchers at the Group Health Cooperative in Seattle found that the cumulative risk of suicide attempt over one year was 0.4% among outpatients reporting thoughts of death or self-harm “not at all,” while it was 4% among those reporting thoughts of death or self-harm “nearly every day.” Even after accounting for treatment history and demographic factors, "item 9 remained a strong predictor of any suicide attempt," the researchers said. In their report "Does Response on the PHQ-9 Questionnaire Predict Subsequent Suicide Attempt or Suicide Death?" in the December Psychiatric Services, Gregory Simon, M.D., M.P.H., and colleagues explained that the immediate risk of suicide attempt was low but increased over several days and continued to grow for several months, indicating a need for follow-up care to address ongoing risk. “Suicidal ideation should be viewed as an enduring vulnerability rather than simply a short-term crisis,” they said.
A meta-analysis of studies measuring blood concentrations of zinc in some 1,600 depressed subjects and 800 control subjects has found that zinc concentrations were significantly lower in the patients with depression. And in the studies that measured depressive symptoms, greater depression severity was associated with a greater relative zinc deficiency. The senior researcher was Krista Lanctot, Ph.D., of the University of Toronto, and results are published in Biological Psychiatry. What the results mean from a clinical viewpoint, however, remains to be determined, the researchers point out. Since the literature on zinc and depression is largely limited to case-control and cross-sectional studies, it is not known whether depression creates a zinc deficiency or a zinc deficiency helps set the stage for depression. Zinc is an essential nutrient with multiple biological functions. It is possible that depression creates a zinc deficiency, the researchers suggest, since appetite changes are a common component of major depression. One study of subjects with the disorder identified trends between lower zinc concentrations and weight loss and anorexia symptoms. On the other hand, a zinc deficiency can induce depressive-like behaviors in animals, which in turn can be reversed by zinc supplements, the researchers point out. Thus "the potential benefits of zinc supplementation in depressed patients warrant further investigation," they note. A comprehensive overview of depression and how to offer optimal care to depressed patients can be found in the new American Psychiatric Publishing book, Clinical Guide to Depression and Bipolar Disorder: Findings From the Collaborative Depression Study. For more on treating depression, see Treatment-Resistant Depression: A Roadmap for Effective Care.
The federal Centers for Medicare and Medicaid Services (CMS) last week released the final rule for the Medicare Physician Fee Schedule for 2014. Even more than in past years, the fee schedule rule is a mixed bag of good and bad news for physicians—but the good news for psychiatry is that CMS accepted work values for a number of psychiatric codes (90791/92 and the 908XX codes) that will result in increased Medicare payment for psychiatrists using those codes. The work values, which are recommended by the American Medical Association’s Relative Value Update Committee (RUC), are part of a complex payment formula that includes practice expense and other variables to derive a fee for every code used by physicians.
“CMS has adopted all of the RUC-recommended work values, which means that payment for those codes will go up,” Ronald Burd, M.D., chair of APA’s Committee on RBRVS, Codes, and Reimbursements and APA’s representative to the RUC, told Psychiatric News. “This is the best outcome we could have hoped for at this juncture. There are obviously many, many other items impacting payment. But next time someone asks what APA has done for them, I would point to this as a specific situation where the work of APA, our professional organization, has increased reimbursement for psychiatric care.”
A one-hour complimentary webinar on physicians' interactions with industry will be held Wednesday, December 18, at 11 a.m. EST. Citing the importance of this topic for psychiatrists, Saul Levin, M.D., M.P.A., CEO and medical director of APA, is urging APA members to sign up for the webinar. Beginning in 2014, U.S. companies will use their websites to start publicly reporting their financial relationships with physicians. This requirement is part of the Physician Payment Sunshine Act. The webinar, titled "The Natural Consequences of Relationships Between Physicians and Industry: What You Need to Know About Public Reporting and More," will address the many facets to consider and help psychiatrists decide whether they want to enter into a relationship with industry and, if so, to what extent. The webinar is being sponsored by the Council of Medical Specialty Societies (CMSS), which played a major role in drafting of the payment transparency law. Among the speakers will be Norm Kahn, M.D., executive director of CMSS, and Julie Clements, J.D., APA's deputy director for regulatory affairs. Dial-in information for the webinar is available in the U.S. at (800) 882-3610 and in Canada at (866) 605-3851. The passcode is 4495084.More information about the webinar is available from Heidi Lapka at CMSS via e-mail at email@example.com and phone at (312) 224-2585. Click here to register.
Further evidence that cognitive deficits appear in individuals at risk for psychosis well before the first episode of acute psychosis appears comes from a study published online in Schizophrenia Research. Researchers in the Department of Psychiatry at the Istanbul Faculty of Medicine in Turkey compared cognitive functions of 52 individuals at ultra high risk (UHR) for psychosis, 53 patients who had a first episode of psychosis (FES), their 30 healthy siblings (who were considered to be at familial high risk, FHR), and 35 healthy controls with no familial risk.
The researchers found that the FES group had worse neuropsychological performance than did controls on all of the cognitive domains measured, and the UHR group had worse performance on three of them—verbal learning, attention, and working memory—than did controls. They also found that individuals with familial risk had worse performance on executive functions and measures of attention than did the control group. In addition, the FES group had lower global composite scores than did the UHR group and scored worse on a measure of sustained attention than did their siblings in the FHR group.
The researchers concluded that their findings "suggest that cognitive deficits in schizophrenia may start before the first episode, since cognitive functions were similar among FHR, UHR, and FES groups. Our aim as a next step is to detect cognitive predictors of transition to psychosis in both groups in a study with a longitudinal design and with larger sample size."
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