American College Of Psychiatrists Annual Meeting

KAUAI, HAWAII – The way Dr. James (Jay) H. Shore sees it, current advances in technology are transforming the practice of psychiatry more than at any other time in history.

"The information age holds this beautiful promise of crossing the quality chasm and getting to a patient-centered health care where we’re moving from centralization to redistributing the health care to where the patient is," he said at the annual meeting of the American College of Psychiatrists. "I would say that it is a promise that has yet to be achieved."

One of the most important advances over the past 20 years, he said, has been the maturation of convergence science – the concept of bringing disparate scientific disciplines and fields together to work on problems. "I think psychiatry has been on the leading edge of convergence science in the fact that we often turned to the humanities in the beginning of our field to find models and conceptualizations for how the brain works," explained Dr. Shore, an associate professor in the department of psychiatry at the University of Colorado Denver Anschutz Medical Campus. "Nowadays, teams of engineers, mathematicians, and bioscientists are working more closely with physicians."

He discussed three examples of ways in which convergence science is helping clinicians to better understand brain mechanisms. The first involves reconstructing visual experiences from brain activity evoked by natural movies. The effort, spearheaded by researchers at the University of California, Berkeley, and described in the journal Current Biology, uses blood oxygen level–dependent signals measured by functional magnetic resonance imaging to measure brain activity in subjects who viewed natural movie scenes (Current Biol. 2011;21:1641-6). "These subjects are having their visual lobes read by functional MRI connected to a computer program that is attempting to reconstruct what the MRI is reading in their brain," said Dr. Shore, who was not involved with the study. "The computer is drawing off of a database of 18 million images. Basically, what you have is a computer reading someone’s mind as they look at a visual stimulus."

The second technology he discussed is a brain-computer interface known as the BrainGate system, an investigational device that allows people with physical disabilities to increase their independence by controlling a computer with their thoughts. Clinical study participants undergo a surgical procedure where a sensor smaller than a contact lens is placed on the area of the brain responsible for movement. The sensor records electrical signals from the brain. These signals feed into a device, where they are interpreted by an operator using special software. To date, clinical studies have involved the use of BrainGate to check e-mail, change the channels of a television, and use a personal computer, said Dr. Shore, who is also with the Centers for American Indian and Alaska Native Health at the University of Colorado.

The third example of convergence science Dr. Shore discussed is the Blue Brain Project, a half-billion-dollar effort based in Switzerland and intended to construct a complete virtual human brain. "This is not an exercise in artificial intelligence, which uses software to mimic call and response," Dr. Shore said. "They started with a computer simulation model of a single neuron. By 2014, they are on target to have a fully functional artificial rat brain, and by 2023 they propose to have a fully functional human brain computer simulation. This project is really pushing us to understand mechanistically the relationships and networks within the brain."

In the current clinical realm, a variety of technologies are being used for patient care each day, including video conferencing, which "is part of standard psychiatric practice," Dr. Shore said. "The current trend is using smaller devices. I have colleagues who are providing care to patients through video conferencing on their mobile devices and computer tablets. That’s a mature application of technology."

He predicted that mobile telephone technology will drive future models of health care delivery. This is already playing out, he said, noting that an estimated 3,000 to 4,000 of the iPhone’s 13,000 apps are dedicated to some aspect of mental health care. "There are no good studies on these apps yet," Dr. Shore said. "From feasibility studies, we know that patients and providers are using them, but we have no idea how, or how they affect outcomes. It’s kind of like the Wild West out there with apps."

In another development, Dr. Shore discussed work occurring at the Telemedicine and Advanced Technology Research Center (TATRC), an office of the headquarters of the U.S. Army Medical Research and Materiel Command. TATRC has a research program bringing together academia and experts in the video game industry to create a video game "that will passively do neuropsychiatric screening assessment and tracking of the subject, things like reaction time, executive function, and task-shifting, for patients with deployment-related mental health issues such as traumatic brain injury or PTSD [post-traumatic stress disorder]," Dr. Shore said.

A separate group led by Dr. Peter Yellowlees at the University of California, Davis, has developed a virtual simulation of hallucinations intended to give patients, family members, students, and the general public a better understanding of schizophrenia.

"In clinical practice, there is a huge gap between technologies we’ve adapted and used, and the data that support them," he pointed out. "I don’t think this is any different from other fields of medicine. We’re seeing an increasing combination of technologies often being driven by our patients rather than by ourselves. We’re all going to be grappling with information overload.

"With all of these different ways to interact with patients and get information about their clinical status, the increasing ratio of signal to noise and how we sort this out is going to be a challenge."

One thing’s for sure, though: There is no slowing down advances in technology. "In a good way, for all of medicine these technologies are shifting the fulcrum and putting control of the care, information about the care, and guidance of the care back in the hands of our patients so they can be more engaged and active partners," Dr. Shore said. "I think we’ll continue to see this."

Dr. Shore said he had no relevant financial conflicts to disclose.

KAUAI, HAWAII – The way Dr. James (Jay) H. Shore sees it, current advances in technology are transforming the practice of psychiatry more than at any other time in history.

"The information age holds this beautiful promise of crossing the quality chasm and getting to a patient-centered health care where we’re moving from centralization to redistributing the health care to where the patient is," he said at the annual meeting of the American College of Psychiatrists. "I would say that it is a promise that has yet to be achieved."

One of the most important advances over the past 20 years, he said, has been the maturation of convergence science – the concept of bringing disparate scientific disciplines and fields together to work on problems. "I think psychiatry has been on the leading edge of convergence science in the fact that we often turned to the humanities in the beginning of our field to find models and conceptualizations for how the brain works," explained Dr. Shore, an associate professor in the department of psychiatry at the University of Colorado Denver Anschutz Medical Campus. "Nowadays, teams of engineers, mathematicians, and bioscientists are working more closely with physicians."

He discussed three examples of ways in which convergence science is helping clinicians to better understand brain mechanisms. The first involves reconstructing visual experiences from brain activity evoked by natural movies. The effort, spearheaded by researchers at the University of California, Berkeley, and described in the journal Current Biology, uses blood oxygen level–dependent signals measured by functional magnetic resonance imaging to measure brain activity in subjects who viewed natural movie scenes (Current Biol. 2011;21:1641-6). "These subjects are having their visual lobes read by functional MRI connected to a computer program that is attempting to reconstruct what the MRI is reading in their brain," said Dr. Shore, who was not involved with the study. "The computer is drawing off of a database of 18 million images. Basically, what you have is a computer reading someone’s mind as they look at a visual stimulus."

The second technology he discussed is a brain-computer interface known as the BrainGate system, an investigational device that allows people with physical disabilities to increase their independence by controlling a computer with their thoughts. Clinical study participants undergo a surgical procedure where a sensor smaller than a contact lens is placed on the area of the brain responsible for movement. The sensor records electrical signals from the brain. These signals feed into a device, where they are interpreted by an operator using special software. To date, clinical studies have involved the use of BrainGate to check e-mail, change the channels of a television, and use a personal computer, said Dr. Shore, who is also with the Centers for American Indian and Alaska Native Health at the University of Colorado.

The third example of convergence science Dr. Shore discussed is the Blue Brain Project, a half-billion-dollar effort based in Switzerland and intended to construct a complete virtual human brain. "This is not an exercise in artificial intelligence, which uses software to mimic call and response," Dr. Shore said. "They started with a computer simulation model of a single neuron. By 2014, they are on target to have a fully functional artificial rat brain, and by 2023 they propose to have a fully functional human brain computer simulation. This project is really pushing us to understand mechanistically the relationships and networks within the brain."

In the current clinical realm, a variety of technologies are being used for patient care each day, including video conferencing, which "is part of standard psychiatric practice," Dr. Shore said. "The current trend is using smaller devices. I have colleagues who are providing care to patients through video conferencing on their mobile devices and computer tablets. That’s a mature application of technology."

He predicted that mobile telephone technology will drive future models of health care delivery. This is already playing out, he said, noting that an estimated 3,000 to 4,000 of the iPhone’s 13,000 apps are dedicated to some aspect of mental health care. "There are no good studies on these apps yet," Dr. Shore said. "From feasibility studies, we know that patients and providers are using them, but we have no idea how, or how they affect outcomes. It’s kind of like the Wild West out there with apps."

In another development, Dr. Shore discussed work occurring at the Telemedicine and Advanced Technology Research Center (TATRC), an office of the headquarters of the U.S. Army Medical Research and Materiel Command. TATRC has a research program bringing together academia and experts in the video game industry to create a video game "that will passively do neuropsychiatric screening assessment and tracking of the subject, things like reaction time, executive function, and task-shifting, for patients with deployment-related mental health issues such as traumatic brain injury or PTSD [post-traumatic stress disorder]," Dr. Shore said.

A separate group led by Dr. Peter Yellowlees at the University of California, Davis, has developed a virtual simulation of hallucinations intended to give patients, family members, students, and the general public a better understanding of schizophrenia.

"In clinical practice, there is a huge gap between technologies we’ve adapted and used, and the data that support them," he pointed out. "I don’t think this is any different from other fields of medicine. We’re seeing an increasing combination of technologies often being driven by our patients rather than by ourselves. We’re all going to be grappling with information overload.

"With all of these different ways to interact with patients and get information about their clinical status, the increasing ratio of signal to noise and how we sort this out is going to be a challenge."

One thing’s for sure, though: There is no slowing down advances in technology. "In a good way, for all of medicine these technologies are shifting the fulcrum and putting control of the care, information about the care, and guidance of the care back in the hands of our patients so they can be more engaged and active partners," Dr. Shore said. "I think we’ll continue to see this."

Dr. Shore said he had no relevant financial conflicts to disclose.

KAUAI, HAWAII – The way Dr. James (Jay) H. Shore sees it, current advances in technology are transforming the practice of psychiatry more than at any other time in history.

"The information age holds this beautiful promise of crossing the quality chasm and getting to a patient-centered health care where we’re moving from centralization to redistributing the health care to where the patient is," he said at the annual meeting of the American College of Psychiatrists. "I would say that it is a promise that has yet to be achieved."

One of the most important advances over the past 20 years, he said, has been the maturation of convergence science – the concept of bringing disparate scientific disciplines and fields together to work on problems. "I think psychiatry has been on the leading edge of convergence science in the fact that we often turned to the humanities in the beginning of our field to find models and conceptualizations for how the brain works," explained Dr. Shore, an associate professor in the department of psychiatry at the University of Colorado Denver Anschutz Medical Campus. "Nowadays, teams of engineers, mathematicians, and bioscientists are working more closely with physicians."

He discussed three examples of ways in which convergence science is helping clinicians to better understand brain mechanisms. The first involves reconstructing visual experiences from brain activity evoked by natural movies. The effort, spearheaded by researchers at the University of California, Berkeley, and described in the journal Current Biology, uses blood oxygen level–dependent signals measured by functional magnetic resonance imaging to measure brain activity in subjects who viewed natural movie scenes (Current Biol. 2011;21:1641-6). "These subjects are having their visual lobes read by functional MRI connected to a computer program that is attempting to reconstruct what the MRI is reading in their brain," said Dr. Shore, who was not involved with the study. "The computer is drawing off of a database of 18 million images. Basically, what you have is a computer reading someone’s mind as they look at a visual stimulus."

The second technology he discussed is a brain-computer interface known as the BrainGate system, an investigational device that allows people with physical disabilities to increase their independence by controlling a computer with their thoughts. Clinical study participants undergo a surgical procedure where a sensor smaller than a contact lens is placed on the area of the brain responsible for movement. The sensor records electrical signals from the brain. These signals feed into a device, where they are interpreted by an operator using special software. To date, clinical studies have involved the use of BrainGate to check e-mail, change the channels of a television, and use a personal computer, said Dr. Shore, who is also with the Centers for American Indian and Alaska Native Health at the University of Colorado.

The third example of convergence science Dr. Shore discussed is the Blue Brain Project, a half-billion-dollar effort based in Switzerland and intended to construct a complete virtual human brain. "This is not an exercise in artificial intelligence, which uses software to mimic call and response," Dr. Shore said. "They started with a computer simulation model of a single neuron. By 2014, they are on target to have a fully functional artificial rat brain, and by 2023 they propose to have a fully functional human brain computer simulation. This project is really pushing us to understand mechanistically the relationships and networks within the brain."

In the current clinical realm, a variety of technologies are being used for patient care each day, including video conferencing, which "is part of standard psychiatric practice," Dr. Shore said. "The current trend is using smaller devices. I have colleagues who are providing care to patients through video conferencing on their mobile devices and computer tablets. That’s a mature application of technology."

He predicted that mobile telephone technology will drive future models of health care delivery. This is already playing out, he said, noting that an estimated 3,000 to 4,000 of the iPhone’s 13,000 apps are dedicated to some aspect of mental health care. "There are no good studies on these apps yet," Dr. Shore said. "From feasibility studies, we know that patients and providers are using them, but we have no idea how, or how they affect outcomes. It’s kind of like the Wild West out there with apps."

In another development, Dr. Shore discussed work occurring at the Telemedicine and Advanced Technology Research Center (TATRC), an office of the headquarters of the U.S. Army Medical Research and Materiel Command. TATRC has a research program bringing together academia and experts in the video game industry to create a video game "that will passively do neuropsychiatric screening assessment and tracking of the subject, things like reaction time, executive function, and task-shifting, for patients with deployment-related mental health issues such as traumatic brain injury or PTSD [post-traumatic stress disorder]," Dr. Shore said.

A separate group led by Dr. Peter Yellowlees at the University of California, Davis, has developed a virtual simulation of hallucinations intended to give patients, family members, students, and the general public a better understanding of schizophrenia.

"In clinical practice, there is a huge gap between technologies we’ve adapted and used, and the data that support them," he pointed out. "I don’t think this is any different from other fields of medicine. We’re seeing an increasing combination of technologies often being driven by our patients rather than by ourselves. We’re all going to be grappling with information overload.

"With all of these different ways to interact with patients and get information about their clinical status, the increasing ratio of signal to noise and how we sort this out is going to be a challenge."

One thing’s for sure, though: There is no slowing down advances in technology. "In a good way, for all of medicine these technologies are shifting the fulcrum and putting control of the care, information about the care, and guidance of the care back in the hands of our patients so they can be more engaged and active partners," Dr. Shore said. "I think we’ll continue to see this."

Dr. Shore said he had no relevant financial conflicts to disclose.

KAUAI, HAWAII – When it comes to the body’s ability to metabolize medications, ancestry matters.

"In our clinical experience we know that some patients respond [to certain medications] and others don’t," Dr. Keh-Ming Lin said at the annual meeting of the American College of Psychiatrists. "There are also toxic responders, even though we give them the same type of treatment. Right now, we don’t have a way of identifying who will respond or who will have serious side effects.

"This occurs although humans are 99.99% the same from a genetic standpoint," said Dr. Lin, a psychiatrist at the University of California, Los Angeles. "We have the same chromosome structures and the same number of genes, and the genes are structured in the same way. It often just takes one single mutation to alter the function of the genes. As a result, there are individual and ethnic differences in the way genes respond to treatment."

Variations in pharmacokinetics are mediated by a number of cytochrome P450 enzymes (CYPs), he said, including CYP2D6, CYP3A4, and CYP1A2. "These enzyme activities are determined not only by genetic dispositions but also by environmental factors like diet and herbs that people take," said Dr. Lin, who is also a distinguished life fellow of the American Psychiatric Association.

He described CYP2D6 as "interesting" for at least two reasons: First, it is involved in about 40% of all drugs currently on the market, including many antidepressants, neuroleptics, drugs of abuse, cardiovascular drugs, and antiemetics. Second, there are different mutations of CYP2D6 that translate to four different rates of metabolism. For example, genotype CYP2D6*4 is associated with very slow rates of metabolism (PM); genotypes CYP2D6*17 and CYP2D6*10 are associated with slow rates of metabolism (SM); CYP2D6 is associated with normal rates of metabolism (EM), and genotypes CYP2D6*1XN and CYP2D6*2XN are associated with fast rates of metabolism (UM).

"These could be determined by a simple genetic test," Dr. Lin said. "We have known for about 40 years that Asians seem to be more sensitive to medication and need a lower dosage of some of the commonly prescribed drugs. Part of this may be because a higher proportion of East Asians are slow metabolizers due to a specific gene mutation. On the other hand, about 9% of Caucasians are poor metabolizers. They have absolutely no CYP2D6, so they tend to be very sensitive to medication."

Dr. Lin also noted that a high proportion of people who are part of certain ethnic groups metabolize drugs very rapidly, including Ethiopians, Arabs, Melanesians, and others of East African descent. "They require much larger doses of medication to have the same effect," he said.

Such differences occur because these CYP2D6 phenotypes "were not specifically designed to metabolize these drugs but rather are part of a system crucial for the body’s defenses against foreign and potentially dangerous substances," he explained.

Another enzyme that plays a role in drug metabolism is CYP1A2, which is inhibited by many natural substances, including coffee, flavone, quercetin, and corn and is induced by a high-protein diet, constituents of tobacco, charbroiled beef, and cruciferous vegetables.

The enzyme CYP3A4 is also important in drug metabolism. It is inhibited by grapefruit juice, red wine, star fruit, and kava and is induced by St. John’s wort. Drugs metabolized by CYP3A4 include some atypical antipsychotics; some antidepressants; mood stabilizers carbamazepine, gabapentin, and lamotrigine; benzodiazepines; steroids; and statins.

"The bottom line is that we should consider ethnic and individual variations on drug-metabolizing genes such as CYP2D6 PM and UM, and watch out for drug-drug interactions and drug–natural substance interactions," he concluded.

Dr. Lin said he had no relevant financial disclosures.

KAUAI, HAWAII – When it comes to the body’s ability to metabolize medications, ancestry matters.

"In our clinical experience we know that some patients respond [to certain medications] and others don’t," Dr. Keh-Ming Lin said at the annual meeting of the American College of Psychiatrists. "There are also toxic responders, even though we give them the same type of treatment. Right now, we don’t have a way of identifying who will respond or who will have serious side effects.

"This occurs although humans are 99.99% the same from a genetic standpoint," said Dr. Lin, a psychiatrist at the University of California, Los Angeles. "We have the same chromosome structures and the same number of genes, and the genes are structured in the same way. It often just takes one single mutation to alter the function of the genes. As a result, there are individual and ethnic differences in the way genes respond to treatment."

Variations in pharmacokinetics are mediated by a number of cytochrome P450 enzymes (CYPs), he said, including CYP2D6, CYP3A4, and CYP1A2. "These enzyme activities are determined not only by genetic dispositions but also by environmental factors like diet and herbs that people take," said Dr. Lin, who is also a distinguished life fellow of the American Psychiatric Association.

He described CYP2D6 as "interesting" for at least two reasons: First, it is involved in about 40% of all drugs currently on the market, including many antidepressants, neuroleptics, drugs of abuse, cardiovascular drugs, and antiemetics. Second, there are different mutations of CYP2D6 that translate to four different rates of metabolism. For example, genotype CYP2D6*4 is associated with very slow rates of metabolism (PM); genotypes CYP2D6*17 and CYP2D6*10 are associated with slow rates of metabolism (SM); CYP2D6 is associated with normal rates of metabolism (EM), and genotypes CYP2D6*1XN and CYP2D6*2XN are associated with fast rates of metabolism (UM).

"These could be determined by a simple genetic test," Dr. Lin said. "We have known for about 40 years that Asians seem to be more sensitive to medication and need a lower dosage of some of the commonly prescribed drugs. Part of this may be because a higher proportion of East Asians are slow metabolizers due to a specific gene mutation. On the other hand, about 9% of Caucasians are poor metabolizers. They have absolutely no CYP2D6, so they tend to be very sensitive to medication."

Dr. Lin also noted that a high proportion of people who are part of certain ethnic groups metabolize drugs very rapidly, including Ethiopians, Arabs, Melanesians, and others of East African descent. "They require much larger doses of medication to have the same effect," he said.

Such differences occur because these CYP2D6 phenotypes "were not specifically designed to metabolize these drugs but rather are part of a system crucial for the body’s defenses against foreign and potentially dangerous substances," he explained.

Another enzyme that plays a role in drug metabolism is CYP1A2, which is inhibited by many natural substances, including coffee, flavone, quercetin, and corn and is induced by a high-protein diet, constituents of tobacco, charbroiled beef, and cruciferous vegetables.

The enzyme CYP3A4 is also important in drug metabolism. It is inhibited by grapefruit juice, red wine, star fruit, and kava and is induced by St. John’s wort. Drugs metabolized by CYP3A4 include some atypical antipsychotics; some antidepressants; mood stabilizers carbamazepine, gabapentin, and lamotrigine; benzodiazepines; steroids; and statins.

"The bottom line is that we should consider ethnic and individual variations on drug-metabolizing genes such as CYP2D6 PM and UM, and watch out for drug-drug interactions and drug–natural substance interactions," he concluded.

Dr. Lin said he had no relevant financial disclosures.

KAUAI, HAWAII – When it comes to the body’s ability to metabolize medications, ancestry matters.

"In our clinical experience we know that some patients respond [to certain medications] and others don’t," Dr. Keh-Ming Lin said at the annual meeting of the American College of Psychiatrists. "There are also toxic responders, even though we give them the same type of treatment. Right now, we don’t have a way of identifying who will respond or who will have serious side effects.

"This occurs although humans are 99.99% the same from a genetic standpoint," said Dr. Lin, a psychiatrist at the University of California, Los Angeles. "We have the same chromosome structures and the same number of genes, and the genes are structured in the same way. It often just takes one single mutation to alter the function of the genes. As a result, there are individual and ethnic differences in the way genes respond to treatment."

Variations in pharmacokinetics are mediated by a number of cytochrome P450 enzymes (CYPs), he said, including CYP2D6, CYP3A4, and CYP1A2. "These enzyme activities are determined not only by genetic dispositions but also by environmental factors like diet and herbs that people take," said Dr. Lin, who is also a distinguished life fellow of the American Psychiatric Association.

He described CYP2D6 as "interesting" for at least two reasons: First, it is involved in about 40% of all drugs currently on the market, including many antidepressants, neuroleptics, drugs of abuse, cardiovascular drugs, and antiemetics. Second, there are different mutations of CYP2D6 that translate to four different rates of metabolism. For example, genotype CYP2D6*4 is associated with very slow rates of metabolism (PM); genotypes CYP2D6*17 and CYP2D6*10 are associated with slow rates of metabolism (SM); CYP2D6 is associated with normal rates of metabolism (EM), and genotypes CYP2D6*1XN and CYP2D6*2XN are associated with fast rates of metabolism (UM).

"These could be determined by a simple genetic test," Dr. Lin said. "We have known for about 40 years that Asians seem to be more sensitive to medication and need a lower dosage of some of the commonly prescribed drugs. Part of this may be because a higher proportion of East Asians are slow metabolizers due to a specific gene mutation. On the other hand, about 9% of Caucasians are poor metabolizers. They have absolutely no CYP2D6, so they tend to be very sensitive to medication."

Dr. Lin also noted that a high proportion of people who are part of certain ethnic groups metabolize drugs very rapidly, including Ethiopians, Arabs, Melanesians, and others of East African descent. "They require much larger doses of medication to have the same effect," he said.

Such differences occur because these CYP2D6 phenotypes "were not specifically designed to metabolize these drugs but rather are part of a system crucial for the body’s defenses against foreign and potentially dangerous substances," he explained.

Another enzyme that plays a role in drug metabolism is CYP1A2, which is inhibited by many natural substances, including coffee, flavone, quercetin, and corn and is induced by a high-protein diet, constituents of tobacco, charbroiled beef, and cruciferous vegetables.

The enzyme CYP3A4 is also important in drug metabolism. It is inhibited by grapefruit juice, red wine, star fruit, and kava and is induced by St. John’s wort. Drugs metabolized by CYP3A4 include some atypical antipsychotics; some antidepressants; mood stabilizers carbamazepine, gabapentin, and lamotrigine; benzodiazepines; steroids; and statins.

"The bottom line is that we should consider ethnic and individual variations on drug-metabolizing genes such as CYP2D6 PM and UM, and watch out for drug-drug interactions and drug–natural substance interactions," he concluded.

Dr. Lin said he had no relevant financial disclosures.

KAUAI, HAWAII – It’s been nearly 12 years since former U.S. Surgeon General David Satcher released a report spotlighting the impact of mental illnesses on racial and ethic minority groups in the United States.

Today, that report "still rings true in terms of its findings of the striking ethnic, racial, and linguistic disparities in mental health care, with members of diverse groups being less likely to receive services and to have a poorer quality of care once they enter the door for psychiatric care," Dr. Annelle B. Primm said at the annual meeting of the American College of Psychiatrists.

"To compound matters, they are underrepresented in mental health research, making it more difficult for us to be certain that we’re providing these populations the best care. Taken together, these disparities impose a great disability burden."

In 2011, minority births exceeded white births, she said, and 50% of 3- and 4-year-olds were white and 50% were nonwhite. "Our country is becoming more and more diverse to the point where we may need to start referring to these populations as an emerging majority," said Dr. Primm, director of minority and national affairs at the American Psychiatric Association (APA). "What this means is that in our mental health care settings, there are going to be even greater cross-cultural interactions. This is something that we in the psychiatry community need to be prepared for."

Patient-level factors, system-level factors, and individual practitioner factors contribute to the existing disparities, said Dr. Primm, who is also the APA’s deputy medical director. Data from the Agency for Healthcare Research and Quality’s (AHRQ’s) National Healthcare Disparities Report, which was published in 2011, show that blacks and Hispanics who had major depressive episodes within the last 12 months were less likely to receive treatment during that time, compared with whites.

"There are also some differences with respect to education level, with people with any college education being more likely to receive treatment, compared with those who are either high school graduates or had less than a high school education," Dr. Primm said.

The AHRQ also notes disparities in substance abuse treatment. For example, among people aged 12 and older who need treatment for illicit drug use or an alcohol problem, blacks are more likely to receive treatment, compared with their white or American Indian counterparts. Yet, blacks are less likely to complete treatment, compared with the other cohorts.

The rate of uninsured also is a barrier to mental health care. Data from the 2010 U.S. Census estimate that about 20% of the nonelderly population are uninsured. Of those uninsured, 46% are white, 31% are Hispanic, 16% are black, and 5% are Asian American. "We can expect an influx of these populations with health care reform and Medicaid expansion," Dr. Primm said.

Another access challenge is the shortage of behavioral health providers in some geographic areas, major cutbacks in public mental health services, and a lack of mental health workforce diversity. "If we look at the diversity of the psychiatry workforce, in almost all groups, there is a mismatch between the population percentage and the percentage of the psychiatric workforce," she said.

Despite current challenges that mental health care clinicians face in providing services to underserved patient populations, Dr. Primm emphasized that significant efforts are underway to bring meaningful change. Whatever shape pending health care reform ultimately takes, she predicted, it will contribute to improving access to mental health services by special populations. For example, mental health parity "will be helpful in terms of access to mental health services for diverse groups," she said. "Expanding health coverage through the employer mandate, health exchanges, Medicaid expansion, and allowance of coverage for people with preexisting conditions will also be [important]."

She said she envisions improved access through other pathways as well, such as community health centers, the Indian Health Care Improvement Act, and the Health Resources and Services Administration’s National Health Service Corps, "which pays for medical school and other health professional training for those who are prepared to ‘give back’ after they finish their training," Dr. Primm said.

Other trends underway aimed at eliminating disparities in the provision of mental health services include the involvement of peer support specialists – which has been proposed by recovery-oriented models of care. This trend "also stems from the saying ‘nothing about us without us,’ where people with mental illness who have been successful in managing their illness become a part of the team to help patients who are struggling, to identify with their recovery success," Dr. Primm explained. "We also need to see that community health workers and mental health navigators can serve as cultural brokers, particularly if they reflect the culture of the patient population served.

"This is new for many of us who have not had the opportunity to work with people in these sorts of positions."

Health care reform’s emphasis on prevention and primary care also is likely to drive change for the better, she said, noting that people with serious mental illness die, on average, 25 years earlier than the general population. "The integrated care between primary care and mental health is particularly important with ethnically and racially diverse groups," she said. "There are very high rates of chronic disease and premature death, so this is another way in which these patients can benefit from having a ‘one-stop shop,’ to benefit from collaborative care."

In 2006, the APA and the National Alliance on Mental Illness embarked on a project to develop a 3-hour continuing medical education curriculum called "In Living Color: Depression Treatment in Primary Care." The curriculum was developed to equip primary care practitioners with the knowledge and skills to work more effectively with diverse populations.

"The approach in teaching this is innovative in that it involves physicians working with a person of color with a history of depression as well as with a family mental health advocate from a diverse background," Dr. Primm said. "So the primary care practitioners [gain] a full appreciation – not only of the science but also of the lived experience of what it’s like to be a person of color with a mental illness and to struggle with it." To date, the curriculum has been rolled out in California, Florida, Louisiana, Missouri, and Tennessee.

The recent proliferation of cultural competence training, and practitioner and organizational assessments, also are likely to result in improved access to quality mental health care. The Affordable Care Act "does pay attention to the issue of cultural competency training," she said. "Some states have taken the lead on this, including New Jersey, which requires cultural competency training for medical licensure and renewal. In addition, California requires that all CME programs include a cultural competence focus."

On the national front, the Department of Health and Human Services Office of Minority Health has launched a National Partnership for Action to End Health Disparities. According to its website, the mission of NPA is to "increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action." Efforts by the Patient Care Outcomes Research Institute to conduct comparative effectiveness research also will be key. "Perhaps this will be an opportunity to learn more about what sort of treatments work best in which populations and by which providers, et cetera," Dr. Primm said. "In terms of quality improvement, it’s important to have national indicators tracked by race and ethnicity."

Other quality standards focused on eliminating disparities include the National Standards on Culturally and Linguistically Appropriate Services, the National Quality Forum’s Healthcare Disparities and Cultural Competency Consensus Standards, and the National Committee for Quality Assurance’s Standards and Guidelines for Distinction in Multicultural Health Care. "These will all be more prominent going forward," Dr. Primm said.

Dr. Primm said she had no relevant financial disclosures.

d.brunk@elsevier.com

KAUAI, HAWAII – It’s been nearly 12 years since former U.S. Surgeon General David Satcher released a report spotlighting the impact of mental illnesses on racial and ethic minority groups in the United States.

Today, that report "still rings true in terms of its findings of the striking ethnic, racial, and linguistic disparities in mental health care, with members of diverse groups being less likely to receive services and to have a poorer quality of care once they enter the door for psychiatric care," Dr. Annelle B. Primm said at the annual meeting of the American College of Psychiatrists.

"To compound matters, they are underrepresented in mental health research, making it more difficult for us to be certain that we’re providing these populations the best care. Taken together, these disparities impose a great disability burden."

In 2011, minority births exceeded white births, she said, and 50% of 3- and 4-year-olds were white and 50% were nonwhite. "Our country is becoming more and more diverse to the point where we may need to start referring to these populations as an emerging majority," said Dr. Primm, director of minority and national affairs at the American Psychiatric Association (APA). "What this means is that in our mental health care settings, there are going to be even greater cross-cultural interactions. This is something that we in the psychiatry community need to be prepared for."

Patient-level factors, system-level factors, and individual practitioner factors contribute to the existing disparities, said Dr. Primm, who is also the APA’s deputy medical director. Data from the Agency for Healthcare Research and Quality’s (AHRQ’s) National Healthcare Disparities Report, which was published in 2011, show that blacks and Hispanics who had major depressive episodes within the last 12 months were less likely to receive treatment during that time, compared with whites.

"There are also some differences with respect to education level, with people with any college education being more likely to receive treatment, compared with those who are either high school graduates or had less than a high school education," Dr. Primm said.

The AHRQ also notes disparities in substance abuse treatment. For example, among people aged 12 and older who need treatment for illicit drug use or an alcohol problem, blacks are more likely to receive treatment, compared with their white or American Indian counterparts. Yet, blacks are less likely to complete treatment, compared with the other cohorts.

The rate of uninsured also is a barrier to mental health care. Data from the 2010 U.S. Census estimate that about 20% of the nonelderly population are uninsured. Of those uninsured, 46% are white, 31% are Hispanic, 16% are black, and 5% are Asian American. "We can expect an influx of these populations with health care reform and Medicaid expansion," Dr. Primm said.

Another access challenge is the shortage of behavioral health providers in some geographic areas, major cutbacks in public mental health services, and a lack of mental health workforce diversity. "If we look at the diversity of the psychiatry workforce, in almost all groups, there is a mismatch between the population percentage and the percentage of the psychiatric workforce," she said.

Despite current challenges that mental health care clinicians face in providing services to underserved patient populations, Dr. Primm emphasized that significant efforts are underway to bring meaningful change. Whatever shape pending health care reform ultimately takes, she predicted, it will contribute to improving access to mental health services by special populations. For example, mental health parity "will be helpful in terms of access to mental health services for diverse groups," she said. "Expanding health coverage through the employer mandate, health exchanges, Medicaid expansion, and allowance of coverage for people with preexisting conditions will also be [important]."

She said she envisions improved access through other pathways as well, such as community health centers, the Indian Health Care Improvement Act, and the Health Resources and Services Administration’s National Health Service Corps, "which pays for medical school and other health professional training for those who are prepared to ‘give back’ after they finish their training," Dr. Primm said.

Other trends underway aimed at eliminating disparities in the provision of mental health services include the involvement of peer support specialists – which has been proposed by recovery-oriented models of care. This trend "also stems from the saying ‘nothing about us without us,’ where people with mental illness who have been successful in managing their illness become a part of the team to help patients who are struggling, to identify with their recovery success," Dr. Primm explained. "We also need to see that community health workers and mental health navigators can serve as cultural brokers, particularly if they reflect the culture of the patient population served.

"This is new for many of us who have not had the opportunity to work with people in these sorts of positions."

Health care reform’s emphasis on prevention and primary care also is likely to drive change for the better, she said, noting that people with serious mental illness die, on average, 25 years earlier than the general population. "The integrated care between primary care and mental health is particularly important with ethnically and racially diverse groups," she said. "There are very high rates of chronic disease and premature death, so this is another way in which these patients can benefit from having a ‘one-stop shop,’ to benefit from collaborative care."

In 2006, the APA and the National Alliance on Mental Illness embarked on a project to develop a 3-hour continuing medical education curriculum called "In Living Color: Depression Treatment in Primary Care." The curriculum was developed to equip primary care practitioners with the knowledge and skills to work more effectively with diverse populations.

"The approach in teaching this is innovative in that it involves physicians working with a person of color with a history of depression as well as with a family mental health advocate from a diverse background," Dr. Primm said. "So the primary care practitioners [gain] a full appreciation – not only of the science but also of the lived experience of what it’s like to be a person of color with a mental illness and to struggle with it." To date, the curriculum has been rolled out in California, Florida, Louisiana, Missouri, and Tennessee.

The recent proliferation of cultural competence training, and practitioner and organizational assessments, also are likely to result in improved access to quality mental health care. The Affordable Care Act "does pay attention to the issue of cultural competency training," she said. "Some states have taken the lead on this, including New Jersey, which requires cultural competency training for medical licensure and renewal. In addition, California requires that all CME programs include a cultural competence focus."

On the national front, the Department of Health and Human Services Office of Minority Health has launched a National Partnership for Action to End Health Disparities. According to its website, the mission of NPA is to "increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action." Efforts by the Patient Care Outcomes Research Institute to conduct comparative effectiveness research also will be key. "Perhaps this will be an opportunity to learn more about what sort of treatments work best in which populations and by which providers, et cetera," Dr. Primm said. "In terms of quality improvement, it’s important to have national indicators tracked by race and ethnicity."

Other quality standards focused on eliminating disparities include the National Standards on Culturally and Linguistically Appropriate Services, the National Quality Forum’s Healthcare Disparities and Cultural Competency Consensus Standards, and the National Committee for Quality Assurance’s Standards and Guidelines for Distinction in Multicultural Health Care. "These will all be more prominent going forward," Dr. Primm said.

Dr. Primm said she had no relevant financial disclosures.

d.brunk@elsevier.com

KAUAI, HAWAII – It’s been nearly 12 years since former U.S. Surgeon General David Satcher released a report spotlighting the impact of mental illnesses on racial and ethic minority groups in the United States.

Today, that report "still rings true in terms of its findings of the striking ethnic, racial, and linguistic disparities in mental health care, with members of diverse groups being less likely to receive services and to have a poorer quality of care once they enter the door for psychiatric care," Dr. Annelle B. Primm said at the annual meeting of the American College of Psychiatrists.

"To compound matters, they are underrepresented in mental health research, making it more difficult for us to be certain that we’re providing these populations the best care. Taken together, these disparities impose a great disability burden."

In 2011, minority births exceeded white births, she said, and 50% of 3- and 4-year-olds were white and 50% were nonwhite. "Our country is becoming more and more diverse to the point where we may need to start referring to these populations as an emerging majority," said Dr. Primm, director of minority and national affairs at the American Psychiatric Association (APA). "What this means is that in our mental health care settings, there are going to be even greater cross-cultural interactions. This is something that we in the psychiatry community need to be prepared for."

Patient-level factors, system-level factors, and individual practitioner factors contribute to the existing disparities, said Dr. Primm, who is also the APA’s deputy medical director. Data from the Agency for Healthcare Research and Quality’s (AHRQ’s) National Healthcare Disparities Report, which was published in 2011, show that blacks and Hispanics who had major depressive episodes within the last 12 months were less likely to receive treatment during that time, compared with whites.

"There are also some differences with respect to education level, with people with any college education being more likely to receive treatment, compared with those who are either high school graduates or had less than a high school education," Dr. Primm said.

The AHRQ also notes disparities in substance abuse treatment. For example, among people aged 12 and older who need treatment for illicit drug use or an alcohol problem, blacks are more likely to receive treatment, compared with their white or American Indian counterparts. Yet, blacks are less likely to complete treatment, compared with the other cohorts.

The rate of uninsured also is a barrier to mental health care. Data from the 2010 U.S. Census estimate that about 20% of the nonelderly population are uninsured. Of those uninsured, 46% are white, 31% are Hispanic, 16% are black, and 5% are Asian American. "We can expect an influx of these populations with health care reform and Medicaid expansion," Dr. Primm said.

Another access challenge is the shortage of behavioral health providers in some geographic areas, major cutbacks in public mental health services, and a lack of mental health workforce diversity. "If we look at the diversity of the psychiatry workforce, in almost all groups, there is a mismatch between the population percentage and the percentage of the psychiatric workforce," she said.

Despite current challenges that mental health care clinicians face in providing services to underserved patient populations, Dr. Primm emphasized that significant efforts are underway to bring meaningful change. Whatever shape pending health care reform ultimately takes, she predicted, it will contribute to improving access to mental health services by special populations. For example, mental health parity "will be helpful in terms of access to mental health services for diverse groups," she said. "Expanding health coverage through the employer mandate, health exchanges, Medicaid expansion, and allowance of coverage for people with preexisting conditions will also be [important]."

She said she envisions improved access through other pathways as well, such as community health centers, the Indian Health Care Improvement Act, and the Health Resources and Services Administration’s National Health Service Corps, "which pays for medical school and other health professional training for those who are prepared to ‘give back’ after they finish their training," Dr. Primm said.

Other trends underway aimed at eliminating disparities in the provision of mental health services include the involvement of peer support specialists – which has been proposed by recovery-oriented models of care. This trend "also stems from the saying ‘nothing about us without us,’ where people with mental illness who have been successful in managing their illness become a part of the team to help patients who are struggling, to identify with their recovery success," Dr. Primm explained. "We also need to see that community health workers and mental health navigators can serve as cultural brokers, particularly if they reflect the culture of the patient population served.

"This is new for many of us who have not had the opportunity to work with people in these sorts of positions."

Health care reform’s emphasis on prevention and primary care also is likely to drive change for the better, she said, noting that people with serious mental illness die, on average, 25 years earlier than the general population. "The integrated care between primary care and mental health is particularly important with ethnically and racially diverse groups," she said. "There are very high rates of chronic disease and premature death, so this is another way in which these patients can benefit from having a ‘one-stop shop,’ to benefit from collaborative care."

In 2006, the APA and the National Alliance on Mental Illness embarked on a project to develop a 3-hour continuing medical education curriculum called "In Living Color: Depression Treatment in Primary Care." The curriculum was developed to equip primary care practitioners with the knowledge and skills to work more effectively with diverse populations.

"The approach in teaching this is innovative in that it involves physicians working with a person of color with a history of depression as well as with a family mental health advocate from a diverse background," Dr. Primm said. "So the primary care practitioners [gain] a full appreciation – not only of the science but also of the lived experience of what it’s like to be a person of color with a mental illness and to struggle with it." To date, the curriculum has been rolled out in California, Florida, Louisiana, Missouri, and Tennessee.

The recent proliferation of cultural competence training, and practitioner and organizational assessments, also are likely to result in improved access to quality mental health care. The Affordable Care Act "does pay attention to the issue of cultural competency training," she said. "Some states have taken the lead on this, including New Jersey, which requires cultural competency training for medical licensure and renewal. In addition, California requires that all CME programs include a cultural competence focus."

On the national front, the Department of Health and Human Services Office of Minority Health has launched a National Partnership for Action to End Health Disparities. According to its website, the mission of NPA is to "increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action." Efforts by the Patient Care Outcomes Research Institute to conduct comparative effectiveness research also will be key. "Perhaps this will be an opportunity to learn more about what sort of treatments work best in which populations and by which providers, et cetera," Dr. Primm said. "In terms of quality improvement, it’s important to have national indicators tracked by race and ethnicity."

Other quality standards focused on eliminating disparities include the National Standards on Culturally and Linguistically Appropriate Services, the National Quality Forum’s Healthcare Disparities and Cultural Competency Consensus Standards, and the National Committee for Quality Assurance’s Standards and Guidelines for Distinction in Multicultural Health Care. "These will all be more prominent going forward," Dr. Primm said.

Dr. Primm said she had no relevant financial disclosures.

d.brunk@elsevier.com

KAUAI, HAWAII – The future of psychiatry in the era of health care reform will involve more team-based integrative care than ever before, according to Dr. James H. Scully Jr.

That means a shift away from the fee-for-service, volume-based model of care to which psychiatrists are accustomed. "We’re going to have to change the way we do business in order to survive," said Dr. Scully, CEO and medical director of the American Psychiatric Association. "We have to change our availability. We can’t say ‘I’ll see the patient in a couple of months’ like we do now sometimes. We’ll have to say ‘I’ll be there this afternoon’ and structure our clinical work around that, not only to do good liaison work but to be able to see the patient."

Volume-based fee-for-service health care "is a great risk," he said at the annual meeting of the American College of Psychiatrists. "That’s not sustainable [under] the Affordable Care Act. The insurance companies don’t want to do it anymore and certainly the companies who buy health insurance for their employees don’t want to spend money in the way they’ve been spending it."

The Center for Medicare and Medicaid Innovation (CMMI) – part of the Centers for Medicare and Medicaid Services – is funding numerous pilot programs aimed at fostering integrated care in primary and specialty care.

Dr. Scully offered examples of projects that are well developed, in his opinion: North Carolina Center of Excellence in Integrated Care; the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) project; Integrated Behavioral Health Project in California; Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) in Washington State; Mental Health Integration Program, also in Washington State; and TEAMcare, a multidisciplinary collaboration between the University of Washington and the Group Health Research Institute.

"These are all grant funded, so the question is, are they sustainable in the current way we pay for health care?" Dr. Scully asked. "Probably not. We have to change the way we pay for the services. Service delivery models and service payment models are two aspects of how this will get dealt with."

At the same time, mounting evidence from published studies is demonstrating that integrated health care can improve outcomes and lower cost. For example, in one randomized, controlled trial, diabetes patients who participated in the IMPACT program experienced fewer days of depression over a 2 year period compared with patients who received usual care (Diabetes Care 2006;29:265-70).

New payment models also are being developed under the ACA, Dr. Scully said. Many models include bundled payment for episodes of care "where you get a fee for caring for an episode or for a period of time."

Global capitation and partial capitation are being studied as well. "There are lots of different variations to change away from fee-for-service to a different kind of model to get paid for what we do," Dr. Scully said. "It’s an exciting time for us. We can’t walk away from [health care reform efforts]. We could, but I think it would be at our peril in the long-term. I think we have to participate in this and show some leadership. I’m optimistic."

Dr. Scully said that he had no relevant financial conflicts to disclose.

KAUAI, HAWAII – The future of psychiatry in the era of health care reform will involve more team-based integrative care than ever before, according to Dr. James H. Scully Jr.

That means a shift away from the fee-for-service, volume-based model of care to which psychiatrists are accustomed. "We’re going to have to change the way we do business in order to survive," said Dr. Scully, CEO and medical director of the American Psychiatric Association. "We have to change our availability. We can’t say ‘I’ll see the patient in a couple of months’ like we do now sometimes. We’ll have to say ‘I’ll be there this afternoon’ and structure our clinical work around that, not only to do good liaison work but to be able to see the patient."

Volume-based fee-for-service health care "is a great risk," he said at the annual meeting of the American College of Psychiatrists. "That’s not sustainable [under] the Affordable Care Act. The insurance companies don’t want to do it anymore and certainly the companies who buy health insurance for their employees don’t want to spend money in the way they’ve been spending it."

The Center for Medicare and Medicaid Innovation (CMMI) – part of the Centers for Medicare and Medicaid Services – is funding numerous pilot programs aimed at fostering integrated care in primary and specialty care.

Dr. Scully offered examples of projects that are well developed, in his opinion: North Carolina Center of Excellence in Integrated Care; the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) project; Integrated Behavioral Health Project in California; Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) in Washington State; Mental Health Integration Program, also in Washington State; and TEAMcare, a multidisciplinary collaboration between the University of Washington and the Group Health Research Institute.

"These are all grant funded, so the question is, are they sustainable in the current way we pay for health care?" Dr. Scully asked. "Probably not. We have to change the way we pay for the services. Service delivery models and service payment models are two aspects of how this will get dealt with."

At the same time, mounting evidence from published studies is demonstrating that integrated health care can improve outcomes and lower cost. For example, in one randomized, controlled trial, diabetes patients who participated in the IMPACT program experienced fewer days of depression over a 2 year period compared with patients who received usual care (Diabetes Care 2006;29:265-70).

New payment models also are being developed under the ACA, Dr. Scully said. Many models include bundled payment for episodes of care "where you get a fee for caring for an episode or for a period of time."

Global capitation and partial capitation are being studied as well. "There are lots of different variations to change away from fee-for-service to a different kind of model to get paid for what we do," Dr. Scully said. "It’s an exciting time for us. We can’t walk away from [health care reform efforts]. We could, but I think it would be at our peril in the long-term. I think we have to participate in this and show some leadership. I’m optimistic."

Dr. Scully said that he had no relevant financial conflicts to disclose.

KAUAI, HAWAII – The future of psychiatry in the era of health care reform will involve more team-based integrative care than ever before, according to Dr. James H. Scully Jr.

That means a shift away from the fee-for-service, volume-based model of care to which psychiatrists are accustomed. "We’re going to have to change the way we do business in order to survive," said Dr. Scully, CEO and medical director of the American Psychiatric Association. "We have to change our availability. We can’t say ‘I’ll see the patient in a couple of months’ like we do now sometimes. We’ll have to say ‘I’ll be there this afternoon’ and structure our clinical work around that, not only to do good liaison work but to be able to see the patient."

Volume-based fee-for-service health care "is a great risk," he said at the annual meeting of the American College of Psychiatrists. "That’s not sustainable [under] the Affordable Care Act. The insurance companies don’t want to do it anymore and certainly the companies who buy health insurance for their employees don’t want to spend money in the way they’ve been spending it."

The Center for Medicare and Medicaid Innovation (CMMI) – part of the Centers for Medicare and Medicaid Services – is funding numerous pilot programs aimed at fostering integrated care in primary and specialty care.

Dr. Scully offered examples of projects that are well developed, in his opinion: North Carolina Center of Excellence in Integrated Care; the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) project; Integrated Behavioral Health Project in California; Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) in Washington State; Mental Health Integration Program, also in Washington State; and TEAMcare, a multidisciplinary collaboration between the University of Washington and the Group Health Research Institute.

"These are all grant funded, so the question is, are they sustainable in the current way we pay for health care?" Dr. Scully asked. "Probably not. We have to change the way we pay for the services. Service delivery models and service payment models are two aspects of how this will get dealt with."

At the same time, mounting evidence from published studies is demonstrating that integrated health care can improve outcomes and lower cost. For example, in one randomized, controlled trial, diabetes patients who participated in the IMPACT program experienced fewer days of depression over a 2 year period compared with patients who received usual care (Diabetes Care 2006;29:265-70).

New payment models also are being developed under the ACA, Dr. Scully said. Many models include bundled payment for episodes of care "where you get a fee for caring for an episode or for a period of time."

Global capitation and partial capitation are being studied as well. "There are lots of different variations to change away from fee-for-service to a different kind of model to get paid for what we do," Dr. Scully said. "It’s an exciting time for us. We can’t walk away from [health care reform efforts]. We could, but I think it would be at our peril in the long-term. I think we have to participate in this and show some leadership. I’m optimistic."

Dr. Scully said that he had no relevant financial conflicts to disclose.

When the DSM-5 is unveiled at the annual meeting of the American Psychiatric Association in May, Dr. David J. Kupfer hopes that clinicians will find a more user-friendly document compared with the DSM-IV.

At the annual meeting of the American College of Psychiatrists, Dr. Kupfer, chair of the DSM-5 task force and professor of psychiatry at the University of Pittsburgh, said the DSM-IV’s organizational structure "failed to reflect shared features or symptoms of related disorders and diagnostic groups, like psychotic disorders with bipolar disorders or internalizing and externalizing disorders. This led us to restructure DSM-5 in a way that better reflects these interrelationships, within and across diagnostic chapters."

The DSM-IV also was limited, he said, because it promoted a strict categorical approach to making diagnoses, the notion that "either you have it or you don’t," Dr. Kupfer said at the annual meeting of the American College of Psychiatrists. "This tends not to capture the variations of disorders that we see in real life. As a consequence, more ‘not otherwise specified’ designations were used than probably were necessary." Nor did the DSM-IV adequately address lifespan perspective, he said, including variations of symptom presentation across the developmental trajectory, or cultural perspectives. "That’s a deficiency, I think."

The 20-chapter DSM-5 – an 8-year effort that involved input from about 400 clinicians at 13 international conferences – "represents an opportunity to integrate cross-cutting symptomatic descriptions which better reflect the true presentation of disorders and may reduce reliance on ‘not otherwise specified’ diagnoses," Dr. Kupfer said. Its chapter structure, criteria revisions, and text outline "actively address age and development as part of diagnosis and classification," he said. "Culture is similarly discussed more explicitly to bring greater attention to cultural variations in symptom presentations."

Dr. Kupfer described the DSM-5 as a "living document," meaning that it will be more amenable to updates in psychiatry and neuroscience, and less susceptible to becoming outdated, compared with its predecessors. "We do not want to wait for 20 or 25 years for the next change to be made in the DSM," he emphasized. "We want to take advantage of advances that are likely to be made in certain areas of diagnostic nomenclature that can be put into the DSM and give us more objective criteria than we currently have for most of our disorders."

At the meeting, Dr. Kupfer and Dr. Darrel A. Regier, vice chair of the DSM-5 task force, highlighted select changes from DSM-IV that clinicians can expect to find in DSM-5. For example, autism spectrum disorder is now a single diagnosis. "The concern within the clinical and research field was that it was not possible to consistently break out autism, Asperger’s disorder, and pervasive developmental disorder not otherwise specified," said Dr. Regier, director of the American Psychiatric Institute for Research and Education and director of the division of research at the American Psychiatric Association. "There was a universal agreement that this needed to be seen as a spectrum of disorders that would be assessed on the basis of two domains: One was social communication and the other was restricted repetitive behaviors and interests.

"If one would rank people on the basis of their impairment in those two areas, that would be much more informative for guiding treatment and educational programs. That was a critical concern," he said.

The DSM-5 includes the addition of a specifier for all neurodevelopmental disorders associated with known medical or genetic conditions, or environmental factors. Specifiers are also included for specific learning disorders in reading, writing, and math.

In schizophrenia, special treatment of bizarre delusions and special hallucinations in criterion A (characteristic symptoms) has been eliminated. "With DSM-IV, you could get a diagnosis of schizophrenia if you just had bizarre delusions, but research shows that there is very poor reliability in separating bizarre and nonbizarre delusions," Dr. Regier said. Now, at least one psychotic symptom is required for a diagnosis of schizophrenia. "You have to have delusions, hallucinations, or disorganized speech in order to meet criteria," he said.

In a related development, catatonia exists as a specifier for neurodevelopmental, psychotic, mood, and other mental disorders, as well as for catatonia due to another medical condition.

In bipolar disorder, increased energy/activity as a criterion A symptom of hypomania/mania has been included. "Although those aspects have been included as symptoms previously, what is now recommended is that they become part of the criterion A, along with changes in mood," Dr. Kupfer said. The DSM-5 also includes a "with mixed features" specifier for manic, hypomanic, and major depressive episodes, which "better reflects what clinicians see and what they need to diagnose."

Depressive disorders are now organized in a dedicated chapter separate from bipolar and related disorders. In major depressive episode, the bereavement exclusion has been eliminated. "The basic message in the bereavement exclusion from DSM-IV was that we as clinicians could not diagnose major depression during the first 2 months following a bereavement," Dr. Kupfer said. "This would be independent of how the person might be suffering during that 2-month period. The other thing that seemed to be implied, which was very unfortunate, was that a number of people concluded that bereavement may only last 2 months, when in fact all of us know that bereavement often lasts a lot longer than 2 months." The DSM-5 includes a criteria note "that allows one to think about the presence of major depression while someone is also experiencing a significant loss."

Anxiety disorders are now organized in a dedicated chapter separate from other anxiety-related disorders. "With panic attacks" is a specifier for any mental disorder, and panic disorder and agoraphobia have become unlinked.

Another set of changes that were made in the DSM-5 related to either new disorders or in named disorders. For example, disruptive mood dysregulation disorder (DMDD) is a newcomer that addresses presentations of severe, nonepisodic irritability that has contributed to an upsurge of pediatric bipolar disorders. In DMDD, "symptoms overlap with oppositional defiance disorder but are considered more severe," Dr. Kupfer said. Meanwhile, premenstrual dysphoric disorder has been elevated from the appendix to the depressive disorders section of DSM-5, while binge eating disorder has been elevated from the appendix to the feeding and eating disorders section of the document.

Hoarding disorder is another newcomer to the DSM-5. "This is one of major public health significance because every department of public health in every county in the country has to deal with a hoarding issue, whether it’s animal-related or other forms of excessive acquisition," Dr. Regier said.

One change to posttraumatic stress disorder diagnoses includes removal of the A2 criteria, "which was that an individual not only has to be exposed an overwhelming stress but they have to react with horror or disgust," Dr. Regier said. "What was happening is that soldiers who are trained to immediately deal with horrendous experiences would say that their training ‘kicked in.’ They didn’t have the reaction – the A2 criteria – yet they subsequently would have clear criteria for PTSD. There was a need to eliminate that criteria to focus on four symptom clusters that filled out the syndrome." Now, the avoidance/numbing cluster has been divided into two distinct clusters: avoidance and persistent negative alterations in cognition and mood.

Dr. Regier predicted that the DSM-5 will make a significant contribution to assisting clinicians with diagnosing neurocognitive disorders. "An enormous amount of information has emerged in the area of neurocognitive disorders [in terms of] early differentiation of a probable Alzheimer’s disease versus a frontal temporal dementia diagnosis and differentiating dementia with Lewy bodies versus vascular dementia," he said. Going forward, he continued: "I think the biggest challenge is going to be making the distinction between mild dementia and normality. We’re working to develop a computer-assisted neurocognitive test that clinicians can use in their office to do some screening in this area. It would also be helpful for looking at cognitive impairment in schizophrenia. That’s in the future, but it’s an area we know we need to move forward with."

Neither Dr. Kupfer nor Dr. Regier had relevant financial conflicts to disclose.

d.brunk@elsevier.com

When the DSM-5 is unveiled at the annual meeting of the American Psychiatric Association in May, Dr. David J. Kupfer hopes that clinicians will find a more user-friendly document compared with the DSM-IV.

At the annual meeting of the American College of Psychiatrists, Dr. Kupfer, chair of the DSM-5 task force and professor of psychiatry at the University of Pittsburgh, said the DSM-IV’s organizational structure "failed to reflect shared features or symptoms of related disorders and diagnostic groups, like psychotic disorders with bipolar disorders or internalizing and externalizing disorders. This led us to restructure DSM-5 in a way that better reflects these interrelationships, within and across diagnostic chapters."

The DSM-IV also was limited, he said, because it promoted a strict categorical approach to making diagnoses, the notion that "either you have it or you don’t," Dr. Kupfer said at the annual meeting of the American College of Psychiatrists. "This tends not to capture the variations of disorders that we see in real life. As a consequence, more ‘not otherwise specified’ designations were used than probably were necessary." Nor did the DSM-IV adequately address lifespan perspective, he said, including variations of symptom presentation across the developmental trajectory, or cultural perspectives. "That’s a deficiency, I think."

The 20-chapter DSM-5 – an 8-year effort that involved input from about 400 clinicians at 13 international conferences – "represents an opportunity to integrate cross-cutting symptomatic descriptions which better reflect the true presentation of disorders and may reduce reliance on ‘not otherwise specified’ diagnoses," Dr. Kupfer said. Its chapter structure, criteria revisions, and text outline "actively address age and development as part of diagnosis and classification," he said. "Culture is similarly discussed more explicitly to bring greater attention to cultural variations in symptom presentations."

Dr. Kupfer described the DSM-5 as a "living document," meaning that it will be more amenable to updates in psychiatry and neuroscience, and less susceptible to becoming outdated, compared with its predecessors. "We do not want to wait for 20 or 25 years for the next change to be made in the DSM," he emphasized. "We want to take advantage of advances that are likely to be made in certain areas of diagnostic nomenclature that can be put into the DSM and give us more objective criteria than we currently have for most of our disorders."

At the meeting, Dr. Kupfer and Dr. Darrel A. Regier, vice chair of the DSM-5 task force, highlighted select changes from DSM-IV that clinicians can expect to find in DSM-5. For example, autism spectrum disorder is now a single diagnosis. "The concern within the clinical and research field was that it was not possible to consistently break out autism, Asperger’s disorder, and pervasive developmental disorder not otherwise specified," said Dr. Regier, director of the American Psychiatric Institute for Research and Education and director of the division of research at the American Psychiatric Association. "There was a universal agreement that this needed to be seen as a spectrum of disorders that would be assessed on the basis of two domains: One was social communication and the other was restricted repetitive behaviors and interests.

"If one would rank people on the basis of their impairment in those two areas, that would be much more informative for guiding treatment and educational programs. That was a critical concern," he said.

The DSM-5 includes the addition of a specifier for all neurodevelopmental disorders associated with known medical or genetic conditions, or environmental factors. Specifiers are also included for specific learning disorders in reading, writing, and math.

In schizophrenia, special treatment of bizarre delusions and special hallucinations in criterion A (characteristic symptoms) has been eliminated. "With DSM-IV, you could get a diagnosis of schizophrenia if you just had bizarre delusions, but research shows that there is very poor reliability in separating bizarre and nonbizarre delusions," Dr. Regier said. Now, at least one psychotic symptom is required for a diagnosis of schizophrenia. "You have to have delusions, hallucinations, or disorganized speech in order to meet criteria," he said.

In a related development, catatonia exists as a specifier for neurodevelopmental, psychotic, mood, and other mental disorders, as well as for catatonia due to another medical condition.

In bipolar disorder, increased energy/activity as a criterion A symptom of hypomania/mania has been included. "Although those aspects have been included as symptoms previously, what is now recommended is that they become part of the criterion A, along with changes in mood," Dr. Kupfer said. The DSM-5 also includes a "with mixed features" specifier for manic, hypomanic, and major depressive episodes, which "better reflects what clinicians see and what they need to diagnose."

Depressive disorders are now organized in a dedicated chapter separate from bipolar and related disorders. In major depressive episode, the bereavement exclusion has been eliminated. "The basic message in the bereavement exclusion from DSM-IV was that we as clinicians could not diagnose major depression during the first 2 months following a bereavement," Dr. Kupfer said. "This would be independent of how the person might be suffering during that 2-month period. The other thing that seemed to be implied, which was very unfortunate, was that a number of people concluded that bereavement may only last 2 months, when in fact all of us know that bereavement often lasts a lot longer than 2 months." The DSM-5 includes a criteria note "that allows one to think about the presence of major depression while someone is also experiencing a significant loss."

Anxiety disorders are now organized in a dedicated chapter separate from other anxiety-related disorders. "With panic attacks" is a specifier for any mental disorder, and panic disorder and agoraphobia have become unlinked.

Another set of changes that were made in the DSM-5 related to either new disorders or in named disorders. For example, disruptive mood dysregulation disorder (DMDD) is a newcomer that addresses presentations of severe, nonepisodic irritability that has contributed to an upsurge of pediatric bipolar disorders. In DMDD, "symptoms overlap with oppositional defiance disorder but are considered more severe," Dr. Kupfer said. Meanwhile, premenstrual dysphoric disorder has been elevated from the appendix to the depressive disorders section of DSM-5, while binge eating disorder has been elevated from the appendix to the feeding and eating disorders section of the document.

Hoarding disorder is another newcomer to the DSM-5. "This is one of major public health significance because every department of public health in every county in the country has to deal with a hoarding issue, whether it’s animal-related or other forms of excessive acquisition," Dr. Regier said.

One change to posttraumatic stress disorder diagnoses includes removal of the A2 criteria, "which was that an individual not only has to be exposed an overwhelming stress but they have to react with horror or disgust," Dr. Regier said. "What was happening is that soldiers who are trained to immediately deal with horrendous experiences would say that their training ‘kicked in.’ They didn’t have the reaction – the A2 criteria – yet they subsequently would have clear criteria for PTSD. There was a need to eliminate that criteria to focus on four symptom clusters that filled out the syndrome." Now, the avoidance/numbing cluster has been divided into two distinct clusters: avoidance and persistent negative alterations in cognition and mood.

Dr. Regier predicted that the DSM-5 will make a significant contribution to assisting clinicians with diagnosing neurocognitive disorders. "An enormous amount of information has emerged in the area of neurocognitive disorders [in terms of] early differentiation of a probable Alzheimer’s disease versus a frontal temporal dementia diagnosis and differentiating dementia with Lewy bodies versus vascular dementia," he said. Going forward, he continued: "I think the biggest challenge is going to be making the distinction between mild dementia and normality. We’re working to develop a computer-assisted neurocognitive test that clinicians can use in their office to do some screening in this area. It would also be helpful for looking at cognitive impairment in schizophrenia. That’s in the future, but it’s an area we know we need to move forward with."

Neither Dr. Kupfer nor Dr. Regier had relevant financial conflicts to disclose.

d.brunk@elsevier.com

When the DSM-5 is unveiled at the annual meeting of the American Psychiatric Association in May, Dr. David J. Kupfer hopes that clinicians will find a more user-friendly document compared with the DSM-IV.

At the annual meeting of the American College of Psychiatrists, Dr. Kupfer, chair of the DSM-5 task force and professor of psychiatry at the University of Pittsburgh, said the DSM-IV’s organizational structure "failed to reflect shared features or symptoms of related disorders and diagnostic groups, like psychotic disorders with bipolar disorders or internalizing and externalizing disorders. This led us to restructure DSM-5 in a way that better reflects these interrelationships, within and across diagnostic chapters."

The DSM-IV also was limited, he said, because it promoted a strict categorical approach to making diagnoses, the notion that "either you have it or you don’t," Dr. Kupfer said at the annual meeting of the American College of Psychiatrists. "This tends not to capture the variations of disorders that we see in real life. As a consequence, more ‘not otherwise specified’ designations were used than probably were necessary." Nor did the DSM-IV adequately address lifespan perspective, he said, including variations of symptom presentation across the developmental trajectory, or cultural perspectives. "That’s a deficiency, I think."

The 20-chapter DSM-5 – an 8-year effort that involved input from about 400 clinicians at 13 international conferences – "represents an opportunity to integrate cross-cutting symptomatic descriptions which better reflect the true presentation of disorders and may reduce reliance on ‘not otherwise specified’ diagnoses," Dr. Kupfer said. Its chapter structure, criteria revisions, and text outline "actively address age and development as part of diagnosis and classification," he said. "Culture is similarly discussed more explicitly to bring greater attention to cultural variations in symptom presentations."

Dr. Kupfer described the DSM-5 as a "living document," meaning that it will be more amenable to updates in psychiatry and neuroscience, and less susceptible to becoming outdated, compared with its predecessors. "We do not want to wait for 20 or 25 years for the next change to be made in the DSM," he emphasized. "We want to take advantage of advances that are likely to be made in certain areas of diagnostic nomenclature that can be put into the DSM and give us more objective criteria than we currently have for most of our disorders."

At the meeting, Dr. Kupfer and Dr. Darrel A. Regier, vice chair of the DSM-5 task force, highlighted select changes from DSM-IV that clinicians can expect to find in DSM-5. For example, autism spectrum disorder is now a single diagnosis. "The concern within the clinical and research field was that it was not possible to consistently break out autism, Asperger’s disorder, and pervasive developmental disorder not otherwise specified," said Dr. Regier, director of the American Psychiatric Institute for Research and Education and director of the division of research at the American Psychiatric Association. "There was a universal agreement that this needed to be seen as a spectrum of disorders that would be assessed on the basis of two domains: One was social communication and the other was restricted repetitive behaviors and interests.

"If one would rank people on the basis of their impairment in those two areas, that would be much more informative for guiding treatment and educational programs. That was a critical concern," he said.

The DSM-5 includes the addition of a specifier for all neurodevelopmental disorders associated with known medical or genetic conditions, or environmental factors. Specifiers are also included for specific learning disorders in reading, writing, and math.

In schizophrenia, special treatment of bizarre delusions and special hallucinations in criterion A (characteristic symptoms) has been eliminated. "With DSM-IV, you could get a diagnosis of schizophrenia if you just had bizarre delusions, but research shows that there is very poor reliability in separating bizarre and nonbizarre delusions," Dr. Regier said. Now, at least one psychotic symptom is required for a diagnosis of schizophrenia. "You have to have delusions, hallucinations, or disorganized speech in order to meet criteria," he said.

In a related development, catatonia exists as a specifier for neurodevelopmental, psychotic, mood, and other mental disorders, as well as for catatonia due to another medical condition.

In bipolar disorder, increased energy/activity as a criterion A symptom of hypomania/mania has been included. "Although those aspects have been included as symptoms previously, what is now recommended is that they become part of the criterion A, along with changes in mood," Dr. Kupfer said. The DSM-5 also includes a "with mixed features" specifier for manic, hypomanic, and major depressive episodes, which "better reflects what clinicians see and what they need to diagnose."

Depressive disorders are now organized in a dedicated chapter separate from bipolar and related disorders. In major depressive episode, the bereavement exclusion has been eliminated. "The basic message in the bereavement exclusion from DSM-IV was that we as clinicians could not diagnose major depression during the first 2 months following a bereavement," Dr. Kupfer said. "This would be independent of how the person might be suffering during that 2-month period. The other thing that seemed to be implied, which was very unfortunate, was that a number of people concluded that bereavement may only last 2 months, when in fact all of us know that bereavement often lasts a lot longer than 2 months." The DSM-5 includes a criteria note "that allows one to think about the presence of major depression while someone is also experiencing a significant loss."

Anxiety disorders are now organized in a dedicated chapter separate from other anxiety-related disorders. "With panic attacks" is a specifier for any mental disorder, and panic disorder and agoraphobia have become unlinked.

Another set of changes that were made in the DSM-5 related to either new disorders or in named disorders. For example, disruptive mood dysregulation disorder (DMDD) is a newcomer that addresses presentations of severe, nonepisodic irritability that has contributed to an upsurge of pediatric bipolar disorders. In DMDD, "symptoms overlap with oppositional defiance disorder but are considered more severe," Dr. Kupfer said. Meanwhile, premenstrual dysphoric disorder has been elevated from the appendix to the depressive disorders section of DSM-5, while binge eating disorder has been elevated from the appendix to the feeding and eating disorders section of the document.

Hoarding disorder is another newcomer to the DSM-5. "This is one of major public health significance because every department of public health in every county in the country has to deal with a hoarding issue, whether it’s animal-related or other forms of excessive acquisition," Dr. Regier said.

One change to posttraumatic stress disorder diagnoses includes removal of the A2 criteria, "which was that an individual not only has to be exposed an overwhelming stress but they have to react with horror or disgust," Dr. Regier said. "What was happening is that soldiers who are trained to immediately deal with horrendous experiences would say that their training ‘kicked in.’ They didn’t have the reaction – the A2 criteria – yet they subsequently would have clear criteria for PTSD. There was a need to eliminate that criteria to focus on four symptom clusters that filled out the syndrome." Now, the avoidance/numbing cluster has been divided into two distinct clusters: avoidance and persistent negative alterations in cognition and mood.

Dr. Regier predicted that the DSM-5 will make a significant contribution to assisting clinicians with diagnosing neurocognitive disorders. "An enormous amount of information has emerged in the area of neurocognitive disorders [in terms of] early differentiation of a probable Alzheimer’s disease versus a frontal temporal dementia diagnosis and differentiating dementia with Lewy bodies versus vascular dementia," he said. Going forward, he continued: "I think the biggest challenge is going to be making the distinction between mild dementia and normality. We’re working to develop a computer-assisted neurocognitive test that clinicians can use in their office to do some screening in this area. It would also be helpful for looking at cognitive impairment in schizophrenia. That’s in the future, but it’s an area we know we need to move forward with."

Neither Dr. Kupfer nor Dr. Regier had relevant financial conflicts to disclose.

d.brunk@elsevier.com

In the opinion of Dr. Darrell G. Kirch, physicians who work in academic medical centers are in a unique position to lead health care reform efforts in America.

"We have to do it, because I don’t think there’s anyone else out there," Dr. Kirch, president and CEO of the Association of American Medical Colleges (AAMC), told attendees at the annual meeting of the American College of Psychiatrists. "With all due respect to those of you who are in private practice and small group practice – which will have a real place in the system of the future – the task of redesigning the health care system is going to take new kinds of activity and partnerships between physicians and health care systems unlike anything we’ve seen in the past."

Though AAMC member institutions represent only 6% of all hospitals, he said, they are well represented among the demonstration projects and new health care models being rolled out by the Center for Medicare and Medicaid Innovation. One in five of Medicare accountable care organizations is an AAMC member institution, as are more than two in five health care innovation award grantees, and a third of innovation adviser program members.

"This does not look to me like academic medicine is holding its breath, threatening to do so until it turns blue and not change," said Dr. Kirch, who is trained as a psychiatrist and clinical neuroscientist. "It looks to me like academic medical centers are really engaging in innovations in a serious way."

Further, psychiatrists are poised to be on the frontline of change, because they excel in certain "core competencies," including delivery of patient care that is compassionate, appropriate, and effective; practice-based learning and improvement; interpersonal and communication skills; a sense of professionalism; and experience with systems-based practice, he said.

"I don’t know of any other medical specialty in a better position to take the lead in finding ways to teach these core competencies than psychiatry," Dr. Kirch said. "It’s our responsibility. If we’re passive, I think we could become an endangered species. I think the opposite is true. This is going to take different kinds of leadership from us, not [from] someone else."

– Doug Brunk

d.brunk@elsevier.com

On Twitter @dougbrunk

In the opinion of Dr. Darrell G. Kirch, physicians who work in academic medical centers are in a unique position to lead health care reform efforts in America.

"We have to do it, because I don’t think there’s anyone else out there," Dr. Kirch, president and CEO of the Association of American Medical Colleges (AAMC), told attendees at the annual meeting of the American College of Psychiatrists. "With all due respect to those of you who are in private practice and small group practice – which will have a real place in the system of the future – the task of redesigning the health care system is going to take new kinds of activity and partnerships between physicians and health care systems unlike anything we’ve seen in the past."

Though AAMC member institutions represent only 6% of all hospitals, he said, they are well represented among the demonstration projects and new health care models being rolled out by the Center for Medicare and Medicaid Innovation. One in five of Medicare accountable care organizations is an AAMC member institution, as are more than two in five health care innovation award grantees, and a third of innovation adviser program members.

"This does not look to me like academic medicine is holding its breath, threatening to do so until it turns blue and not change," said Dr. Kirch, who is trained as a psychiatrist and clinical neuroscientist. "It looks to me like academic medical centers are really engaging in innovations in a serious way."

Further, psychiatrists are poised to be on the frontline of change, because they excel in certain "core competencies," including delivery of patient care that is compassionate, appropriate, and effective; practice-based learning and improvement; interpersonal and communication skills; a sense of professionalism; and experience with systems-based practice, he said.

"I don’t know of any other medical specialty in a better position to take the lead in finding ways to teach these core competencies than psychiatry," Dr. Kirch said. "It’s our responsibility. If we’re passive, I think we could become an endangered species. I think the opposite is true. This is going to take different kinds of leadership from us, not [from] someone else."

– Doug Brunk

d.brunk@elsevier.com

On Twitter @dougbrunk

In the opinion of Dr. Darrell G. Kirch, physicians who work in academic medical centers are in a unique position to lead health care reform efforts in America.

"We have to do it, because I don’t think there’s anyone else out there," Dr. Kirch, president and CEO of the Association of American Medical Colleges (AAMC), told attendees at the annual meeting of the American College of Psychiatrists. "With all due respect to those of you who are in private practice and small group practice – which will have a real place in the system of the future – the task of redesigning the health care system is going to take new kinds of activity and partnerships between physicians and health care systems unlike anything we’ve seen in the past."

Though AAMC member institutions represent only 6% of all hospitals, he said, they are well represented among the demonstration projects and new health care models being rolled out by the Center for Medicare and Medicaid Innovation. One in five of Medicare accountable care organizations is an AAMC member institution, as are more than two in five health care innovation award grantees, and a third of innovation adviser program members.

"This does not look to me like academic medicine is holding its breath, threatening to do so until it turns blue and not change," said Dr. Kirch, who is trained as a psychiatrist and clinical neuroscientist. "It looks to me like academic medical centers are really engaging in innovations in a serious way."

Further, psychiatrists are poised to be on the frontline of change, because they excel in certain "core competencies," including delivery of patient care that is compassionate, appropriate, and effective; practice-based learning and improvement; interpersonal and communication skills; a sense of professionalism; and experience with systems-based practice, he said.

"I don’t know of any other medical specialty in a better position to take the lead in finding ways to teach these core competencies than psychiatry," Dr. Kirch said. "It’s our responsibility. If we’re passive, I think we could become an endangered species. I think the opposite is true. This is going to take different kinds of leadership from us, not [from] someone else."

– Doug Brunk

d.brunk@elsevier.com

On Twitter @dougbrunk