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Impairment persists despite treatment in adult ADHD
SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.
The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.
The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.
“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.
For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).
Other statistically significant between-group differences were seen related to managing affect and emotions, sustaining effort, working memory and recall, and interpersonal relationships.
“In addition to the burden patients report across the day, they also expressed significant challenges with psychosocial functioning and managing the demands of work, social, and family life despite treatment,” said Norman Atkins, PhD, of Shire, a coauthor of the study.
A separate poster by the same research group, using the same study data from the cohort of 616 currently treated adult ADHD patients (mean age 39, 70% female) looked at self-reported impairment across daily life domains by patients under different medication regimens.
Patients in the cohort were treated with short-acting stimulants (n = 166), long-acting stimulants (n = 201), or augmentation strategies (n = 249). The researchers found that afternoons and evenings were most difficult for patients regardless of treatment approach.
Ms. Khachatryan said the study was intended to help clinicians “understand what we’re offering patients and if we’re adequately meeting the needs of patients across the day. And we found that adults experience burden across the day despite being treated, and what they report as the most challenging times of day are the afternoon and evening hours,” when work, family, and household obligations are likely to be present.
Dr. Atkins added: “From an ADHD management perspective, the key takeaway is that these impairments occur across multiple settings and are most problematic at certain times of the day. It’s important for providers to have a meaningful conversation with their patients about their day-to-day challenges to fully appreciate how ADHD impacts their functioning so they can best optimize care.”
The researchers acknowledged as limitations of their study its high number of women participants, potentially reducing the generalizability of its findings; the reliance on self-reported outcomes; and between-group differences for the ADHD and non-ADHD groups that included differences in mean age (39 vs. 43, respectively) and full-time employment status (57% vs. 42%).
The study was sponsored by Shire Pharmaceuticals, with three of its five coauthors employed by the company.
SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.
The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.
The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.
“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.
For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).
Other statistically significant between-group differences were seen related to managing affect and emotions, sustaining effort, working memory and recall, and interpersonal relationships.
“In addition to the burden patients report across the day, they also expressed significant challenges with psychosocial functioning and managing the demands of work, social, and family life despite treatment,” said Norman Atkins, PhD, of Shire, a coauthor of the study.
A separate poster by the same research group, using the same study data from the cohort of 616 currently treated adult ADHD patients (mean age 39, 70% female) looked at self-reported impairment across daily life domains by patients under different medication regimens.
Patients in the cohort were treated with short-acting stimulants (n = 166), long-acting stimulants (n = 201), or augmentation strategies (n = 249). The researchers found that afternoons and evenings were most difficult for patients regardless of treatment approach.
Ms. Khachatryan said the study was intended to help clinicians “understand what we’re offering patients and if we’re adequately meeting the needs of patients across the day. And we found that adults experience burden across the day despite being treated, and what they report as the most challenging times of day are the afternoon and evening hours,” when work, family, and household obligations are likely to be present.
Dr. Atkins added: “From an ADHD management perspective, the key takeaway is that these impairments occur across multiple settings and are most problematic at certain times of the day. It’s important for providers to have a meaningful conversation with their patients about their day-to-day challenges to fully appreciate how ADHD impacts their functioning so they can best optimize care.”
The researchers acknowledged as limitations of their study its high number of women participants, potentially reducing the generalizability of its findings; the reliance on self-reported outcomes; and between-group differences for the ADHD and non-ADHD groups that included differences in mean age (39 vs. 43, respectively) and full-time employment status (57% vs. 42%).
The study was sponsored by Shire Pharmaceuticals, with three of its five coauthors employed by the company.
SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.
The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.
The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.
“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.
For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).
Other statistically significant between-group differences were seen related to managing affect and emotions, sustaining effort, working memory and recall, and interpersonal relationships.
“In addition to the burden patients report across the day, they also expressed significant challenges with psychosocial functioning and managing the demands of work, social, and family life despite treatment,” said Norman Atkins, PhD, of Shire, a coauthor of the study.
A separate poster by the same research group, using the same study data from the cohort of 616 currently treated adult ADHD patients (mean age 39, 70% female) looked at self-reported impairment across daily life domains by patients under different medication regimens.
Patients in the cohort were treated with short-acting stimulants (n = 166), long-acting stimulants (n = 201), or augmentation strategies (n = 249). The researchers found that afternoons and evenings were most difficult for patients regardless of treatment approach.
Ms. Khachatryan said the study was intended to help clinicians “understand what we’re offering patients and if we’re adequately meeting the needs of patients across the day. And we found that adults experience burden across the day despite being treated, and what they report as the most challenging times of day are the afternoon and evening hours,” when work, family, and household obligations are likely to be present.
Dr. Atkins added: “From an ADHD management perspective, the key takeaway is that these impairments occur across multiple settings and are most problematic at certain times of the day. It’s important for providers to have a meaningful conversation with their patients about their day-to-day challenges to fully appreciate how ADHD impacts their functioning so they can best optimize care.”
The researchers acknowledged as limitations of their study its high number of women participants, potentially reducing the generalizability of its findings; the reliance on self-reported outcomes; and between-group differences for the ADHD and non-ADHD groups that included differences in mean age (39 vs. 43, respectively) and full-time employment status (57% vs. 42%).
The study was sponsored by Shire Pharmaceuticals, with three of its five coauthors employed by the company.
AT APA
Long-acting injectables may be best at preventing relapse in psychosis
SAN DIEGO – A new meta-analysis suggests that second-generation long-acting injectable antipsychotics (LAIs) are slightly better than oral antipsychotics at preventing relapse after a first psychotic incident.
The meta-analysis, released at the annual meeting of the American Psychiatric Association, is limited because it looks at only three studies. Still, study lead author Christine Tran-Boynes, DO, said the findings are useful for psychiatrists.
“For a long time, LAIs were associated with severely ill psychotic patients who were frequently hospitalized and not compliant with their oral meds,” Dr. Tran-Boynes, a resident at the University of Maryland, Baltimore, said in an interview. “The purpose of this paper is to change the perception of LAIs. They are not just a medication of last resort in those with severe, chronic psychosis but, instead, can be used in the early stages of psychosis as prophylaxis against relapse.”
Injectable antipsychotics are more commonly used in Europe, where “there also seemed to be a greater willingness among patients to receive this treatment,” said Peter F. Buckley, MD, dean of the medical school at Virginia Commonwealth University, Richmond.
The APA’s schizophrenia treatment guidelines recommend LAIs for patients with “recurrent relapses related to nonadherence” and patients who prefer the shots. Dr. Tran-Boynes notes that “the most common cause of relapse in patients with schizophrenia is partial adherence or nonadherence to oral antipsychotics. If LAIs can improve adherence in patients and monitoring of adherence for clinicians, they could have a role in preventing relapse during this critical period in psychosis.”
The meta-analysis examines three randomized controlled studies – two from 2015 and one from 2013 – that compare second-generation LAIs to first- and second-generation oral antipsychotics after first episodes of psychosis. Dr. Tran-Boynes said researchers could not find any studies comparing first-generation long-acting antipsychotics to oral antipsychotics.
The largest study had 769 participants; the others had 85 and 86. The subjects, all adults, had diagnoses of schizophrenia, schizoaffective disorder, or schizophreniform disorder. Their diagnoses must have been made within the previous 5 years.
According to the meta-analysis, relapses after first-episode psychosis were more likely (relative risk, 1.078; 95% confidence interval, 1.007-1.154; P = 0.012) in patients taking first- or second-generation oral antipsychotics, compared with those on second-generation LAIs.
“There was an 8% greater efficacy for LAIs preventing relapse after early psychosis, compared to oral antipsychotics,” Dr. Tran-Boynes said. She calculated the number needed to treat as 14.
The percentages of patients who did not relapse while taking second-generation LAIs ranged from 73% (31 of 42 patients randomized to an injectable risperidone arm over 24 months) to 95% (38 of 40 patients over a 12-month study, also of injectable risperidone), Dr. Tran-Boynes said.
When asked about the meta-analysis, Robert Rosenheck, MD, expressed concern.
“While well done, it is based on too few studies to give useful guidance to practice,” said Dr. Rosenheck, professor of psychiatry, epidemiology and public health at Yale University, New Haven, Conn.
Dr. Buckley also noted that the meta-analysis includes a small number of studies. “The effect is sizable for a first-episode population, but other studies to date are more mixed,” he added. “For instance, in a study among a more chronic schizophrenic population, we found no difference between a group receiving long-acting injectable risperidone and oral second-generation antipsychotics” (Schizophr Bull. 2015 Mar;41[2]:449-59).
What should psychiatrists know when they consider prescribing LAIs to prevent psychotic relapse? “If a patient expresses willingness to take an oral antipsychotic on a daily basis and/or has someone to monitor his medication intake, then prescribing an oral antipsychotic would be the ideal route,” Dr. Tran-Boynes said. “However, I would recommend LAIs to patients who have demonstrated poor compliance with previous medications in general, poor awareness of psychosis, poor awareness of need for treatment, poor availability of social support to ensure that the patient will take his/her medication daily, and/or if a patient expresses preference for LAIs.”
She cautioned that LAIs have disadvantages. Compared with oral antipsychotics, it’s harder to adjust patients’ dosages in response to side effects or when they improve, she said. LAIs are also more expensive in the short term, she said.
However, LAIs also may have produced fewer side effects, and there aren’t any questions about compliance, she said. In addition, “there’s less pain at the injection site with second-generation LAIs, compared to first-generation LAIs, due to the water-based solution of the former. The oil-based solutions that are characteristic of first-generation LAIs have been shown in studies to be very painful.”
Dr. Tran-Boynes and Dr. Rosenheck reported no relevant disclosures. Dr. Buckley disclosed that he is a research consultant for the National Institute of Mental Health.
SAN DIEGO – A new meta-analysis suggests that second-generation long-acting injectable antipsychotics (LAIs) are slightly better than oral antipsychotics at preventing relapse after a first psychotic incident.
The meta-analysis, released at the annual meeting of the American Psychiatric Association, is limited because it looks at only three studies. Still, study lead author Christine Tran-Boynes, DO, said the findings are useful for psychiatrists.
“For a long time, LAIs were associated with severely ill psychotic patients who were frequently hospitalized and not compliant with their oral meds,” Dr. Tran-Boynes, a resident at the University of Maryland, Baltimore, said in an interview. “The purpose of this paper is to change the perception of LAIs. They are not just a medication of last resort in those with severe, chronic psychosis but, instead, can be used in the early stages of psychosis as prophylaxis against relapse.”
Injectable antipsychotics are more commonly used in Europe, where “there also seemed to be a greater willingness among patients to receive this treatment,” said Peter F. Buckley, MD, dean of the medical school at Virginia Commonwealth University, Richmond.
The APA’s schizophrenia treatment guidelines recommend LAIs for patients with “recurrent relapses related to nonadherence” and patients who prefer the shots. Dr. Tran-Boynes notes that “the most common cause of relapse in patients with schizophrenia is partial adherence or nonadherence to oral antipsychotics. If LAIs can improve adherence in patients and monitoring of adherence for clinicians, they could have a role in preventing relapse during this critical period in psychosis.”
The meta-analysis examines three randomized controlled studies – two from 2015 and one from 2013 – that compare second-generation LAIs to first- and second-generation oral antipsychotics after first episodes of psychosis. Dr. Tran-Boynes said researchers could not find any studies comparing first-generation long-acting antipsychotics to oral antipsychotics.
The largest study had 769 participants; the others had 85 and 86. The subjects, all adults, had diagnoses of schizophrenia, schizoaffective disorder, or schizophreniform disorder. Their diagnoses must have been made within the previous 5 years.
According to the meta-analysis, relapses after first-episode psychosis were more likely (relative risk, 1.078; 95% confidence interval, 1.007-1.154; P = 0.012) in patients taking first- or second-generation oral antipsychotics, compared with those on second-generation LAIs.
“There was an 8% greater efficacy for LAIs preventing relapse after early psychosis, compared to oral antipsychotics,” Dr. Tran-Boynes said. She calculated the number needed to treat as 14.
The percentages of patients who did not relapse while taking second-generation LAIs ranged from 73% (31 of 42 patients randomized to an injectable risperidone arm over 24 months) to 95% (38 of 40 patients over a 12-month study, also of injectable risperidone), Dr. Tran-Boynes said.
When asked about the meta-analysis, Robert Rosenheck, MD, expressed concern.
“While well done, it is based on too few studies to give useful guidance to practice,” said Dr. Rosenheck, professor of psychiatry, epidemiology and public health at Yale University, New Haven, Conn.
Dr. Buckley also noted that the meta-analysis includes a small number of studies. “The effect is sizable for a first-episode population, but other studies to date are more mixed,” he added. “For instance, in a study among a more chronic schizophrenic population, we found no difference between a group receiving long-acting injectable risperidone and oral second-generation antipsychotics” (Schizophr Bull. 2015 Mar;41[2]:449-59).
What should psychiatrists know when they consider prescribing LAIs to prevent psychotic relapse? “If a patient expresses willingness to take an oral antipsychotic on a daily basis and/or has someone to monitor his medication intake, then prescribing an oral antipsychotic would be the ideal route,” Dr. Tran-Boynes said. “However, I would recommend LAIs to patients who have demonstrated poor compliance with previous medications in general, poor awareness of psychosis, poor awareness of need for treatment, poor availability of social support to ensure that the patient will take his/her medication daily, and/or if a patient expresses preference for LAIs.”
She cautioned that LAIs have disadvantages. Compared with oral antipsychotics, it’s harder to adjust patients’ dosages in response to side effects or when they improve, she said. LAIs are also more expensive in the short term, she said.
However, LAIs also may have produced fewer side effects, and there aren’t any questions about compliance, she said. In addition, “there’s less pain at the injection site with second-generation LAIs, compared to first-generation LAIs, due to the water-based solution of the former. The oil-based solutions that are characteristic of first-generation LAIs have been shown in studies to be very painful.”
Dr. Tran-Boynes and Dr. Rosenheck reported no relevant disclosures. Dr. Buckley disclosed that he is a research consultant for the National Institute of Mental Health.
SAN DIEGO – A new meta-analysis suggests that second-generation long-acting injectable antipsychotics (LAIs) are slightly better than oral antipsychotics at preventing relapse after a first psychotic incident.
The meta-analysis, released at the annual meeting of the American Psychiatric Association, is limited because it looks at only three studies. Still, study lead author Christine Tran-Boynes, DO, said the findings are useful for psychiatrists.
“For a long time, LAIs were associated with severely ill psychotic patients who were frequently hospitalized and not compliant with their oral meds,” Dr. Tran-Boynes, a resident at the University of Maryland, Baltimore, said in an interview. “The purpose of this paper is to change the perception of LAIs. They are not just a medication of last resort in those with severe, chronic psychosis but, instead, can be used in the early stages of psychosis as prophylaxis against relapse.”
Injectable antipsychotics are more commonly used in Europe, where “there also seemed to be a greater willingness among patients to receive this treatment,” said Peter F. Buckley, MD, dean of the medical school at Virginia Commonwealth University, Richmond.
The APA’s schizophrenia treatment guidelines recommend LAIs for patients with “recurrent relapses related to nonadherence” and patients who prefer the shots. Dr. Tran-Boynes notes that “the most common cause of relapse in patients with schizophrenia is partial adherence or nonadherence to oral antipsychotics. If LAIs can improve adherence in patients and monitoring of adherence for clinicians, they could have a role in preventing relapse during this critical period in psychosis.”
The meta-analysis examines three randomized controlled studies – two from 2015 and one from 2013 – that compare second-generation LAIs to first- and second-generation oral antipsychotics after first episodes of psychosis. Dr. Tran-Boynes said researchers could not find any studies comparing first-generation long-acting antipsychotics to oral antipsychotics.
The largest study had 769 participants; the others had 85 and 86. The subjects, all adults, had diagnoses of schizophrenia, schizoaffective disorder, or schizophreniform disorder. Their diagnoses must have been made within the previous 5 years.
According to the meta-analysis, relapses after first-episode psychosis were more likely (relative risk, 1.078; 95% confidence interval, 1.007-1.154; P = 0.012) in patients taking first- or second-generation oral antipsychotics, compared with those on second-generation LAIs.
“There was an 8% greater efficacy for LAIs preventing relapse after early psychosis, compared to oral antipsychotics,” Dr. Tran-Boynes said. She calculated the number needed to treat as 14.
The percentages of patients who did not relapse while taking second-generation LAIs ranged from 73% (31 of 42 patients randomized to an injectable risperidone arm over 24 months) to 95% (38 of 40 patients over a 12-month study, also of injectable risperidone), Dr. Tran-Boynes said.
When asked about the meta-analysis, Robert Rosenheck, MD, expressed concern.
“While well done, it is based on too few studies to give useful guidance to practice,” said Dr. Rosenheck, professor of psychiatry, epidemiology and public health at Yale University, New Haven, Conn.
Dr. Buckley also noted that the meta-analysis includes a small number of studies. “The effect is sizable for a first-episode population, but other studies to date are more mixed,” he added. “For instance, in a study among a more chronic schizophrenic population, we found no difference between a group receiving long-acting injectable risperidone and oral second-generation antipsychotics” (Schizophr Bull. 2015 Mar;41[2]:449-59).
What should psychiatrists know when they consider prescribing LAIs to prevent psychotic relapse? “If a patient expresses willingness to take an oral antipsychotic on a daily basis and/or has someone to monitor his medication intake, then prescribing an oral antipsychotic would be the ideal route,” Dr. Tran-Boynes said. “However, I would recommend LAIs to patients who have demonstrated poor compliance with previous medications in general, poor awareness of psychosis, poor awareness of need for treatment, poor availability of social support to ensure that the patient will take his/her medication daily, and/or if a patient expresses preference for LAIs.”
She cautioned that LAIs have disadvantages. Compared with oral antipsychotics, it’s harder to adjust patients’ dosages in response to side effects or when they improve, she said. LAIs are also more expensive in the short term, she said.
However, LAIs also may have produced fewer side effects, and there aren’t any questions about compliance, she said. In addition, “there’s less pain at the injection site with second-generation LAIs, compared to first-generation LAIs, due to the water-based solution of the former. The oil-based solutions that are characteristic of first-generation LAIs have been shown in studies to be very painful.”
Dr. Tran-Boynes and Dr. Rosenheck reported no relevant disclosures. Dr. Buckley disclosed that he is a research consultant for the National Institute of Mental Health.
AT APA
Key clinical point: Second-generation long-acting injectable antipsychotics (LAIs) may be better than oral antipsychotics at preventing relapse after first episode of psychosis.
Major finding: Relapses after first-episode psychosis were more likely (RR, 1.078; 95% CI, 1.007-1.154; P = 0.012) in patients on first- and second-generation oral antipsychotics, compared with second-generation LAIs.
Data source: Meta-analysis of three randomized controlled trials with 940 total patients.
Disclosures: Dr. Tran-Boynes reported having no relevant disclosures.
Hidden burdens, limited follow-up complicate refugee mental health
SAN DIEGO – Psychiatrists may encounter refugee patients from war-torn countries in virtually every part of the United States with complex mental health needs, including high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms, according to two presenters at the annual meeting of the American Psychiatric Association.
Over the past decade, refugees from Middle Eastern counties – particularly Iraq, Syria, and Afghanistan – have increased fourfold as a percentage of all refugees in the United States, while those from Sub-Saharan Africa continue to make up a large share. Despite heated political wrangling, the U.S. Department of State recently increased limits on the number of refugees that can be accepted. California, Texas, New York, Michigan, Ohio, and Washington are the states resettling the most new arrivals.
Refugees with trauma exposure have high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms. In addition, recent research suggests, these refugees may have poorly understood stressors related to migration and adjustment that also may be significant contributors to mental illness risk. Despite this, refugees generally have less access to mental health care than does the general population.
The presenters shared their perspectives on refugee mental health with findings that could inform the timing and nature of interventions in these potentially vulnerable populations.
Cynthia L. Arfken, PhD, of Wayne State University in Detroit, presented results from an ongoing cohort study of Syrian families presenting to a primary care clinic as part of their State Department–mandated health check upon resettlement. Arash Javanbakht, MD, also of the university, led the research.
The investigators recruited families at a primary care clinic in southeastern Michigan, where refugees receive health assessments within the first month of arrival in the United States.
The researchers consecutively enrolled and evaluated 297 individuals, including 59 children aged 6 and older (mean age, 11.3) from Syria. These families represented 95% of refugees seen at the clinic during the study period, from June to December 2016.
The researchers also collected hair and saliva samples from consenting families for a separate study looking at biomarkers and mental health outcomes.
Adults were screened for PTSD using the PTSD checklist for adults, and children for anxiety using the Screen for Child Anxiety Related Emotional Disorders, or SCARED, measure. Psychiatric nurses and bilingual health care workers helped the team obtain consent and conduct assessments.
The researchers found that 61% of the children had a probable anxiety diagnosis, and nearly 85% had probable separation anxiety. Higher child anxiety scores were associated with higher PTSD scores in mothers (P = .05).
Dr. Arfken said in an interview that she and her team were “shocked” at the high prevalence of probable anxiety disorders in the cohort, in part because they’d conducted an earlier study enrolling adult Iraqi refugees and “found hardly any psychiatric symptoms at all.”
The high levels of anxiety seen among the Syrian refugees may be related to the severity of the ongoing conflict, Dr. Arfken said. The children’s results were sufficiently jarring to the team that “we changed our whole plan,” she said, “to concentrate on following up both the children who showed distress and those who did not.” They also attempted some nonmedical interventions, such as dance and mindfulness groups.
Also at the conference, Christopher Morrow, MD, of the University of Maryland in Baltimore, presented findings from a case study that illuminates some of the potential mental health risks for resettled refugees.
Dr. Morrow described a 31-year-old man from Afghanistan who had worked for the U.S. Special Forces in Afghanistan as a translator and subsequently entered the United States as a refugee. About a year later he was admitted to an inpatient psychiatric unit after a violent suicide attempt and was treated for depression.
The researchers noted that the patient had no previous history of depression or other mental illness prior to arriving in the United States. “His symptoms developed over the course of the first year of resettlement,” Dr. Morrow said in an interview.
This patient, Dr. Morrow said, was single and was not religious, leaving him not inclined to join a mosque or other Islamic community group. He was placed in an unskilled work assignment, despite his well-developed skills as a translator. Over the course of a year, he became increasingly isolated and “decompensated to the point where there was a really violent suicide attempt.
“We think that some kind of programmed follow-up – be it a community resource or through primary care – could have helped stabilize him before he got to a point of real hopelessness,” Dr. Morrow said.
Dr. Morrow and his colleagues proposed two interventions as adjustments to current health policy for refugees: adding universal mental health screening to each refugee’s health check in the first month after arrival, and scheduling follow-up later in the resettlement process.
“If there is active follow-up, a way that you could check in with these individuals as they’re acclimating, that’s probably the point where you could intervene best,” he said.
Dr. Morrow and Dr. Arfken disclosed no conflicts of interest related to their research.
SAN DIEGO – Psychiatrists may encounter refugee patients from war-torn countries in virtually every part of the United States with complex mental health needs, including high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms, according to two presenters at the annual meeting of the American Psychiatric Association.
Over the past decade, refugees from Middle Eastern counties – particularly Iraq, Syria, and Afghanistan – have increased fourfold as a percentage of all refugees in the United States, while those from Sub-Saharan Africa continue to make up a large share. Despite heated political wrangling, the U.S. Department of State recently increased limits on the number of refugees that can be accepted. California, Texas, New York, Michigan, Ohio, and Washington are the states resettling the most new arrivals.
Refugees with trauma exposure have high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms. In addition, recent research suggests, these refugees may have poorly understood stressors related to migration and adjustment that also may be significant contributors to mental illness risk. Despite this, refugees generally have less access to mental health care than does the general population.
The presenters shared their perspectives on refugee mental health with findings that could inform the timing and nature of interventions in these potentially vulnerable populations.
Cynthia L. Arfken, PhD, of Wayne State University in Detroit, presented results from an ongoing cohort study of Syrian families presenting to a primary care clinic as part of their State Department–mandated health check upon resettlement. Arash Javanbakht, MD, also of the university, led the research.
The investigators recruited families at a primary care clinic in southeastern Michigan, where refugees receive health assessments within the first month of arrival in the United States.
The researchers consecutively enrolled and evaluated 297 individuals, including 59 children aged 6 and older (mean age, 11.3) from Syria. These families represented 95% of refugees seen at the clinic during the study period, from June to December 2016.
The researchers also collected hair and saliva samples from consenting families for a separate study looking at biomarkers and mental health outcomes.
Adults were screened for PTSD using the PTSD checklist for adults, and children for anxiety using the Screen for Child Anxiety Related Emotional Disorders, or SCARED, measure. Psychiatric nurses and bilingual health care workers helped the team obtain consent and conduct assessments.
The researchers found that 61% of the children had a probable anxiety diagnosis, and nearly 85% had probable separation anxiety. Higher child anxiety scores were associated with higher PTSD scores in mothers (P = .05).
Dr. Arfken said in an interview that she and her team were “shocked” at the high prevalence of probable anxiety disorders in the cohort, in part because they’d conducted an earlier study enrolling adult Iraqi refugees and “found hardly any psychiatric symptoms at all.”
The high levels of anxiety seen among the Syrian refugees may be related to the severity of the ongoing conflict, Dr. Arfken said. The children’s results were sufficiently jarring to the team that “we changed our whole plan,” she said, “to concentrate on following up both the children who showed distress and those who did not.” They also attempted some nonmedical interventions, such as dance and mindfulness groups.
Also at the conference, Christopher Morrow, MD, of the University of Maryland in Baltimore, presented findings from a case study that illuminates some of the potential mental health risks for resettled refugees.
Dr. Morrow described a 31-year-old man from Afghanistan who had worked for the U.S. Special Forces in Afghanistan as a translator and subsequently entered the United States as a refugee. About a year later he was admitted to an inpatient psychiatric unit after a violent suicide attempt and was treated for depression.
The researchers noted that the patient had no previous history of depression or other mental illness prior to arriving in the United States. “His symptoms developed over the course of the first year of resettlement,” Dr. Morrow said in an interview.
This patient, Dr. Morrow said, was single and was not religious, leaving him not inclined to join a mosque or other Islamic community group. He was placed in an unskilled work assignment, despite his well-developed skills as a translator. Over the course of a year, he became increasingly isolated and “decompensated to the point where there was a really violent suicide attempt.
“We think that some kind of programmed follow-up – be it a community resource or through primary care – could have helped stabilize him before he got to a point of real hopelessness,” Dr. Morrow said.
Dr. Morrow and his colleagues proposed two interventions as adjustments to current health policy for refugees: adding universal mental health screening to each refugee’s health check in the first month after arrival, and scheduling follow-up later in the resettlement process.
“If there is active follow-up, a way that you could check in with these individuals as they’re acclimating, that’s probably the point where you could intervene best,” he said.
Dr. Morrow and Dr. Arfken disclosed no conflicts of interest related to their research.
SAN DIEGO – Psychiatrists may encounter refugee patients from war-torn countries in virtually every part of the United States with complex mental health needs, including high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms, according to two presenters at the annual meeting of the American Psychiatric Association.
Over the past decade, refugees from Middle Eastern counties – particularly Iraq, Syria, and Afghanistan – have increased fourfold as a percentage of all refugees in the United States, while those from Sub-Saharan Africa continue to make up a large share. Despite heated political wrangling, the U.S. Department of State recently increased limits on the number of refugees that can be accepted. California, Texas, New York, Michigan, Ohio, and Washington are the states resettling the most new arrivals.
Refugees with trauma exposure have high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms. In addition, recent research suggests, these refugees may have poorly understood stressors related to migration and adjustment that also may be significant contributors to mental illness risk. Despite this, refugees generally have less access to mental health care than does the general population.
The presenters shared their perspectives on refugee mental health with findings that could inform the timing and nature of interventions in these potentially vulnerable populations.
Cynthia L. Arfken, PhD, of Wayne State University in Detroit, presented results from an ongoing cohort study of Syrian families presenting to a primary care clinic as part of their State Department–mandated health check upon resettlement. Arash Javanbakht, MD, also of the university, led the research.
The investigators recruited families at a primary care clinic in southeastern Michigan, where refugees receive health assessments within the first month of arrival in the United States.
The researchers consecutively enrolled and evaluated 297 individuals, including 59 children aged 6 and older (mean age, 11.3) from Syria. These families represented 95% of refugees seen at the clinic during the study period, from June to December 2016.
The researchers also collected hair and saliva samples from consenting families for a separate study looking at biomarkers and mental health outcomes.
Adults were screened for PTSD using the PTSD checklist for adults, and children for anxiety using the Screen for Child Anxiety Related Emotional Disorders, or SCARED, measure. Psychiatric nurses and bilingual health care workers helped the team obtain consent and conduct assessments.
The researchers found that 61% of the children had a probable anxiety diagnosis, and nearly 85% had probable separation anxiety. Higher child anxiety scores were associated with higher PTSD scores in mothers (P = .05).
Dr. Arfken said in an interview that she and her team were “shocked” at the high prevalence of probable anxiety disorders in the cohort, in part because they’d conducted an earlier study enrolling adult Iraqi refugees and “found hardly any psychiatric symptoms at all.”
The high levels of anxiety seen among the Syrian refugees may be related to the severity of the ongoing conflict, Dr. Arfken said. The children’s results were sufficiently jarring to the team that “we changed our whole plan,” she said, “to concentrate on following up both the children who showed distress and those who did not.” They also attempted some nonmedical interventions, such as dance and mindfulness groups.
Also at the conference, Christopher Morrow, MD, of the University of Maryland in Baltimore, presented findings from a case study that illuminates some of the potential mental health risks for resettled refugees.
Dr. Morrow described a 31-year-old man from Afghanistan who had worked for the U.S. Special Forces in Afghanistan as a translator and subsequently entered the United States as a refugee. About a year later he was admitted to an inpatient psychiatric unit after a violent suicide attempt and was treated for depression.
The researchers noted that the patient had no previous history of depression or other mental illness prior to arriving in the United States. “His symptoms developed over the course of the first year of resettlement,” Dr. Morrow said in an interview.
This patient, Dr. Morrow said, was single and was not religious, leaving him not inclined to join a mosque or other Islamic community group. He was placed in an unskilled work assignment, despite his well-developed skills as a translator. Over the course of a year, he became increasingly isolated and “decompensated to the point where there was a really violent suicide attempt.
“We think that some kind of programmed follow-up – be it a community resource or through primary care – could have helped stabilize him before he got to a point of real hopelessness,” Dr. Morrow said.
Dr. Morrow and his colleagues proposed two interventions as adjustments to current health policy for refugees: adding universal mental health screening to each refugee’s health check in the first month after arrival, and scheduling follow-up later in the resettlement process.
“If there is active follow-up, a way that you could check in with these individuals as they’re acclimating, that’s probably the point where you could intervene best,” he said.
Dr. Morrow and Dr. Arfken disclosed no conflicts of interest related to their research.
EXPERT ANALYSIS FROM APA
Seeing a doctor reduces readmission risk in schizophrenia patients
SAN DIEGO – Readmission rates after discharge for patients with schizophrenia are notoriously high, with approximately a quarter of U.S. schizophrenia patients readmitted within 3 months, according to Paul A. Kurdyak, MD, PhD.
In Ontario, Canada, readmission rates for people with schizophrenia are 12.5% within 30 days of discharge. Paradoxically, however, these same patients receive less follow-up than people hospitalized for other psychiatric disorders, Dr. Kurdyak of the Institute for Clinical Evaluative Sciences in Toronto reported at the annual meeting of the American Psychiatric Association.
To explore the relationship between discharge, follow-up, and subsequent readmission in this population, he assessed the impact of physician follow-up in the month after discharge on readmission rates for schizophrenia patients, noting a lack of published evidence on whether or how it helps. “We try and use readmission as a general performance indicator, and we try and use postdischarge follow-up as a general indicator, but there was no evidence to determine whether seeing a physician following discharge has an impact on anything,” Dr. Kurdyak said.
He and his colleagues tracked primary care and outpatient psychiatric visits in the first 30 days after discharge for about 20,000 people who had been hospitalized with schizophrenia in Ontario. “We chose 30 days because we knew the rate of follow-up within 7 days was just so low,” he said.
He said more than one in three of these patients went more than 30 days without seeing any physician at all.
Schizophrenia patients “are individuals with really high needs, whose average length of stay is about 2 weeks,” he said. “It’s hard to stabilize somebody in 2 weeks, so to have so many of them drop off a cliff [after discharge] is not great.”
Another finding was that the patients who saw any doctor – whether their primary care physician or psychiatrist – saw reduced rates of readmission at 30-210 days after discharge.
Where the benefit of seeing a physician was seen in sharpest relief was among the patients deemed, by use of a validated scoring system, to be at highest risk for readmission. These patients, who made up two-thirds of the cohort, saw a 15% reduction in readmission if they’d had a visit with either a primary care physician or psychiatrist and a 19% reduction if they’d seen both types of physician relative to patients who had no physician follow-up post discharge.
“In the high-risk group, you see a very clear separation between those who saw no physician and those who saw any physician,” Dr. Kurdyak said.
Some of the limitations of the study included the fact that little was known about the quality of the follow-up physician visits or about clinical collaboration, the causes for lack of follow-up were not clear, and follow-up by nonphysician health personnel was not captured.
Nonetheless, Dr. Kurdyak said, “the moral of the story is [that] seeing a physician really differentiates from seeing no physician statistically and clinically.”
In Canada, he noted, “we like to feel comfortable with the idea of universal health care, but, when we take a closer look, we often see real inequities and disparities despite universal health care. I think this is one of these situations where, if readmission is an indicator of need, our ability to provide services to those in the greatest need falls short of the ideal.”
Dr. Kurdyak disclosed no conflicts of interest relevant to his research.
SAN DIEGO – Readmission rates after discharge for patients with schizophrenia are notoriously high, with approximately a quarter of U.S. schizophrenia patients readmitted within 3 months, according to Paul A. Kurdyak, MD, PhD.
In Ontario, Canada, readmission rates for people with schizophrenia are 12.5% within 30 days of discharge. Paradoxically, however, these same patients receive less follow-up than people hospitalized for other psychiatric disorders, Dr. Kurdyak of the Institute for Clinical Evaluative Sciences in Toronto reported at the annual meeting of the American Psychiatric Association.
To explore the relationship between discharge, follow-up, and subsequent readmission in this population, he assessed the impact of physician follow-up in the month after discharge on readmission rates for schizophrenia patients, noting a lack of published evidence on whether or how it helps. “We try and use readmission as a general performance indicator, and we try and use postdischarge follow-up as a general indicator, but there was no evidence to determine whether seeing a physician following discharge has an impact on anything,” Dr. Kurdyak said.
He and his colleagues tracked primary care and outpatient psychiatric visits in the first 30 days after discharge for about 20,000 people who had been hospitalized with schizophrenia in Ontario. “We chose 30 days because we knew the rate of follow-up within 7 days was just so low,” he said.
He said more than one in three of these patients went more than 30 days without seeing any physician at all.
Schizophrenia patients “are individuals with really high needs, whose average length of stay is about 2 weeks,” he said. “It’s hard to stabilize somebody in 2 weeks, so to have so many of them drop off a cliff [after discharge] is not great.”
Another finding was that the patients who saw any doctor – whether their primary care physician or psychiatrist – saw reduced rates of readmission at 30-210 days after discharge.
Where the benefit of seeing a physician was seen in sharpest relief was among the patients deemed, by use of a validated scoring system, to be at highest risk for readmission. These patients, who made up two-thirds of the cohort, saw a 15% reduction in readmission if they’d had a visit with either a primary care physician or psychiatrist and a 19% reduction if they’d seen both types of physician relative to patients who had no physician follow-up post discharge.
“In the high-risk group, you see a very clear separation between those who saw no physician and those who saw any physician,” Dr. Kurdyak said.
Some of the limitations of the study included the fact that little was known about the quality of the follow-up physician visits or about clinical collaboration, the causes for lack of follow-up were not clear, and follow-up by nonphysician health personnel was not captured.
Nonetheless, Dr. Kurdyak said, “the moral of the story is [that] seeing a physician really differentiates from seeing no physician statistically and clinically.”
In Canada, he noted, “we like to feel comfortable with the idea of universal health care, but, when we take a closer look, we often see real inequities and disparities despite universal health care. I think this is one of these situations where, if readmission is an indicator of need, our ability to provide services to those in the greatest need falls short of the ideal.”
Dr. Kurdyak disclosed no conflicts of interest relevant to his research.
SAN DIEGO – Readmission rates after discharge for patients with schizophrenia are notoriously high, with approximately a quarter of U.S. schizophrenia patients readmitted within 3 months, according to Paul A. Kurdyak, MD, PhD.
In Ontario, Canada, readmission rates for people with schizophrenia are 12.5% within 30 days of discharge. Paradoxically, however, these same patients receive less follow-up than people hospitalized for other psychiatric disorders, Dr. Kurdyak of the Institute for Clinical Evaluative Sciences in Toronto reported at the annual meeting of the American Psychiatric Association.
To explore the relationship between discharge, follow-up, and subsequent readmission in this population, he assessed the impact of physician follow-up in the month after discharge on readmission rates for schizophrenia patients, noting a lack of published evidence on whether or how it helps. “We try and use readmission as a general performance indicator, and we try and use postdischarge follow-up as a general indicator, but there was no evidence to determine whether seeing a physician following discharge has an impact on anything,” Dr. Kurdyak said.
He and his colleagues tracked primary care and outpatient psychiatric visits in the first 30 days after discharge for about 20,000 people who had been hospitalized with schizophrenia in Ontario. “We chose 30 days because we knew the rate of follow-up within 7 days was just so low,” he said.
He said more than one in three of these patients went more than 30 days without seeing any physician at all.
Schizophrenia patients “are individuals with really high needs, whose average length of stay is about 2 weeks,” he said. “It’s hard to stabilize somebody in 2 weeks, so to have so many of them drop off a cliff [after discharge] is not great.”
Another finding was that the patients who saw any doctor – whether their primary care physician or psychiatrist – saw reduced rates of readmission at 30-210 days after discharge.
Where the benefit of seeing a physician was seen in sharpest relief was among the patients deemed, by use of a validated scoring system, to be at highest risk for readmission. These patients, who made up two-thirds of the cohort, saw a 15% reduction in readmission if they’d had a visit with either a primary care physician or psychiatrist and a 19% reduction if they’d seen both types of physician relative to patients who had no physician follow-up post discharge.
“In the high-risk group, you see a very clear separation between those who saw no physician and those who saw any physician,” Dr. Kurdyak said.
Some of the limitations of the study included the fact that little was known about the quality of the follow-up physician visits or about clinical collaboration, the causes for lack of follow-up were not clear, and follow-up by nonphysician health personnel was not captured.
Nonetheless, Dr. Kurdyak said, “the moral of the story is [that] seeing a physician really differentiates from seeing no physician statistically and clinically.”
In Canada, he noted, “we like to feel comfortable with the idea of universal health care, but, when we take a closer look, we often see real inequities and disparities despite universal health care. I think this is one of these situations where, if readmission is an indicator of need, our ability to provide services to those in the greatest need falls short of the ideal.”
Dr. Kurdyak disclosed no conflicts of interest relevant to his research.
AT APA
Key clinical point:
Major finding: Patients at highest risk of readmission saw a 15% reduction in readmission after 30 days if they’d seen a primary care doctor or psychiatrist, compared with those who’d seen neither.
Data source: Records from about 20,000 schizophrenia patients hospitalized in Ontario in 2012, identified in government databases.
Disclosures: The study was conducted at an institute receiving most of its support from the Ontario government.
Trump presidency prompts Goldwater Rule debate at APA
SAN DIEGO – Over the past year, the American Psychiatric Association has reasserted its commitment to the Goldwater Rule, yet many psychiatrists have questioned – some publicly – whether the rule needs to be revisited based on their concerns about Donald Trump’s mental fitness to be president.
[polldaddy:9767626]Both sides of the issue got a hearing during a pro and con discussion of the Goldwater Rule at the annual meeting of the American Psychiatric Association. A trio of leading psychiatrists called for the Goldwater Rule to be revised and APA past leadership defended the ethical standards of the existing rule. One past-president of the APA remarked that psychiatrists who object to the rule can choose to quit the APA, a comment that one audience member said harkened back to the Vietnam War–era rebuttal to protesters: “Love it or leave it.”
Several news stories in recent months have highlighted the Trump-spawned debate over the Goldwater Rule, which states that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
The APA created the rule in 1973 after a backlash over the hundreds of U.S. psychiatrists who responded to a magazine survey by diagnosing 1964 GOP presidential candidate Barry Goldwater. He later won a libel suit against the magazine.
Prior to last year’s presidential election, the APA stood by its rule. Then, in March 2017, the APA’s Ethics Committee affirmed that “the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.”
During the pro and con discussion at the annual meeting, Paul S. Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University in New York, called the Goldwater incident “a major embarrassment for psychiatry.”
But, he added, “there are more important justifications than whether we’re embarrassed or not. Part of [the rule] is to protect persons who may be harmed by our blithe speculation to the media. We’re also interested in avoiding an impact on people who may be in need of psychiatric care but are discouraged by what they see and hear about psychiatry in the media,” he said.
“A diagnosis based on casual encounters with a person through the media is necessarily inadequate as a basis for a psychiatric diagnosis or formulation of any reliable sort,” he pointed out.
Claire Pouncey, MD, PhD, a psychiatrist who practices in Philadelphia, questioned why speaking publicly about a public figure is inherently harmful.
“How does it threaten my integrity or integrity of the profession for me to choose to speak publicly about a public figure? The APA seems to not trust its members or recognize us as moral agents who are the arbiters of our own integrity. I wish the APA would trust me,” Dr. Pouncey said.
Last year, she outlined her concerns in an article written with Jerome Kroll, MD, and published in the Journal of the American Academy of Psychiatry and the Law (June 2016;44[2]:226-35).
As for concerns about the adequacy of information, she added, “we never have complete information. And I know we don’t always have a full consent of the person being evaluated. Anyone who’s been in an emergency room knows that in their heart and soul.”
Nassir Ghaemi, MD, MPH, who chaired the session and is professor and director of the mood disorders program at Tufts University in Boston, said that strictly abiding by the Goldwater Rule is “sending out the message that the world’s psychiatrists think it’s bad to get diagnosed with a psychiatric illness. … You are not going to harm patients by talking about psychiatric illness. You help them. We know that.”
Further, Dr. Ghaemi, author of the book “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness” (Penguin Books, 2012), argued that the “very qualities that mark those with mood disorders also make for the best leaders in times of crisis.”
President Trump’s reported traits, such as lack of sleep and talkativeness, could be portrayed as mania, he said. However, those qualities also could boost his creativity and resilience.
Jerrold M. Post, MD, a pioneer in profiling for the Central Intelligence Agency and professor of psychiatry, political psychology, and international affairs at George Washington University in Washington, D.C., said that psychiatrists have a role to play as experts, especially now. “I’m increasingly uncomfortable in not having commented on a welter of psychiatric diagnoses by people without psychiatric training,” he said. “It seems unethical to not comment at this time.”
Paul Summergrad, MD, a former APA president and chair of the department of psychiatry at Tufts, dismissed the idea that psychiatrists could mold public debate. “The assumption that we’ll somehow change opinion if we all speak out about these matters is giving us much more credit than we deserve.”
“The reality,” he said, “is that we need to wear a certain yoke of limitation and responsibility rather than thinking this is simply an issue of freedom.”
Dr. Post, Dr. Summergrad, and Dr. Pouncey reported no relevant disclosures. Dr. Ghaemi reported support (consultant/advisory board, speakers bureau, honoraria) from Sunovion. Dr. Appelbaum disclosed stock/other financial relationship with COVR.
[polldaddy:9767626]
SAN DIEGO – Over the past year, the American Psychiatric Association has reasserted its commitment to the Goldwater Rule, yet many psychiatrists have questioned – some publicly – whether the rule needs to be revisited based on their concerns about Donald Trump’s mental fitness to be president.
[polldaddy:9767626]Both sides of the issue got a hearing during a pro and con discussion of the Goldwater Rule at the annual meeting of the American Psychiatric Association. A trio of leading psychiatrists called for the Goldwater Rule to be revised and APA past leadership defended the ethical standards of the existing rule. One past-president of the APA remarked that psychiatrists who object to the rule can choose to quit the APA, a comment that one audience member said harkened back to the Vietnam War–era rebuttal to protesters: “Love it or leave it.”
Several news stories in recent months have highlighted the Trump-spawned debate over the Goldwater Rule, which states that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
The APA created the rule in 1973 after a backlash over the hundreds of U.S. psychiatrists who responded to a magazine survey by diagnosing 1964 GOP presidential candidate Barry Goldwater. He later won a libel suit against the magazine.
Prior to last year’s presidential election, the APA stood by its rule. Then, in March 2017, the APA’s Ethics Committee affirmed that “the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.”
During the pro and con discussion at the annual meeting, Paul S. Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University in New York, called the Goldwater incident “a major embarrassment for psychiatry.”
But, he added, “there are more important justifications than whether we’re embarrassed or not. Part of [the rule] is to protect persons who may be harmed by our blithe speculation to the media. We’re also interested in avoiding an impact on people who may be in need of psychiatric care but are discouraged by what they see and hear about psychiatry in the media,” he said.
“A diagnosis based on casual encounters with a person through the media is necessarily inadequate as a basis for a psychiatric diagnosis or formulation of any reliable sort,” he pointed out.
Claire Pouncey, MD, PhD, a psychiatrist who practices in Philadelphia, questioned why speaking publicly about a public figure is inherently harmful.
“How does it threaten my integrity or integrity of the profession for me to choose to speak publicly about a public figure? The APA seems to not trust its members or recognize us as moral agents who are the arbiters of our own integrity. I wish the APA would trust me,” Dr. Pouncey said.
Last year, she outlined her concerns in an article written with Jerome Kroll, MD, and published in the Journal of the American Academy of Psychiatry and the Law (June 2016;44[2]:226-35).
As for concerns about the adequacy of information, she added, “we never have complete information. And I know we don’t always have a full consent of the person being evaluated. Anyone who’s been in an emergency room knows that in their heart and soul.”
Nassir Ghaemi, MD, MPH, who chaired the session and is professor and director of the mood disorders program at Tufts University in Boston, said that strictly abiding by the Goldwater Rule is “sending out the message that the world’s psychiatrists think it’s bad to get diagnosed with a psychiatric illness. … You are not going to harm patients by talking about psychiatric illness. You help them. We know that.”
Further, Dr. Ghaemi, author of the book “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness” (Penguin Books, 2012), argued that the “very qualities that mark those with mood disorders also make for the best leaders in times of crisis.”
President Trump’s reported traits, such as lack of sleep and talkativeness, could be portrayed as mania, he said. However, those qualities also could boost his creativity and resilience.
Jerrold M. Post, MD, a pioneer in profiling for the Central Intelligence Agency and professor of psychiatry, political psychology, and international affairs at George Washington University in Washington, D.C., said that psychiatrists have a role to play as experts, especially now. “I’m increasingly uncomfortable in not having commented on a welter of psychiatric diagnoses by people without psychiatric training,” he said. “It seems unethical to not comment at this time.”
Paul Summergrad, MD, a former APA president and chair of the department of psychiatry at Tufts, dismissed the idea that psychiatrists could mold public debate. “The assumption that we’ll somehow change opinion if we all speak out about these matters is giving us much more credit than we deserve.”
“The reality,” he said, “is that we need to wear a certain yoke of limitation and responsibility rather than thinking this is simply an issue of freedom.”
Dr. Post, Dr. Summergrad, and Dr. Pouncey reported no relevant disclosures. Dr. Ghaemi reported support (consultant/advisory board, speakers bureau, honoraria) from Sunovion. Dr. Appelbaum disclosed stock/other financial relationship with COVR.
[polldaddy:9767626]
SAN DIEGO – Over the past year, the American Psychiatric Association has reasserted its commitment to the Goldwater Rule, yet many psychiatrists have questioned – some publicly – whether the rule needs to be revisited based on their concerns about Donald Trump’s mental fitness to be president.
[polldaddy:9767626]Both sides of the issue got a hearing during a pro and con discussion of the Goldwater Rule at the annual meeting of the American Psychiatric Association. A trio of leading psychiatrists called for the Goldwater Rule to be revised and APA past leadership defended the ethical standards of the existing rule. One past-president of the APA remarked that psychiatrists who object to the rule can choose to quit the APA, a comment that one audience member said harkened back to the Vietnam War–era rebuttal to protesters: “Love it or leave it.”
Several news stories in recent months have highlighted the Trump-spawned debate over the Goldwater Rule, which states that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
The APA created the rule in 1973 after a backlash over the hundreds of U.S. psychiatrists who responded to a magazine survey by diagnosing 1964 GOP presidential candidate Barry Goldwater. He later won a libel suit against the magazine.
Prior to last year’s presidential election, the APA stood by its rule. Then, in March 2017, the APA’s Ethics Committee affirmed that “the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.”
During the pro and con discussion at the annual meeting, Paul S. Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University in New York, called the Goldwater incident “a major embarrassment for psychiatry.”
But, he added, “there are more important justifications than whether we’re embarrassed or not. Part of [the rule] is to protect persons who may be harmed by our blithe speculation to the media. We’re also interested in avoiding an impact on people who may be in need of psychiatric care but are discouraged by what they see and hear about psychiatry in the media,” he said.
“A diagnosis based on casual encounters with a person through the media is necessarily inadequate as a basis for a psychiatric diagnosis or formulation of any reliable sort,” he pointed out.
Claire Pouncey, MD, PhD, a psychiatrist who practices in Philadelphia, questioned why speaking publicly about a public figure is inherently harmful.
“How does it threaten my integrity or integrity of the profession for me to choose to speak publicly about a public figure? The APA seems to not trust its members or recognize us as moral agents who are the arbiters of our own integrity. I wish the APA would trust me,” Dr. Pouncey said.
Last year, she outlined her concerns in an article written with Jerome Kroll, MD, and published in the Journal of the American Academy of Psychiatry and the Law (June 2016;44[2]:226-35).
As for concerns about the adequacy of information, she added, “we never have complete information. And I know we don’t always have a full consent of the person being evaluated. Anyone who’s been in an emergency room knows that in their heart and soul.”
Nassir Ghaemi, MD, MPH, who chaired the session and is professor and director of the mood disorders program at Tufts University in Boston, said that strictly abiding by the Goldwater Rule is “sending out the message that the world’s psychiatrists think it’s bad to get diagnosed with a psychiatric illness. … You are not going to harm patients by talking about psychiatric illness. You help them. We know that.”
Further, Dr. Ghaemi, author of the book “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness” (Penguin Books, 2012), argued that the “very qualities that mark those with mood disorders also make for the best leaders in times of crisis.”
President Trump’s reported traits, such as lack of sleep and talkativeness, could be portrayed as mania, he said. However, those qualities also could boost his creativity and resilience.
Jerrold M. Post, MD, a pioneer in profiling for the Central Intelligence Agency and professor of psychiatry, political psychology, and international affairs at George Washington University in Washington, D.C., said that psychiatrists have a role to play as experts, especially now. “I’m increasingly uncomfortable in not having commented on a welter of psychiatric diagnoses by people without psychiatric training,” he said. “It seems unethical to not comment at this time.”
Paul Summergrad, MD, a former APA president and chair of the department of psychiatry at Tufts, dismissed the idea that psychiatrists could mold public debate. “The assumption that we’ll somehow change opinion if we all speak out about these matters is giving us much more credit than we deserve.”
“The reality,” he said, “is that we need to wear a certain yoke of limitation and responsibility rather than thinking this is simply an issue of freedom.”
Dr. Post, Dr. Summergrad, and Dr. Pouncey reported no relevant disclosures. Dr. Ghaemi reported support (consultant/advisory board, speakers bureau, honoraria) from Sunovion. Dr. Appelbaum disclosed stock/other financial relationship with COVR.
[polldaddy:9767626]
EXPERT ANALYSIS FROM APA
Results prove lasting from iCBT in mild to moderate depression
SAN DIEGO – Cognitive-behavioral therapy (CPT) interventions delivered online are effective in reducing symptoms of mild to moderate depression in adults, according to results presented at the annual meeting of the American Psychiatric Association.
The findings, presented by Charles Koransky, MD, of the University of Maryland, Baltimore, derive from a meta-analysis of 14 randomized studies, conducted between 2005 and 2015, that enrolled more than 1,600 patients aged 18 years and older in Europe and Australia.
Patients in the studies were not receiving any other form of therapy, though some studies allowed concurrent use of antidepressant medications.
Results from patients assigned to the web-based interventions, which lasted 1 month or more, were compared with those who remained on waiting lists for treatment. Most of the interventions included brief clinician contact as part of their designs. Others were entirely self-guided.
Dr. Koransky and his colleagues found that completion rates were high, with between 55% and 93% of patients finishing the assigned interventions. The intervention groups saw significant improvement in symptoms after the online CBT interventions, with a standard mean difference of 0.74 (95% confidence interval, 0.63-0.86; P less than 0.001), compared with patients randomized to wait lists.
For the 11 studies that included between 3- and 6-months’ follow-up, improvement in depressive symptoms was seen to be durable, with a large SMD of 0.85 (95% CI, 0.79-0.90; P less than 0.001). “This shows that the effects last,” Dr. Koransky told conference attendees.
Dr. Koransky noted that statistically significant difference was seen between the studies with interventions that included clinician contact and those that did not. “This is probably because the clinician contact in the studies was brief, 10-minute chats or emails,” he said.
“Internet-based CBT leads to immediate and sustained reduction of depressive symptoms, which is consistent with analyses in the past,” Dr. Koransky said. “We also found that iCBT may be a good option for patients not able to access traditional face-to-face therapy,” he said, noting that several of the interventions in the study were designed to help address access issues in rural Australia.
Dr. Koransky noted that the results might not be generalizable because of the large portion of female patients across studies – more than 75% – and the fact that all patients were recruited through advertisements, suggesting that these were “highly motivated participants seeking some alleviation of their symptoms.” Another limitation of the study was a lack of uniformity across iCBT interfaces.
Nonetheless, he said, the findings have implications for U.S. practitioners, particularly primary care doctors in regions with poor access to mental health specialists.
Internet-delivered CBT may be “great for people in rural settings, especially if prescribed by primary care providers who don’t have the training to provide CBT,” he said.
Dr. Koransky said his group aimed to study these interventions in a U.S. population and among patients referred to iCBT by their primary care doctors. The researchers disclosed no conflicts of interest related to their findings.
SAN DIEGO – Cognitive-behavioral therapy (CPT) interventions delivered online are effective in reducing symptoms of mild to moderate depression in adults, according to results presented at the annual meeting of the American Psychiatric Association.
The findings, presented by Charles Koransky, MD, of the University of Maryland, Baltimore, derive from a meta-analysis of 14 randomized studies, conducted between 2005 and 2015, that enrolled more than 1,600 patients aged 18 years and older in Europe and Australia.
Patients in the studies were not receiving any other form of therapy, though some studies allowed concurrent use of antidepressant medications.
Results from patients assigned to the web-based interventions, which lasted 1 month or more, were compared with those who remained on waiting lists for treatment. Most of the interventions included brief clinician contact as part of their designs. Others were entirely self-guided.
Dr. Koransky and his colleagues found that completion rates were high, with between 55% and 93% of patients finishing the assigned interventions. The intervention groups saw significant improvement in symptoms after the online CBT interventions, with a standard mean difference of 0.74 (95% confidence interval, 0.63-0.86; P less than 0.001), compared with patients randomized to wait lists.
For the 11 studies that included between 3- and 6-months’ follow-up, improvement in depressive symptoms was seen to be durable, with a large SMD of 0.85 (95% CI, 0.79-0.90; P less than 0.001). “This shows that the effects last,” Dr. Koransky told conference attendees.
Dr. Koransky noted that statistically significant difference was seen between the studies with interventions that included clinician contact and those that did not. “This is probably because the clinician contact in the studies was brief, 10-minute chats or emails,” he said.
“Internet-based CBT leads to immediate and sustained reduction of depressive symptoms, which is consistent with analyses in the past,” Dr. Koransky said. “We also found that iCBT may be a good option for patients not able to access traditional face-to-face therapy,” he said, noting that several of the interventions in the study were designed to help address access issues in rural Australia.
Dr. Koransky noted that the results might not be generalizable because of the large portion of female patients across studies – more than 75% – and the fact that all patients were recruited through advertisements, suggesting that these were “highly motivated participants seeking some alleviation of their symptoms.” Another limitation of the study was a lack of uniformity across iCBT interfaces.
Nonetheless, he said, the findings have implications for U.S. practitioners, particularly primary care doctors in regions with poor access to mental health specialists.
Internet-delivered CBT may be “great for people in rural settings, especially if prescribed by primary care providers who don’t have the training to provide CBT,” he said.
Dr. Koransky said his group aimed to study these interventions in a U.S. population and among patients referred to iCBT by their primary care doctors. The researchers disclosed no conflicts of interest related to their findings.
SAN DIEGO – Cognitive-behavioral therapy (CPT) interventions delivered online are effective in reducing symptoms of mild to moderate depression in adults, according to results presented at the annual meeting of the American Psychiatric Association.
The findings, presented by Charles Koransky, MD, of the University of Maryland, Baltimore, derive from a meta-analysis of 14 randomized studies, conducted between 2005 and 2015, that enrolled more than 1,600 patients aged 18 years and older in Europe and Australia.
Patients in the studies were not receiving any other form of therapy, though some studies allowed concurrent use of antidepressant medications.
Results from patients assigned to the web-based interventions, which lasted 1 month or more, were compared with those who remained on waiting lists for treatment. Most of the interventions included brief clinician contact as part of their designs. Others were entirely self-guided.
Dr. Koransky and his colleagues found that completion rates were high, with between 55% and 93% of patients finishing the assigned interventions. The intervention groups saw significant improvement in symptoms after the online CBT interventions, with a standard mean difference of 0.74 (95% confidence interval, 0.63-0.86; P less than 0.001), compared with patients randomized to wait lists.
For the 11 studies that included between 3- and 6-months’ follow-up, improvement in depressive symptoms was seen to be durable, with a large SMD of 0.85 (95% CI, 0.79-0.90; P less than 0.001). “This shows that the effects last,” Dr. Koransky told conference attendees.
Dr. Koransky noted that statistically significant difference was seen between the studies with interventions that included clinician contact and those that did not. “This is probably because the clinician contact in the studies was brief, 10-minute chats or emails,” he said.
“Internet-based CBT leads to immediate and sustained reduction of depressive symptoms, which is consistent with analyses in the past,” Dr. Koransky said. “We also found that iCBT may be a good option for patients not able to access traditional face-to-face therapy,” he said, noting that several of the interventions in the study were designed to help address access issues in rural Australia.
Dr. Koransky noted that the results might not be generalizable because of the large portion of female patients across studies – more than 75% – and the fact that all patients were recruited through advertisements, suggesting that these were “highly motivated participants seeking some alleviation of their symptoms.” Another limitation of the study was a lack of uniformity across iCBT interfaces.
Nonetheless, he said, the findings have implications for U.S. practitioners, particularly primary care doctors in regions with poor access to mental health specialists.
Internet-delivered CBT may be “great for people in rural settings, especially if prescribed by primary care providers who don’t have the training to provide CBT,” he said.
Dr. Koransky said his group aimed to study these interventions in a U.S. population and among patients referred to iCBT by their primary care doctors. The researchers disclosed no conflicts of interest related to their findings.
AT APA
Key clinical point: CBT delivered online with minimal therapist involvement can produce immediate and sustained reduction of depressive symptoms.
Major finding: Treatment groups saw a standard mean difference of 0.74 vs. nontreated patients immediately after intervention and 0.85 after 3-6 months follow-up (P less than 0.001 for both) .
Data source: A meta-analysis of 14 randomized, controlled trials from Europe and Australia randomizing 1,600 patients to online CBT or a wait list for care.
Disclosures: The researchers disclosed no conflicts of interest related to their findings.
APA Presidential Symposium will focus on trials in geriatric psychiatry
Designing clinical trials within a psychiatric practice is a challenging endeavor, regardless of the population. But, setting up trials for older adults can involve unique ethical and economic considerations.
On Saturday, May 20, a panel of four experts will explore these issues in an Invited Presidential Symposium at this year’s annual meeting of the American Psychiatric Association in San Diego. The symposium, which will be held that morning from 8 to 11 a.m., will feature Mary Sano, PhD, of the Mount Sinai School of Medicine, New York; Joan A. Mackell, PhD, of JM Neuroscience, New York; Olga Brawman-Mintzer, MD, of the Medical University of South Carolina, Charleston; and Maria I. Lapid, MD, of the Mayo Clinic, Rochester, Minn. Dr. Sano will chair the symposium, and Dr. Brawman-Mintzer will be the cochair.
The discussion will examine some of the basics of clinical trial design for geriatric psychiatry for several disorders, including dementia and depression, and for numerous conditions, including agitation and behavioral disturbances. It will also explore other key issues, such as the regulatory knowledge needed to conduct clinical trials, the role of the institutional review board in protecting human subjects, and whether the protocol works and will pay the bills.
It will take place on the upper level of the San Diego Convention Center (session ID: 8012). To look up other sessions, check out the APA’s search function.
Designing clinical trials within a psychiatric practice is a challenging endeavor, regardless of the population. But, setting up trials for older adults can involve unique ethical and economic considerations.
On Saturday, May 20, a panel of four experts will explore these issues in an Invited Presidential Symposium at this year’s annual meeting of the American Psychiatric Association in San Diego. The symposium, which will be held that morning from 8 to 11 a.m., will feature Mary Sano, PhD, of the Mount Sinai School of Medicine, New York; Joan A. Mackell, PhD, of JM Neuroscience, New York; Olga Brawman-Mintzer, MD, of the Medical University of South Carolina, Charleston; and Maria I. Lapid, MD, of the Mayo Clinic, Rochester, Minn. Dr. Sano will chair the symposium, and Dr. Brawman-Mintzer will be the cochair.
The discussion will examine some of the basics of clinical trial design for geriatric psychiatry for several disorders, including dementia and depression, and for numerous conditions, including agitation and behavioral disturbances. It will also explore other key issues, such as the regulatory knowledge needed to conduct clinical trials, the role of the institutional review board in protecting human subjects, and whether the protocol works and will pay the bills.
It will take place on the upper level of the San Diego Convention Center (session ID: 8012). To look up other sessions, check out the APA’s search function.
Designing clinical trials within a psychiatric practice is a challenging endeavor, regardless of the population. But, setting up trials for older adults can involve unique ethical and economic considerations.
On Saturday, May 20, a panel of four experts will explore these issues in an Invited Presidential Symposium at this year’s annual meeting of the American Psychiatric Association in San Diego. The symposium, which will be held that morning from 8 to 11 a.m., will feature Mary Sano, PhD, of the Mount Sinai School of Medicine, New York; Joan A. Mackell, PhD, of JM Neuroscience, New York; Olga Brawman-Mintzer, MD, of the Medical University of South Carolina, Charleston; and Maria I. Lapid, MD, of the Mayo Clinic, Rochester, Minn. Dr. Sano will chair the symposium, and Dr. Brawman-Mintzer will be the cochair.
The discussion will examine some of the basics of clinical trial design for geriatric psychiatry for several disorders, including dementia and depression, and for numerous conditions, including agitation and behavioral disturbances. It will also explore other key issues, such as the regulatory knowledge needed to conduct clinical trials, the role of the institutional review board in protecting human subjects, and whether the protocol works and will pay the bills.
It will take place on the upper level of the San Diego Convention Center (session ID: 8012). To look up other sessions, check out the APA’s search function.