For the folks back home...

SOURCE: The Boston Globe
May 30, 2014 | Liz Kowalczyk

Three months after state regulators allowed a Brookline psychiatric hospital to start accepting new patients again, federal investigators found deficiencies with psychiatric evaluations and treatment plans, problems they said may have hindered patients’ recovery.

The federal report, based on a February inspection, concluded that Arbour HRI failed to provide active treatment for at least four patients. The patients, whose diagnoses included bipolar disorder and paranoid schizophrenia, spent many hours without structured activity, the report said.

Instead of attending group therapy, they spent many hours sleeping or wandering around the hallways, inspectors said. When investigators asked one nurse about the lack of alternative treatments, she disagreed.  “Sleep is an alternative,” she replied.

Massachusetts regulators prohibited the hospital from accepting any patients in November, citing unsafe conditions. When they allowed admissions to gradually resume two weeks later, in early December, mental health officials said Arbour HRI was working to bring the “culture of care’’ up to “our high standards.’’

Yet in February, inspectors for the federal Centers for Medicare & Medicaid Services found serious shortcomings in the quality of treatment at the 66-bed hospital in Brookline. Soon after, Arbour HRI’s chief executive, Patrick Moallemian, left his job. Arbour spokeswoman Judith Merel would not disclose the reason for his departure. Despite the federal findings, she said, patients at the hospital received good treatment.

The federal investigators’ report, which Medicare provided to the Globe in response to a public records request, details the latest in a series of problems at Arbour Health System hospitals and clinics resulting from poor training and understaffing.

One Tuesday afternoon during the February inspection at Arbour HRI, there were 11 patients in a unit for those diagnosed with both mental illness and a substance abuse disorder. Only three were in therapy. Eight were found in bed. Staff members often wrote in the medical records that patients were offered “educational materials’’ as an alternative, but they did not specify what the materials were or how the patients responded.

Inspectors also faulted the hospital for not including patients’ strengths in psychiatric evaluations, which is information that could help psychiatrists decide upon the best approach to therapy. Treatment plans consisted of boilerplate language and were not tailored to individuals, investigators found.

In the improvement plan it submitted to Medicare after the February inspection, Arbour said it hired consultants, educated staff about proper procedures, and brought in a new chief executive, who started in April. The hospital said the board of advisers would take a more active role overseeing the hospital. A press release on the hospital’s website said that William Zella, a licensed psychologist, is now chief executive.

In a written statement to the Globe, Merel, Arbour’s spokeswoman, said that despite Medicare’s findings, Arbour HRI patients “received appropriate and individualized, effective care and treatment.’’ She said that patients may not be able to attend group therapy for clinical reasons, and that in those cases “alternatives such as individual activities or therapies are offered.’’

The hospital’s electronic medical records did not allow staff members to record specific treatment plans for individual patients, Merel said, but the system has since been updated to make that possible.

Arbour Health System operates five psychiatric hospitals and 12 mental health clinics in Massachusetts. Its for-profit parent, Universal Health Services, is a publicly traded company that earned more than $500 million last year and has staked its future largely on expanding in the behavioral health care market.

Arbour HRI in particular has been very profitable. The hospital earned a 32 percent profit in 2012, compared with an average 9 percent earned by other non-acute care hospitals in Massachusetts, according to the most recent state reports. Nearly 85 percent of patients at the hospital are covered by the federal and state Medicare and Medicaid insurance programs, meaning that many are poor, and that most care is paid for by taxpayers.

Frank Barnes, a longtime mental health worker at the hospital and a union representative for 1199SEIU, said the problems at Arbour HRI reflect the culture of the administration.

“The emphasis wasn’t on the quality of care,” he said. “It was on increasing income.’’ Staff members have filed numerous complaints with hospital leaders and regulators about a lack of security personnel; inadequate staff; and patients not having enough towels, blankets, and food at night, he said.

State regulators have identified staffing problems elsewhere in the Arbour Health System, including allowing therapists without required training or supervision to treat patients at outpatient clinics. Arbour Hospital in Jamaica Plain was found to have too few nurses during four consecutive inspection cycles and was cited for staff failures related to two questionable deaths.

State inspectors made a surprise visit to Arbour HRI in October, after receiving a report about a female patient being forcibly searched, an incident that state Mental Health Commissioner Marcia Fowler described in an interview as “a very serious human rights violation.”

Inspectors identified a range of problems, including dirty conditions and untrained or inexperienced staff, prompting the state to stop admissions for two weeks. When the Department of Mental Health allowed the hospital to start accepting patients again in December, licensing director Lizbeth Kinkead said in an e-mail, regulators were “satisfied that Arbour HRI is working to ensure that the changes are made, that the culture of care is up to our high standards, and that these are visible throughout the hospital.”

Federal inspectors also visited the hospital in December after receiving a complaint. They found numerous problems, prompting the in-depth review in February.

When asked why the state cleared Arbour HRI in December, only to have federal inspectors find serious deficiencies three months later, state officials said they were working intensely with the hospital during those months to spur improvements. State regulators visited Arbour HRI and met with staff 11 times between Dec. 10 and March 20, they said. Last month, the state allowed the hospital to open all units to new patients — with assurances of adequate staff, medical coverage, and group programming.

Massachusetts Health and Human Services Department spokesman Alec Loftus said that in addition to the Medicare efforts, Arbour has made improvements. “Many of the ongoing issues identified by DMH in site visits and discussions with the company’s leadership have resulted in improvements to the quality of care at the facility,” he said in a written statement to the Globe. “We are encouraged by the decision to make leadership changes at the facility, which is a visible sign of its commitment to change.’’

Representative Elizabeth Malia, a Jamaica Plain Democrat and chair of the Joint Committee on Mental Health and Substance Abuse, said Arbour takes many chronically ill patients with very challenging conditions. She said it probably makes more sense for the state to work with the hospital than shut it down.

“You can pull their license, but then what?” she said. “Where do these folks go? You can’t just put people back onto the street.’’

Barnes said he is hopeful the hospital will improve under Zella, the new chief executive. Zella, he said, has hired more nurses and mental health workers and has instituted policies to more carefully evaluate patients for serious medical problems. Those patients may not be able to be safely cared for at Arbour HRI, he said. “We’re very pleased with the changes he’s making,’’ Barnes said. “There’s a long way to go.’’

SOURCE: The Carlat Psychiatry Report
October 2012 | Sarah Hollingsworth Lisanby

How commonly is electroconvulsive therapy (ECT) performed these days? Does it seem to be getting more or less use, and why is that?

Dr. Lisanby: ECT is alive and well. It is still the most effective psychiatric treatment that we have for medication-resistant major depression. Utilization figures are hard to track because it is not centrally reported in the United States, but my impression is that use remains steady. The number of psychiatrists doing ECT has been fairly constant. In another way, despite the periodic availability of novel antidepressant medications and, in more recent years, novel devices, the utilization of ECT remains robust because it continues to fill a need that is not being filled by other available treatments.

Is that also reflected in insurance coverage? Is it as likely to be covered today as it was 10 or 20 years ago?

Dr. Lisanby: Yes, and I believe that is because of its efficacy. Insurers look at healthcare utilization and efficacy when they are making those decisions, and ECT is helpful in shortening length of stay and in achieving remission and preventing relapse; these are things that are important both for patient outcomes, and, from the payers’ perspective, controlling health care costs. Private and public payers have consistently been covering ECT because it is not only effectively clinically but cost-effective.

What about changes in the field and how ECT is being used differently?

Dr. Lisanby: ECT is not one-size-fits-all. There are different choices in dosing, electrode placement, and the parameters of the electrical stimulus. So taking those in order:

• Individualizing the dosage is important for ensuring the efficacy and also the safety of ECT. In the early days of ECT, it was a maximal dose, enough to get a seizure. Later, other methods were introduced, like basing the dose on the age of the patient, and then more recent innovations to titrate the dosage for each patient. Several strategies exist for individualizing the dosage, which often results in better outcomes.

• Electrode placement is critical for cognitive safety. Amnesia is the major side effect that dissuades people from getting ECT and dissuades clinicians from referring patients for ECT. Options in electrode placement like unilateral and bifrontal (compared to the standard, which is bilateral) provide opportunities to lower the cognitive risk of the treatment, so that patients can get effective treatment with a lower risk of amnesia.

• Alteration in the stimulus parameters, specifically ultra-brief pulse ECT, which refers to the length of each pulse. With standard pulse ECT, the electrical pulse lasts 1 to 2 milliseconds. With ultra-brief pulse ECT, it is about a quarter of a millisecond. Ultra-brief unilateral ECT, when it is personalized to the individual seizure threshold (combining all three of those innovations), has dramatically improved cognitive outcomes so that we can effectively use ECT with a substantially lowered risk of memory loss. As the use of this form of ECT increases, the overall utilization of ECT should begin to climb because this ameliorates a significant barrier to utilization.

If a patient is going in for a course of ECT, how do you determine when to stop?

Dr. Lisanby: We divide the course of ECT into different phases. The acute phase—during which we are giving three times a week treatment—ideally ends when the patient achieves remission. We recommend measurement-based care using a rating scale like the Hamilton Depression Rating Scale or Montgomery Asberg Depression Rating Scale. And we use the standard format to really get a full sense of how the patient is doing, including sleep, appetite, and neurovegetative symptoms. A remission is essentially an absence of symptoms, not just a 50% drop in the rating scale score. We advocate treating until remission because when you stop early the chance of relapse is higher. A recommended practice for the acute phase of ECT is three treatments a week until remission. After that, we want to prevent relapse. A course of ECT for the purpose of preventing relapse may involve two treatments per week, then one per week for a couple of weeks, while adjusting antidepressant medication and a mood stabilizer. Another approach is to transition to a maintenance course of ECT, where you space out the treatments once a week and then once every other week, every three weeks, and so on. Maintenance courses can last six months or more.

What happens after a course of ECT?

Dr. Lisanby: Although ECT remains most effective in acute treatment, the problem is we stop it as soon as it works. When you stop ECT once you achieve remission, the chance of relapse is 80% within six months if the patient receives no treatment afterwards. The standard relapse-prevention strategies have been combination pharmacotherapy, which is an antidepressant medication plus lithium, or maintenance ECT. Recent results of the consortium for research on ECT (CORE) found that regardless of which of those strategies you use, 50% of patients will still relapse within six months. I am a coprinciple investigator on an NIMH-sponsored study called PRIDE (Prolonging Remission in Depressed Elders). The study is a multicenter trial in the geriatric population. We are systematically evaluating whether maintenance ECT can provide additional benefit to combination pharmacotherapy, but with an attempt to titrate the frequency of ECT treatments based on the symptoms of the patient. It is called a System-Titrated Algorithm-Based Longitudinal ECT, or STABLE. We hope to personalize the maintenance schedule based on clinical need, while also preventing the overtreatment of patients in remission.

What other seizure-based treatments are on the horizon?

Dr. Lisanby: We are doing research in other groups on reducing the amplitude or how much amperage is actually being given in ECT. When you lower the amperage, this makes the seizure more focal. We also have an NIMH R01 grant for the rational design of electrical and magnetic seizure therapies, evaluating these innovations in a preclinical model and also a computational model prior to human use. Another experimental approach is using magnetic fields to induce seizures, which leads in to the area of transcranial magnetic stimulation (TMS). The form of TMS that is FDA-approved today is subconvulsive, or below the level for inducing seizures. However, magnetic stimulation can be used to induce seizures, and that is called magnetic seizure therapy. Magnetic fields pass through the scalp and skull without impedance, giving you better control over the site of stimulation. This makes it easier to localize the treatment, and opens the door to inducing focal seizures on just the parts of the brain that are important for effective antidepressant response. It has been developed in preclinical models and also clinical trials and international clinical trials but is not FDA approved.

How effective is subconvulsive TMS?

Dr. Lisanby: If you look at individual trials or metaanalyses, what we can say about efficacy is related to a very small subset of a very large terrain of possible doses, and we have only scratched the surface of how to optimize the efficacy of these devices. That is where I feel preclinical studies play a very important role, because we can rapidly and systematically examine this multifactorial dosage space to improve efficacy. There are many avenues to potentially enhance the potency of TMS that are currently being explored. With the present FDA-approved dosage, TMS has a modest effect, but that is the effect of 10 Hz given at 120% above the motor threshold to the left prefrontal cortex for three to six weeks of daily treatments. Other options to investigate include increasing the number of pulses per day, giving bilateral treatment, changing treatment location, or individualizing it based on an MRI scan.

The idea of doing office-based TMS or investing in some of these devices is pretty daunting. Is it a worthwhile investment for a practicing psychiatrist?

Dr. Lisanby: As with any technology, the costs come down over time and we have already seen that to some degree in new models. When I started working in the field of TMS, physicians administered every treatment. Now with increased knowledge about the safety of the protocols and ways to establish reliability in the training and supervision of the operators, more programs are using allied health professionals or others to do the treatment under supervision. That certainly brings down costs. TMS has some benefits over ECT. The costs of ECT are significant. You have the anesthesia; in some cases an inpatient admission—though increasingly it is done on an outpatient basis. ECT has remained robust and strong because it works. The future of TMS is going to hinge on its efficacy.

Do you think the narrowing pipeline of psychiatric drugs might open the space for greater use and acceptance of devices to treat depression and other conditions?

Dr. Lisanby: It may. These are orthogonal approaches. As we are seeking to discover novel effective treatments for depression and other conditions we have to look beyond the synapse. Brain stimulation is definitely beyond the synapse. It is a fundamentally different way of delivering therapy. The treatments of the future are probably going to combine pharmacotherapy with device-based interventions in intelligent ways—not just putting together two things that seem to work and seeing if they are additive, but rather looking for the synergistic interactions between stimulating neurons and then using pharmacotherapy to augment what happens after that. Using those two together may ultimately be the most effective.

SOURCE: HealthDay News
April 29, 2014 | Robert Preidt

Teens who like to help others may be less likely to develop depression, a new study suggests.

The study included 15- and 16-year-olds who were given three types of tasks: give money to others, keep the money for themselves or take financial risks with the hope of earning a reward.

The researchers monitored activity levels in a brain area called the ventral striatum, which controls feelings of pleasure linked to rewards. The teens were checked for symptoms of depression at the start of the study and a year later.

Activity in the ventral striatum in response to the different types of rewards predicted whether the teens would have an increase or decrease in depression symptoms, according to the study published online recently in the Proceedings of the National Academy of Sciences.

"If they show higher levels of reward activation in the ventral striatum in the context of the risk-taking task, they show increases in depressive symptoms over time. And if they show higher reward activation in the pro-social context, they show declines in depression," study author Eva Telzer, a psychology professor at the University of Illinois at Urbana-Champaign, said in a university news release.

"This study suggests that if we can somehow redirect adolescents away from risk-taking or self-centered rewards and toward engaging in these more pro-social behaviors, then perhaps that can have a positive impact on their well-being over time," she added.

Previous research has shown that teens tend to have higher levels of ventral striatum activity, suggesting that they experience the pleasure of rewards more intensely than adults or younger children, according to the news release. Most of that research has focused on the link between ventral striatum activity and risk-taking by teens. This study shows that ventral striatum activity may also have a positive effect in teens, Telzer said.

I have been off and on the phone with Humana/Medicare for a total of an hour's time today and speaking with no less than 7 different people in 5 different departments. 

I have about had it.. really I have. At first, I kept myself in check while dealing with one script-following lackey after another. Eventually, the last two unfortunate souls got to hear me rant about how the insurance company has no business telling me how to prescribe. 

Not every person matches the instructions on the box! Pharmacodynamics/kinetics vary... a half-life is a best guess sometimes. 

So what if I need to dose an XR med twice a day to get symptom relief? If that is what it takes so that my patient is able to get out of bed, go to work, take care of her children, and stay out of the hospital... than you as her insurance provider should support that! Isn't that what folks fork over an often absurd amount of their paycheck to have you do? 

SOURCE: Carlat Psychiatry Report
April 2012 | Inge Hansen

Patients who identify themselves within the broad category of LGBTQ (lesbian, gay, bisexual, transgender, and queer or questioning) are an increasingly visible population. Research has consistently shown that LGBTQ-identified individuals suffer higher rates of depression, suicide, anxiety, smoking, substance abuse, and sexually transmitted infections (STIs) than the general population.

For instance, a recent large-scale study of teens found that 21.5% of LGB teens were likely to have attempted suicide in the past year, compared to 4.2% of heterosexual teens. Unfortunately, not many providers are experienced with treating this community, so these statistics may stem from disenfranchisement and stigma, rather than any pathology inherently associated with LGBTQ identity.

SOURCE: Carlat Psychiatry Report
June 2012 | Timothy Lineberry

Assessing a patient’s risk of suicide is one of the most common, yet challenging, exercises for the psychiatrist. You’re probably familiar with the known risk factors. These include male sex, past suicide attempt(s), family history of suicide, and being divorced, unemployed, or older. Although these particular factors may clearly identify groups at risk, you can’t do anything to change them. As such, they tend to be of minimal use when you are making decisions about how to manage suicide risk in a patient in your office.

The intent of this article is to provide some direct, usable interventions to improve your management of suicide risk. Here are seven clinical pearls based on emerging evidence that can be useful in your daily practice. To help you remember and translate them, each is linked with a theme.

1. Enter Sandman
Decades ago, sleep problems were identified as a short-term (defined as one year) risk factor for suicide. Recent research in multiple clinical populations also emphasizes the importance of managing sleep disorders to reduce suicide risk. Importantly, sleep problems were identified as a risk factor even after controlling for other variables including depression, gender, hopelessness, and alcohol problems.

It’s unclear whether there is a specific sleep problem associated with suicide/suicide attempts. In practice, however, global sleep problems can be identified and treated. Fortunately, patients generally feel no difficulty or stigma describing their problems with sleep. This may be critically important in young men who may be less willing, or able, to describe depressive and anxiety symptoms or thoughts of suicide. A focus on sleep assessment and treatment can also be a point of entry for fleshing out other syndromes.

2. High Anxiety
Agitation and anxiety are critical risk factors in suicidal ideation and suicide attempts that must be addressed. Recent population-level research indicates that anxiety or agitation can mediate the change from thinking about suicide to acting on those thoughts. Anxiety disorders are also strongly associated with suicide. And in a study of 76 patients who committed suicide while hospitalized or shortly after discharge, 79% reported “severe or extreme” anxiety or agitation, while only 22% endorsed suicidal ideation when last asked about this.

Anxiety and agitation have purposely been placed together. Such symptoms may not be obvious on exam. It is not unusual, for instance, for a patient who does not appear anxious to endorse profound internal anxiety/agitation. Also, there are no scales to define the particular state of internal restlessness/ anxiety/agitation that individuals commonly report. However, from a suicide risk assessment perspective, it’s important for you to follow this symptom over time in your patients through careful clinical interview.

Asking questions such as, “Do you feel like you’re crawling out of your skin?” and “Do you feel like you are going to explode?” may be helpful in identifying, and naming for patients, a key symptom in suicidal states. Distinct from akathisia, this agitation (sometimes described as psychache or anguish) drives a need to take action to resolve the internal state. Similar to akathisia, there may be motoric symptoms that can be observed on exam; however, this is not always the case. Prompt treatment of anxiety or agitation with benzodiazepines or antipsychotics can be potentially life-saving in a crisis. Consider increasing your patient’s observation level on inpatient units until the symptom is well controlled.

3. Danger, Will Robinson
Though the actual risk associated with antidepressants in suicide has probably been overstated and misapplied, it is now a part of the patient’s and physician’s canon. After almost a decade of research, the following key principles are most relevant. First, adolescents and young adults are the group at greatest risk for suicidal ideation and are the basis for the FDA’s revised black-box warning (see table), issued in 2009. For those 25 or over, the risk is the same with antidepressants versus placebo. For older adults, treatment with antidepressants appears to decrease suicidality. Nonetheless, regardless of age, it is important to keep in mind periods when risk might be greater. These include the initiation of antidepressants, the period after changes in dose (both increases and decreases), and after antidepressant discontinuation. With this in mind, tailor your informed consent with patients to address these particular points in time/risk.

4. The Safety Dance
A suicide attempt with a firearm is 90% fatal, while other methods are far less lethal. Although guns are a hot-button issue politically, there is little controversy related to their role in suicide in those with psychiatric illness. According to some research, more than half of completed suicides are by gun. In fact, more gun deaths are the result of suicide (close to 19,000 in 2009) than homicide (about 11,500 in the same time period).

Clinically, there are very clear reasons for asking about access to firearms in patients who are depressed, misusing substances, suicidal, or a combination of these. The APA guidelines and expert guidance are very black and white about the need for identification of access to firearms and their subsequent removal. Practical matters, however, often introduce many gray areas. It’s important, therefore, to look for opportunities to build a shared understanding with your patients, and their families, of reducing firearm access, should that be necessary.

One way to do this is to systematically ask about access at the time of a patient’s initial assessment and options for safe storage or removal of firearms. Another is to use a pragmatic intervention such as a “means restriction receipt,” a signed receipt by the patient stating they have removed potential means for suicide. This has been very effective in promoting dialogue and action in patients, and could be used not just for firearms but for supplies of medications or other potential suicide methods.

5. Replace It With a Dimmer Switch
Often, clinicians and families think of suicide risk as a binary issue: you’re either suicidal or you’re not. To change this conceptualization, try to think of suicide risk as a light with a dimmer switch. Psychosocial triggers, physical pain, decreased sleep, intoxication, or worsening illness—which effectively “turn up the light”—may increase suicide risk and affect one’s behavior, while elimination of these triggers decreases risk.

6. Everybody Needs a Plan
Contracting for safety has no evidence base, and asking a patient to sign a document stating that they will not harm themselves is problematic on multiple levels. They may feel that they can’t talk about being suicidal. They may also ignore their contract when they have actual suicidal intent. Finally, a contract may give the clinical team a false sense of security. However, developing a plan for what to do when patients are suicidal can be helpful.

Safety Planning Intervention (SPI) is a brief intervention to mitigate suicide risk that can be utilized by clinicians or support staff. Though its efficacy has not been confirmed and clinical trials are ongoing, it is a Suicide Prevention Resource Center/American Foundation for Suicide Prevention best practice. SPI involves patients writing down the signs that they are suicidal, and prioritizing and defining the psychosocial factors they can access to help decrease that risk. It helps patients to define their own internal coping strategies, to identify their social supports and how to contact them, and to determine how to make their environment safer. SPI is widely used in the Veterans Administration and has been extremely well received.

7. It’s a Wrap
Assessment and management of suicide risk obviously demands careful documentation of your assessment and thought process in the medical record. To improve your documentation of suicide risk assessment, consider the dimmer switch example and the fact that people move in and out of suicidal crises. Document when a suicidal crisis has resolved, but also be sure to describe that a chronic risk may remain which can be reactivated/precipitated in the future. Intervene with medication, psychotherapy or other risk-reduction strategies during crises to resolve them, and describe your approach to reducing risk and managing current and future crises.

TCPR’S Verdict
Though suicide can’t always be prevented, a careful and pragmatic suicide risk assessment can focus on interventions to decrease suicide risk and improve symptom response. By focusing on sleep, anxiety/agitation, risk reduction strategies, and developing a plan for treatment, you can potentially make a difference in people’s lives and resolve a suicidal crisis.

SOURCE: HealthDay News
April 24, 2014 | Serena Gordon

More than 7% of American schoolchildren are taking at least one medication for emotional or behavioral difficulties, a new government report shows.

Apparently, the medications are working: More than half of the parents said the drugs are helping their children, according to the report. "We can't advise parents on what they should do, but I think it's positive that over half of parents reported that medications helped 'a lot,' " said report author LaJeana Howie, a statistical research scientist at the U.S. National Center for Health Statistics.

Howie and her colleagues weren't able to identify the specific disorders the children were being treated for, although she said 81 percent of the children with emotional or behavioral difficulties had been diagnosed with attention-deficit/hyperactivity disorder (ADHD) at some point in their lives.

The researchers were also unable to identify the specific medications prescribed to the children for their emotional and behavioral difficulties, according to Howie. An expert not involved with the report agreed that ADHD likely would be one of the most common conditions involved.

"Although the authors don't really talk about the diagnoses, ADHD is likely the most overwhelming diagnosis. Oppositional defiant disorder, anxiety and depression are other likely diagnoses," said Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Steven and Alexandra Cohen Children's Medical Center of New York, in New Hyde Park.

Data for the study came from the National Health Interview Survey, which continually collects information about health and health care in the United States. All of the information on children is obtained through parental (or other guardian) responses. None of the information comes from medical records.

Overall, the researchers found that 7.5 percent of U.S. children between the ages of 6 and 17 were taking medication for an emotional or behavioral problem. Significantly more boys than girls were given medication -- 9.7 percent of boys compared with 5.2 percent of girls.

Older females were more likely than younger females to be given medication, but the age difference among males wasn't significant, according to the report.

White children were the most likely to be on psychiatric medications (9.2 percent), followed by black children (7.4 percent) and Hispanic children (4.5 percent), according to the report.

The study found that significantly more children on Medicaid or the Children's Health Insurance Program were on medication for emotional and behavioral problems (9.9 percent), versus 6.7 percent with private insurance and just 2.7 percent of children without insurance.

Additionally, more families living below 100 percent of the federal poverty level had children taking medications for emotional and behavioral problems than those above the federal poverty level.

Fifty-five percent of parents reported that these medications helped their children "a lot," while another 26 percent said they helped "some." Just under 19 percent said they didn't help at all or helped just a little.

Parents of younger children (between 6 and 11) were slightly more likely to feel the medications helped a lot compared to parents of older children. Parents of males were also more likely to feel the medications helped a lot -- about 58 percent of parents of males reported that they helped a lot compared to about 50 percent of the parents of females.

The report found that parents with incomes less than 100 percent of the federal poverty level were the least likely to feel the medications helped a lot. Just 43 percent of those parents said the medications helped a lot, while about 31 percent said they helped some. More than one-quarter of these parents said the medications only helped a little or not at all. Of those findings, Howie said, "We really can't speculate what factors would account for the difference."

For his part, Adesman said there are many factors that might contribute to more use of medications in people living under the poverty line and for those on government insurance programs. "There may be parenting challenges, such as more single-parent households, medications may be more available than access to behavioral treatments, there may be more logistical issues with nonpharmaceutical interventions, like getting time off from work," Adesman said. "Many more families have access to prescription medications than to non-pharmaceutical interventions. There's a lack of mental health treatment parity.

"It's encouraging that children who are identified as taking prescription medications are benefiting from those medications," Adesman said. However, he added, "There are nonpharmaceutical treatments for virtually all psychiatric diagnoses in children. For households where a child has significant emotional or behavioral difficulties, counseling, behavior management and some forms of psychotherapy can be helpful as well."

SOURCE: MPR
May 19. 2014 | Beth Gilbert

According to the Anxiety and Depression Association of America (ADAA), hoarding is a disorder in which individuals have a tendency to acquire items, regardless of whether these items have value, and fail to discard a large number of these items. The disorder not only puts a negative strain on the hoarder but also on family, friends, and others because it has emotional, physical, social, financial, and even legal impacts and leads to lower quality of life. The disorder and its impact have been depicted on the A&E television series,Hoarders, a reality show chronicling the struggles of individuals with hoarding disorder and their journey to recovery.

Hoarding Recognized as Separate Anxiety Disorder
Hoarding disorder was recently classified as a separate disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Prior to this new classification, hoarding disorder was listed as a variant of obsessive-compulsive disorder (OCD) but was not well described.

According to Sanjaya Saxena, MD, director of the Obsessive-Compulsive Disorders Program and Outpatient Psychiatric Services at the University of California in San Diego, “there is a wealth of evidence that demonstrates hoarding disorder may share similarities to obsessive compulsive disorder (OCD) but is not the same thing. Hoarding disorder is a discrete entity of its own. Hoarding disorder is a fairly common disorder and is approximately 1.5 times more common than OCD,” Overall, according to Saxena the disorder affects approximately 2–5% of the population. In the United States, this represents approximately 8–10 million people who meet the diagnostic criteria for the disorder.

Based on the DSM-5 criteria, symptoms of hoarding include but are not limited to excessive acquisition and saving, even if the individual doesn't need or have space for such things. Individuals with hoarding disorder have difficulty discarding possessions, which leads to clutter and congestion in their home, work spaces, or even outside areas. This can compromise the use of rooms, surfaces, and other areas of the home. “Hoarding disorder clearly impacts activities of daily living and causes a significant amount of functional impairment – even risks to physical health in more severe cases, infestations of rodents, falls, mold, dust build up, and fire hazards,” said Saxena.

SOURCE: PsychCentral  
May 5, 2014 | Margarita Tartakovsky

When we are upset or overwhelmed, we may inadvertently turn to activities or habits that can spike our stress, not soothe it.

Below, two experts reveal what doesn’t reduce stress and why — and what really does.

Watching TV
Many of us — myself included — tend to unwind after a long or stressful day by spacing out in front of the TV,” said Carla Naumburg, Ph.D, LICSW, a clinical social worker and writer who pens the Psych Central blog “Mindful Parenting.”

However, what we typically watch — the evening news, suspenseful dramas — can boost our body’s levels of stress hormones, “even if we’re not aware of it.”

Heidi Hanna, PhD, author of the book Stressaholic: 5 Steps to Transform Your Relationship with Stress, agreed. “The problem is, your brain is always scanning your environment to see what might be potentially threatening, and will turn on the stress response just in anticipation of something dangerous.” And even though we might be watching a fictional crime show, it still amplifies our senses, which can be stressful, she said.

Also, TV-watching takes time away from truly nourishing activities. According to Naumburg, these activities may include cooking, crafting, meditating, reading, journaling and spending time with loved ones. Plus, the bright screen and rapid-fire images can make it harder to fall asleep, she said. “Sleep deprivation is a major source of increased stress in our lives.” Even if you’re used to falling asleep to the TV, your “brain is not able to get quality rest,” Hanna said.

High Intensity Exercise
Engaging in physical activities is a great way to relieve stress. However, “if you’re physically exhausted, your brain and body are in a deprived state, and the extra energy required to work out may end up pushing you over the top,” leading to “overtraining,” said Hanna, a fellow with the American Institute of Stress.

This may “potentially weaken your immune system, increase inflammation, and even cause hormone imbalances that lead to more long-term issues.” Instead, practicing gentle movement, such as yoga and walking, helps to relieve stress, she said.

Thinking Your Way Out
It may sound pretty obvious, but most of us move through life lost in a storm of thoughts without even realizing that we are soaking wet,” said Naumburg, author of the forthcoming book Parenting in the Present Moment: How to Stay Connected, Sane, and Focused on What Really Matters.

Reflecting on our thoughts and reactions to a certain situation can help us gain clarity, she said. However, “that’s quite different from the endless mental spinnings that so many of us engage in when we’re faced with a confusing or challenging situation.”

Instead, we may ruminate about the past, berate ourselves or others for different actions and mull over every potential result or scenario. This just adds another unnecessary level of stress and anxiety, she said.

The key is to observe your thoughts. Helpful thoughts propel us toward clarity or the next steps in solving the problem, Naumburg said. Unhelpful thoughts only push you further into feeling anxious, angry, frustrated or sad.

Socializing
Social connections are key for our health. But being constantly connected can be exhausting, especially if you’re surrounded by people who tend to deplete you.

“Because the brain is so sensitive to stressful cues in the environment, being around people who are stuck in a stress response [such as] talking quickly, running from one place to the next [and] complaining can quickly shift your own body into fight or flight,” Hanna said. That’s why it’s important to spend time with individuals who “nourish your energy, not add more to your already full plate.”

Solitude
If you feel disconnected, being alone also can boost your stress, Hanna said. And when you’re alone you might turn to social media and the Internet for a sense of connection. These “are often full of negative, stressful news that puts us in a fear state and triggers the stress response.”

Ignoring Stress
According to Naumburg, choosing not to think about a problem isn’t the same as ignoring it. It’s healthy to observe our thoughts, consider them, and then decide whether we’d like to engage with those thoughts, she said.

Ignoring thoughts, on the other hand, is sprinting at the “slightest reminder of the stressful situation.” This also may include distracting ourselves by watching TV, shopping compulsively or drinking alcohol, she said. But ignoring stress is ineffective because it never really goes away. Naumburg cited Carl Jung: “that which we resist, persists.”

“[Stress] may pop up in an angry outburst, an aching back, sleepless nights, or any other number of unhelpful outcomes that will only serve to increase our stress — the exact opposite of what we were hoping to achieve.”

Confronting the sources of stress may be intimidating, but it’s likelier to be less stressful in the long run, she said. You can confront stress by engaging in healthy strategies such as journaling, talking to trusted loved ones, meditating and working with a therapist, she said.

SOURCE: The Carlat Psychiatry Report 
April 2012 | Dan Karasic

Most psychiatrists have not been specifically trained in treating transgender patients. This is a problem, because as society has become more accepting of sexual and gender diversity, more of your patients are likely to divulge to you their transgender identity. In this article I will discuss transgender care and how you can respond to the unique needs of transgender patients in your practice.

Let’s start with some definitions. “Transgender” is a general term, referring to individuals or behaviors that vary from the gender conventions of one’s culture. Older clinical terms include “transexualism,” introduced in DSM-III, and “gender identity disorder” (GID), which is found in DSM-III-R and DSM-IV.

GID has been an unpopular label among patients and professionals alike, because it labels as a “disorder” something that people perceive as being intrinsic to their identity. A person’s subjective gender identity, regardless of the sex they were assigned at birth, can lie anywhere on a gender spectrum. Sometimes, people experience distress or discomfort due to a discrepancy between their gender identity and birth gender. We refer to this as “gender dysphoria,” the term that will replace GID in DSM-5.

Gender dysphoria may be related to discomfort with one’s physical body, one’s social role (and societal expectations), or both. So it’s a very broad term. We should be careful not to confuse it with “gender nonconformity,” which simply means that a person expresses one’s gender in a manner different from what’s conventional. We use this term, for instance, to refer to boys who prefer girls’ play or girls’ dress, or vice versa.

Gender nonconformity is, in itself, not pathological, and does not presuppose that a person experiences distress. If a child exhibits distress, it’s usually due to bullying or rejection by a family member or acquaintance. A national organization called Gender Spectrum works with parents and families of gender-nonconforming children to try to improve their experience. In adults, distress often arises from the effects of stigma, marginalization, or discrimination.

SOURCE: Global Medical Education

SOURCE: Psychiatric Times
August 21, 2013 | Arline Kaplan

Lithium, used to treat affective disorders for more than a half-century, has neurotrophic and neuroprotective properties that may help preserve cognitive function in patients with bipolar disorder and possibly in those with Alzheimer disease. At the American Psychiatric Association’s annual meeting in San Francisco, Ariel Gildengers, MD, Associate Professor of Psychiatry at the University of Pittsburgh, told scientific session participants that “more than 75 studies and more than 5 reviews have established an association between bipolar disorder and cognitive dysfunction.” 

Specifically, Gildengers described a large meta-analysis of individual patient data across 31 studies of cognitive impairment in bipolar disorder by Bourne and colleagues. The researchers found evidence of significant cognitive impairment in patients with bipolar disorder, even during periods of euthymia. They concluded that the impairments “seem unrelated to drug treatment.”

Dysfunction is present in executive function, verbal memory, and information processing, and the deficits are apparent in first-degree relatives, said Gildengers, who spoke during the Advances in Geriatric Psychopharmacology session. There are studies of identical twins who are discordant for bipolar disorder. The twin without the illness has a similar pattern of cognitive deficits, although not as severe, but “there is something genetically present.”

The two most common findings in patients with bipolar disorder are enlarged ventricles and increased white matter hyperintensities (WMHs), Gildengers said. While acknowledging that enlarged ventricles are present in patients with schizophrenia and that WMHs are present in aging adults, he said their prevalence is higher than expected in individuals with bipolar disorder.

Bipolar disorder is “not simply a disease of the brain,” but it is rather “a multisystem disorder,” according to Gildengers. Some of the biological mechanisms include altered mitochondrial function, dysregulated dopaminergic/glutamatergic systems, and inflammation.

“The good news is that some of the medications, such as lithium, quetiapine (Seroquel), and valproate (Depakote, Depakene), have very positive effects on some of the things that may be deranged in bipolar disorder, such as abnormalities of brain-derived neurotrophic factor (BDNF) and the protein Bcl-2,” Gildengers said. “Lithium enhances BDNF and Bcl-2. These are neuroprotective factors that may lead to neuronal health. Lithium may also reduce oxidative stress.”

SOURCE: Medical Daily
May 9, 2014 | Lizette Borreli

Arguments and fights with family, friends, partners, and even neighbors are inevitable. Although these experiences are stressful, we seldom think about the possible long-term health risks they pose, especially in the heat of the moment. If you’re hot-headed, temperamental, and stubborn, you may want to adopt a better strategy to deal with conflict. People who frequently argue with family and friends or worry too much about their loved ones, are up to three times as likely to die in middle age, compared to their less argumentative counterparts, according to a recent study published in the Journal of Epidemiology & Community Health.

"Having an argument every now and then is fine, but having it all the time seems dangerous," said Rikke Lund, study researcher, and an associate professor of medical sociology at the University of Copenhagen, Denmark, according to LiveScience. Social relations' stressful aspects such as conflicts, demands, insensitivity, and worries, have been associated with physiological factors detrimental to our health. They can cause a dysregulation of endocrine, cardiovascular, and even immune system functioning.

SOURCE: Medical News Today 
March 12, 2014 | Honor Whiteman

Bipolar disorder is characterized by dramatic changes in mood, energy and activity levels that impact a person's ability to carry out everyday tasks. The exact cause of the condition is unknown. But now, researchers are one step closer to finding out with the discovery of two new genetic regions that are connected to the disease.

The international research team, led by investigators from Germany and Switzerland, recently published their findings in the journalNature Communications. Although the cause of bipolar disorder is unclear, researchers do know that genetic factors play a large part. "There is no one gene that has a significant effect on the development of bipolar disorder," says Dr. Markus M. Nöthen, of the University of Bonn Hospital in Germany. "Many different genes are evidently involved and these genes work together with environmental factors in a complex way."

For their study, the researchers obtained genetic data from 2,226 patients with bipolar disorder and 5,028 individuals without the condition. This data was merged with existing data sets and analyzed.

This led to the comparison of genetic material from 9,747 bipolar patients with that of 14,728 healthy individuals - the largest investigation of the genetic foundations of bipolar disorder to date, according to the researchers.

The team says that the search for genes involved in bipolar disorder is like "looking for a needle in a haystack." Dr. Sven Cichon, of the University of Basel Hospital in Switzerland, explains that individual genes make contributions to the disease that are so small, it is difficult to identify them.

However, comparing the DNA of large numbers of bipolar patients with the DNA of large numbers of healthy individuals makes this process easier, as differences between the two groups can be confirmed statistically. Five risk regions found, two newly discovered Using their large data collection, the investigators analyzed around 2.3 million different genetic regions, first in the bipolar patients, then in the healthy controls.

Subsequent evaluation of these regions revealed five risk regions on DNA that are associated with bipolar disorder. Three of these regions - ANK3, ODZ4 and TRANK1 - have been described in previous studies, although the researchers note that they were statistically better confirmed in this study. But the other two risk regions - ADCY2 on chromosome five and so-called MIR2113-POU3F2 on chromosome six - were newly discovered. The research team says the ADCY2 region is of particular interest, as it codes an enzyme that plays a part in sending signals to nerve cells.

"This fits very well with observations that the signal transfer in certain regions of the brain is impaired in patients with bipolar disorder," explains Dr. Nöthen.

The research team concludes that their findings - particularly the discovery of the ADCY2 risk region - provide new insight into the biological mechanisms involved in the development of bipolar disorder.

Last year, Medical News Today reported on a study detailing new brain scans that measure blood flow, which could diagnose bipolar disorder in its early stages and differentiate it from depression.