Back to table of contents Previous article Next article PsychopharmacologyFull AccessVilazodone May Be Safer Option to Treat Adult MDDJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:26 Dec 2017https://doi.org/10.1176/appi.pn.2018.pp11b2AbstractThe FDA requires clinical trials of new psychotropic drugs include a prospective assessment of suicidal ideation and behavior.Vilazodone appears to pose little or no risk of treatment-emergent suicidal ideation or behavior in adults with major depressive disorder (MDD) or generalized anxiety disorder (GAD), according to a study in the journal International Clinical Psychopharmacology.Treatment-emergent suicidal ideation and behavior remain ongoing concerns with antidepressants, says Michael Thase, M.D.Data pooled from four double-blind, placebo-controlled vilazodone trials for MDD (including 2,233 patients) and three for GAD (including 1,475 patients) revealed that suicide-related adverse events occurred in less than 1 percent of patients treated with vilazodone and placebo. Vilazodone, which is approved for the treatment of MDD in adults, has also been evaluated as a possible treatment for adults with GAD. “We found this result reassuring, and it might steer us to picking this drug more often,” said lead author Michael Thase, M.D., a professor of psychiatry at Perelman School of Medicine at the University of Pennsylvania. For other types of antidepressants, the risk of suicide ideation may be as high as 4 percent compared with 2 percent for placebo, he said. The Food and Drug Administration (FDA) requires clinical trials of new psychotropic drugs to include a prospective assessment of suicidal ideation and behavior. “The FDA’s duty is to warn when there is evidence of some risk of initiating treatment,” Thase said. “In the previous decade, comprehensive reviews suggested a small, but real increase—not due to chance—in suicidal thoughts compared with placebo.” For the vilazodone meta-analysis, Thase and colleagues evaluated treatment-emergent suicidal ideation using adverse event reporting and Columbia Suicide Severity Rating Scale (C-SSRS) monitoring. They analyzed treatment-emergent suicide by C-SSRS category shift from no suicidal ideation (C-SSRS=0) at baseline to suicidal ideation (C-SSRS=1-5). Studies in the meta-analysis included MDD patients with 17-item Hamilton Depression Rating Scale (HAMD17) total score ≥22 and item 1 (depressed mood) score ≥2 or HAMD17 total score ≥18; and Montgomery-Åsberg Depression Rating Scale total score ≥26. Key eligibility criteria for GAD studies included patients with Hamilton Anxiety Rating Scale total score ≥20, item 1 (anxious mood) score ≥2, and item 2 (tension) score ≥2; Clinical Global Impressions-Severity of Illness score ≥4; and HAMD17 total score ≤17.Incidences of suicidal ideation/behavior were as follows: MDD (vilazodone=19.9 percent, placebo=24.7 percent); GAD (vilazodone=7.7 percent, placebo=9.4 percent). Shifts from no suicidal ideation/behavior at baseline to suicidal ideation during treatment are as follows: MDD (vilazodone=9.4 percent, placebo=10.3 percent); GAD (vilazodone=4.4 percent, placebo=6.1 percent). The difference between any suicidal ideation during vilazodone treatment and any suicidal ideation during placebo treatment is statistically significant, Thase said. Among patients who entered these studies with no recent suicidal ideation or behavior at baseline, more than 85 percent continued to have no suicidality during treatment. “I think the Thase data showing a favorable profile with respect to treatment-emergent suicidal features in the manufacturer’s pooled trials are compelling, credible, and useful,” said Joseph Goldberg, M.D., a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York. Goldberg said he has prescribed the medication extensively with success for patients with major depression and depression with prominent anxiety. Vilazodone, a serotonin partial agonist-reuptake inhibitor (SPARI), was introduced in the United States in 2011. SPARI medications have the potential for faster onset of action, greater efficacy, and better tolerability, according to a 2014 study.This medication also could have benefits for subgroups of people with depression, including those with anxiety disorders, and might have fewer sexual side effects than selective serotonin reuptake inhibitors (SSRIs), according to a 2015 study on vilazodone.Thase told Psychiatric News that treatment-emergent suicidal ideation and behavior remain ongoing concerns with antidepressants. He cautioned that all patients be monitored for suicidal thoughts and behaviors during antidepressant treatment. The study was funded by Forest Research Institute Inc., an Allergan affiliate, makers of vilazodone (Viibryd). Thase reported a potential conflict of interest in his role as an advisor or consultant for Allergan and Forest Laboratories. The other authors on the study acknowledged a potential conflict of interest as full-time employees of Allergan or Forest Research Institute at time of study. ■Back to Psychopharmacology Newsletter Table of Contents ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessVarenicline May Lower Heavy Drinking, Smoking In Men With AUDJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:16 Mar 2018https://doi.org/10.1176/appi.pn.2018.2a14AbstractThe findings add to the converging evidence of the need for more specific and targeted treatments for women and men.Varenicline, an FDA-approved smoking-cessation medication (Chantix), may be effective in treating both alcohol use disorder (AUD) and smoking in men, according to a study published in the February issue of JAMA Psychiatry.iStock/AlexRaths“Men appeared to derive benefit from varenicline, compared with placebo, on measures of heavy drinking, whereas women did better taking placebo,” wrote lead author Stephanie S. O’Malley, Ph.D., director of the Division of Substance Abuse Research in Psychiatry at Yale School of Medicine. “In the overall sample, more patients taking varenicline quit smoking (13 percent versus none on placebo) even though they were not seeking smoking cessation counseling,” O’Malley told Psychiatric News by email. Researchers conducted the phase 2, randomized, double-blind, placebo-controlled trial at two outpatient clinics (New York City and New Haven, Conn.) from September 19, 2012, to August 31, 2015. The researchers recruited men and women aged 18 to 70 who were seeking treatment for AUD. Individuals who met the criteria for alcohol dependence (according to DSM-IV-TR), reported heavy drinking (≥5 standard alcoholic drinks for men and ≥4 drinks for women) two or more times a week and cigarette smoking two or more times a week were included in the trial. Patients who had been diagnosed with a serious psychiatric illness, experienced suicidal ideation, and had taken psychotropic medications other than a stable dose of selective serotonin reuptake inhibitors were excluded from the trial, said O’Malley. Previous clinical trials involving varenicline mostly have excluded participants with mental illness because of possible neuropsychiatric side effects that prompted the Food and Drug Administration in 2008 to issue a black-box warning. This warning was removed from the Chantix label in December 2016 after an analysis of more than 8,000 smokers with and without psychiatric illnesses found varenicline and bupropion did not significantly increase the risk of adverse neuropsychiatric events (Psychiatric News, January 6, 2017).O’Malley and colleagues randomly assigned 131 participants to receive either 2 mg of varenicline or placebo daily for 16 weeks. Medication was titrated in the following standard doses: 0.5 mg once daily for three days, 0.5 mg twice daily for four days, and 1 mg twice daily for the remainder of the 16-week treatment. Daily medication adherence was monitored through a combination of pill counts returned from blister packs and self-reported compliance.Over the course of the trial, participants attended 12 medical management sessions during which they met with a medical professional to discuss the tolerability of the assigned medication, medication adherence, and the importance of drinking goals as well as developing and implementing strategies for changing drinking behaviors. During these sessions, the participants were also asked about their drinking and smoking behavior, adverse effects of the medication, changes in mood, and more.Stephanie S. O’Malley, Ph.D., notes that women subjects were less likely to comply with the study regimen for varenicline than men.The varenicline (n=64) and placebo (n=67) treatment groups were similar in the median percentage of pills taken out of the total possible pills over the 16-week treatment period (85 percent versus 81 percent); however, women receiving varenicline took fewer pills (58 percent) than did men receiving the medication (91 percent). Women also were more likely than men to reduce or discontinue use of varenicline (37 percent versus 4 percent). In contrast, the percentage of placebo pills taken by men and women was similar (80 percent and 83 percent, respectively). Women taking varenicline reported higher rates of abnormal dreams and nausea—common adverse effects of varenicline, which may have caused them to take fewer pills. “The medication management treatment protocol specially supported dose reductions in response to adverse events, because lower doses were found to be effective for smoking cessation in prior research, although this may not be the case for AUD,” said O’Malley. The mean change from baseline in the percentage of heavy drinking days in the overall sample by the end of the study was not different between the placebo and medication groups, but varenicline appeared to have different effects on drinking in men and women. Compared with placebo, varenicline resulted in a greater decrease in percentage of heavy drinking days in men and a smaller decrease in women. Even though the subjects were not seeking or provided smoking-cessation counseling, varenicline resulted in significantly higher rates of smoking abstinence compared with placebo (13 percent versus 0 percent) at the end of treatment.“It may be premature to conclude that varenicline is not effective in reducing heavy drinking in women, given that severity of dependence, lower dose of varenicline, poorer adherence, and/or higher rate of abnormal dreaming or other adverse events affecting adherence, rather than sex per se, may underlie efficacy,” wrote A. Eden Evans, M.D., Ph.D., and John F. Kelly, Ph.D., both of the Center for Addiction Medicine at Massachusetts General Hospital and Harvard Medical School, in an accompanying editorial in JAMA Psychiatry.The question of whether it is more difficult for individuals to quit smoking and drinking at the same time, rather than addressing one problem at a time remains an important question for researchers, commented O’Malley. “We know that individuals with AUD are more likely to die from smoking-related consequences than from alcohol-related problems, and individuals with AUD who quit smoking have a better long-term prognosis,” O’Malley said. “We undertook this trial with the hope that varenicline … would be effective for helping patients seeking treatment for their drinking and that it might also reduce their smoking.” ■An abstract of “Effect of Varenicline Combined With Medical Management on Alcohol Use Disorder With Comorbid Cigarette Smoking: A Randomized Clinical Trial” can be accessed here. The related editorial, “A Call to Action for Treatment of Comorbid Tobacco and Alcohol Dependence,” is available here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessPsychiatrists Face Barriers to Managing Common Medical ConditionsJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:31 Jan 2018https://doi.org/10.1176/appi.pn.2018.1b6AbstractOffice-based psychiatrists are less likely than most other specialists to provide general medical management care, a new study found.Psychiatrists may become more involved in managing general medical care for their patients in the coming years, suggests a study published online December 1, 2017, in Psychiatric Services in Advance.The report found that only 37 percent of the sampled visits to psychiatrists involved general medical management activities such as measuring weight and blood pressure and ordering blood work. In comparison, 74 percent of visits to other specialist physicians involved these activities. The researchers focused on four medical diagnoses commonly encountered in both general medical and psychiatric settings: hypertension, hyperlipidemia, diabetes, and obesity. “Psychiatrists are significantly less likely than most other physicians, except for ophthalmologists, to conduct physical examinations and significantly less likely than most other physicians, except for dermatologists and ophthalmologists, to measure blood pressure or weight,” wrote Ramin Mojtabai, M.D., Ph.D., of Johns Hopkins University School of Medicine and Mark Olfson, M.D., of Columbia University and New York State Psychiatric Institute.For the study, Mojtabai and Olfson relied on eight years of data (2006-2013) from the National Ambulatory Medical Care Survey (NAMCS)—an annual survey of visits to office-based physicians. A sample of visits to each physician was drawn during a randomly selected one-week period. To be included, an adult had to have seen a physician during the visit. A total of 236,246 visits to 11,724 physicians met the criteria and were included in the sample; these visits included 11,046 to 735 psychiatrists, 66,267 visits to 3,024 general medical physicians (general and family physicians and internists), and 158,933 visits to 7,965 physicians in other specialties.For each visit, information was extracted from medical charts regarding the patient and characteristics of the visit, including diagnoses made, laboratory tests ordered, whether a physical exam was conducted, and/or health education and counseling were offered. The authors specifically focused on general medical management activities including recordings of hypertension, hyperlipidemia, diabetes, or obesity; prescriptions of medications for hypertension, hyperlipidemia, or diabetes; blood pressure or weight measurements; ordering glucose, glycohemoglobin (HbA1c), lipids, or cholesterol laboratory tests; and education or counseling for weight, exercise, diet and nutrition, or tobacco use.Overall, psychiatrists were found to be less likely to engage in management of common general medical conditions. However, differences between psychiatrists and all other physician groups were smaller for health education and counseling.One of the key barriers, explained Olfson in an interview with Psychiatric News, is that psychiatrists with office-based practices often have large caseloads and are stretched to the limit. “Adding more functions for these psychiatrists may be unreasonable, especially considering the shortage of psychiatrists,” he said. Additionally, psychiatrists in solo or small group practices often have few or no support staff, limiting their ability to conduct basic health assessments.Additionally, the authors wrote, “Psychiatric assessment and treatment, which are priorities in psychiatric visits, are time consuming and often involve extensive mental status examination, assessment of safety, and psychotherapy.” Still, Olfson said that he believes it is important for psychiatrists to expand their roles as much as possible to include general medical care, especially for patients with major psychiatric disorders, such as schizophrenia and bipolar disorder. “This [issue] is less about what psychiatrists want and more about what patients need,” he said. The authors noted that a major driver of the low prevalence of general medical management activities during psychiatric visits was the substantial percentage of psychiatrists who did not did not engage in general medical activities for any of their sampled visits. For example, the study found that 67.6 percent did not prescribe any medications for the treatment of hypertension, hyperlipidemia, or diabetes, and 89 percent did not order any laboratory tests for glucose-HgA1c or lipids-cholesterol—proportions that were higher than with other physician groups.Psychiatrists were as likely as general medical physicians to provide tobacco counseling, a finding Mojtabai and Olfson noted was possibly due to the high prevalence of tobacco use among psychiatric patients. Psychiatrists were also more likely than many other specialists to provide counseling and health education for patients with specific health conditions, such as hypertension and diabetes. Among psychiatric diagnoses, researchers found that schizophrenia was consistently associated with higher odds of general medical management activities by psychiatrists, followed by bipolar disorder. However, diagnoses of mood disorders were associated with lower odds of general medical care activities.“With ongoing trends toward integration of general medical and mental health care, demands on psychiatrists to expand their scope of practice will likely increase. Identifying appropriate opportunities for such expansion and providing necessary medical support services and continuing medical education may encourage psychiatrists to increase their involvement in the general medical care of their patients in the coming years,” the authors wrote.Still, the authors cautioned, “efforts to expand psychiatrists’ scope of practice to include general medical activities should be moderated by judicious considerations of competing demands on their attention and time.” ■“Management of Common Medical Conditions by Office-Based Psychiatrists” can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessPregnant Women With Dissociative Subtype of PTSD Have High Levels of CortisolJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:1 Feb 2018https://doi.org/10.1176/appi.pn.2018.1b23AbstractWomen with a complex form of PTSD may be more adversely affected during pregnancy than other women with a history of trauma.Pregnant women with a dissociative subtype of posttraumatic stress disorder (PTSD-D) appear to have higher levels of the stress hormone cortisol than other pregnant women with a history of trauma, reported a study in the Journal of Obstetric, Gynecological, and Neonatal Nursing. An elevated cortisol level is a risk factor for preterm birth and other adverse health conditions in offspring, according to the study authors.iStock/kjekolPTSD-D, which is characterized by altered perception of oneself and the world, is associated with a greater number of lifetime trauma exposures, including a history of childhood maltreatment.“Exposure to early relational trauma that predisposes a person to dissociation and PTSD may affect that individual’s short- and long-term cortisol patterns,” wrote Julia S. Seng, Ph.D., of the University of Michigan and colleagues. The difference between cortisol levels in the women with PTSD-D and the other groups was most apparent in early pregnancy, which is a critical period for fetal development, noted the authors.The study by Seng and colleagues involved 395 women expecting their first child who were divided into four groups: those without trauma, those with trauma but no PTSD, those with lifetime PTSD, and those with PTSD-D (presence of depersonalization and/or derealization consistent with the DSM-5 dissociative subtype definition). The researchers analyzed saliva cortisol specimens collected from these women at three different times on a single day during the first half of their pregnancy. A subsample of 111 women, including women from each of the four cohorts, provided three salivary cortisol specimens per day, 12 times, from early pregnancy to six weeks postpartum. (This sample included 34 women without trauma, 38 with trauma but no PTSD, 31 with PTSD only, and eight with PTSD-D.)In early pregnancy (gestational week 8), the cortisol levels of participants in the PTSD-D group were two times greater in the morning, eight times greater in the afternoon, and 10 times greater at bedtime than the cortisol levels of participants in the non-exposed control group. In late pregnancy (gestational week 32), participants in the PTSD-D group had cortisol levels that were less than two times greater in the morning and 1.5 times greater levels in the afternoon and at bedtime compared with participants in the non-exposed control group. “We don’t know why this group had higher cortisol levels,” Seng told Psychiatric News. “Likely there are other stress-response systems that may be dysregulated by early childhood relational trauma that is often the index trauma for PTSD-D.”These cortisol levels were so high that the researchers considered them “possibly toxic,” but Seng said it isn’t known at what level cortisol sets into motion adverse perinatal outcomes.“Although some women with histories of childhood maltreatment are resilient or recovered by the time they become pregnant, these biological findings indicate that some are very adversely affected psychologically and very stressed during the childbearing year,” the authors wrote. “We can screen and apply a stepped approach to maternity care that includes case-finding and interventions for women with PTSD, posttraumatic depression, and PTSD-D.”The study was funded by a National Institutes of Health grant. ■An abstract of “Gestational and Postnatal Cortisol Profiles of Women With Posttraumatic Stress Disorder and the Dissociative Subtype” can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessBinge Drinking May Offer Clues About Risk for AUDJoAnn BlakeJoAnn BlakePublished Online:14 Sep 2017https://doi.org/10.1176/appi.pn.2017.9b6AbstractYoung social drinkers at risk for an alcohol use disorder (AUD) had consumption patterns that were markedly different from low-risk drinkers during a free-access intravenous alcohol self-administration session.Binge drinking may be an early indicator of vulnerability to alcohol use disorder (AUD) and should be carefully assessed as part of a clinical evaluation, suggests a study published on August 4 in AJP in Advance. "Identifying early phenotypic differences between vulnerable individuals and healthy control subjects could help identify those at higher risk [for AUD]," wrote Joshua L. Gowin, Ph.D., a postdoctoral researcher at the National Institutes of Health in Bethesda, Md., and colleagues.Defined as a pattern of drinking that brings the blood alcohol level to 0.08 g/dL or above, binge drinking may indicate vulnerability to AUD, according to researchers. The study consisted of 159 young social drinkers who had taken part in an experimental laboratory session where they self-administered alcohol. To be included, participants must have consumed at least five drinks on at least one occasion previously. After the participant ate a standard meal, an intravenous catheter was inserted into a vein in the subject's forearm. Alcohol self-administration was conducted using the computer-assisted alcohol infusion system software, which controlled the rate of infusion of 6 percent v/v (volume/volume) alcohol in saline for each person, using a physiologically based pharmacokinetic model for alcohol distribution and metabolism that accounts for sex, age, height, and weight. Researchers tested the hypothesis that risk factors for AUD—including family history of alcoholism, male sex, behavioral impulsivity, and low level of response to alcohol—would predict the rate of binging during an individual alcohol consumption session. Overall, 60 participants reached a binge-level exposure. A greater percentage of relatives with alcoholism (hazard ratio: 1.04), male sex (hazard ratio: 1.74), and higher impulsivity (hazard ratio: 1.17) were associated with a higher rate of binging throughout the session. Participants with all three of these risk factors had the highest rate of binging throughout the session compared with the lowest risk group (hazard ratio: 5.27). Level of response to alcohol was not a significant predictor of the rate of binging throughout the session.The study demonstrated that alcohol consumption patterns of young social drinkers at risk for AUD varied markedly from young low-risk drinkers. Researchers found that vulnerable drinkers showed higher rates of binging throughout the session and a greater overall exposure to alcohol. To the investigators' knowledge, this is the first large pharmacokinetically controlled study to suggest that risk factors for AUD may lead to different patterns of drinking in young social drinkers who have not yet developed the disorder. The study was supported by the National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research. Development of the software used for the intravenous alcohol self-administration session was supported by Sean O'Connor, M.D., of the Indiana Alcohol Research Center. ■"Vulnerability for Alcohol Use Disorder and Rate of Alcohol Consumption" can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and ResearchFull AccessBrain Scans May Indicate Optimal Treatment for DepressionJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:19 May 2017https://doi.org/10.1176/appi.pn.2017.5b10AbstractThe degree of resting-state functional connectivity between brain regions involved in mood regulation hinted at depression patients most likely to respond to CBT or antidepressants.Brain-based measures used in emerging research may help psychiatrists to personalize treatments for patients with major depressive disorder (MDD). Helen Mayberg, M.D., says that research suggests there is a group of people who should not be prescribed an antidepressant because of their specific neural circuitry. Neuroimaging may one day help identify these individuals.As it stands now—apart from weighing a wide-ranging set of symptoms or patient preference—psychiatrists often resort to a trial-and-error process, according to Helen Mayberg, M.D., a professor of psychiatry, neurology, and radiology at Emory University School of Medicine. “We’re all looking for markers that will move us toward precision treatment, like our colleagues in cancer research who took the same stance and turned the field upside down,” she said. While previous studies suggest psychotherapy and antidepressants in combination improve remission rates in MDD patients, the cost and time associated with this combination therapy can serve as barriers for some. Mayberg together with Broadie Dunlop, M.D., director of the Emory Mood and Anxiety Disorder Program and W. Edward Craighead, Ph.D., a professor of psychiatry and behavioral science at Emory, set out to see if they could identify brain signatures capable of predicting how MDD patients receiving cognitive-behavioral therapy (CBT) or an antidepressant medication would respond.Using functional MRI (fMRI), the researchers assessed the resting-state functional connectivity between the subcallosal cingulate cortex (SCC) and three other brain regions—the dorsal midbrain, the ventrolateral prefrontal cortex and anterior insula, and the ventromedial prefrontal cortex—in 122 patients with depression. The patients, none of whom had received previous treatment for depression, were then randomly assigned to receive 12 weeks of CBT or treatment with one of two antidepressant medications: escitalopram or duloxetine. CBT consisted of 16 individual sessions, 50 minutes each. No placebo was used, and patients who did not remit after 12 weeks with a single treatment were offered combination treatment for an additional 12 weeks (CBT was added to medication nonremitters and escitalopram was added to CBT nonremitters). Of the 122 participants, 58 achieved remission at weeks 10 and 12 (defined as a HAM-D score of ≤7), and 24 had treatment failure (defined as a <30 percent reduction from baseline HAM-D score at week 12). A total of 40 patients had intermediate outcomes.Overall, patients with positive connections (greater functional connectivity) between the SCC and other regions examined were significantly more likely to achieve remission with CBT, while those with negative or absent connectivity were likely to remit to medication. Conversely, patients with positive connections did not remit when medications were used, and those with negative or absent connectivity did not remit to CBT. Some patients fell into a middle “gray zone,” which did not suggest a specific treatment.Precision medicine should involve the prediction of both the desired outcome (remission) and the most undesired outcome (treatment failure), the study authors noted. “Severe consequences for choosing the ‘wrong’ treatment underscore the need for biomarkers predictive of both remission and treatment failure,” they wrote.These emerging findings should help shape the prescribing patterns of clinicians, said Mayberg.“A person who seeks out help from a psychiatrist and receives treatment is likely to get a first-line SSRI. If that doesn’t make the person better, the clinician should not assume the patient needs more drugs,” she said. “This research suggests trying psychotherapy instead. There is clearly a group of people who should never use a drug to get well.” From a practical standpoint, Mayberg believes it is premature to advocate that brain scans be used now to determine the best treatments for depression patients in clinics because of cost and other considerations. Still, her findings in this area demonstrate the way imaging technology today may one day be used to personalize therapy for patients with MDD. (Another imaging study by Mayberg and colleagues, published in 2013, found evidence to suggest that using positron emission tomography [PET] to measure blood glucose in depressed patients might help predict response to CBT and escitalopram.) Brain-based measures of major depression “may provide a basis for possible future algorithms for triaging subjects to the appropriate treatment, likely as a component within a multivariate approach to prediction,” the authors concluded.This research, which appeared March 24 in AJP in Advance, was supported in part by the National Institutes of Health. Eli Lilly and Forest Laboratories donated the study medications, escitalopram and duloxetine, respectively, but were otherwise uninvolved in the study. ■“Functional Connectivity of the Subcallosal Cingulate Cortex and Differential Outcomes to Treatment with Cognitive-Behavioral Therapy or Antidepressant Medication for Major Depressive Disorder” can be accessed here. Mayberg’s 2013 study, “Toward a Neuroimaging Treatment Selection Biomarker for Major Depressive Disorder” is available here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessOpioid Epidemic Extends to Post-Surgical PatientsJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:13 Jun 2017https://doi.org/10.1176/appi.pn.2017.6b1AbstractExperts estimate that as many as 2 million patients will transition to persistent opioid use following elective, outpatient surgery this year in the United States.Opioid use that persists past normal surgical healing time has become so prevalent in the United States that a study published April 12 in JAMA Surgery called this overuse “one of the most common complications of elective surgery.”Chad M. Brummett, M.D., says that patients likely continued using opioids for reasons other than for treating the intensity of surgical pain.The study, “New Persistent Opioid Use after Minor and Major Surgical Procedures in U.S. Adults,” found higher-than-expected rates of opioid consumption that could translate into millions of new, long-term opioid users, among a large group of privately insured patients following minor and major surgical procedures. Perioperative prescribing for acute care has received little attention until now, said lead author Chad M. Brummett, M.D., an associate professor at the University of Michigan School of Medicine and director of clinical research in the Department of Anesthesiology. “The data in this study are among the first to quantify the serious scope of this problem,” he said. Brummett and colleagues used a nationwide insurance claims dataset from 2013 to 2014 to identify U.S. adults aged 18 to 64 with no history of opiate use in the 11 months prior to surgery. For patients filling a perioperative opioid prescription, researchers calculated the incidence of persistent opioid use for more than 90 days among “opioid-naïve” patients after minor surgical procedures (for example, varicose vein removal, carpal tunnel surgery, and laparoscopic appendectomy) and major surgical procedures (examples: bariatric surgery, hysterectomy, and ventral incisional hernia repair). “Persistent use” is defined as filling an opioid prescription, such as hydrocodone or oxycodone, between 90 and 180 days after surgery. This definition represents the time a normal surgical recovery would be expected from the procedures selected and is more conservative than the three-month definition of long-term postsurgical pain by the International Association for the Study of Pain, according to the study. The final study group consisted of 36,177 patients, with 29,068 (80 percent) receiving minor surgical procedures and 7,109 receiving major procedures. The study group had a mean age of 44.6 years and was predominately female (29,913, or 66 percent) and white (26,091, or 72 percent). The rates of new persistent opioid use were similar between the two surgery groups, ranging from 5.9 percent to 6.5 percent. The incidence in the nonoperative control group was only 0.4 percent. Risk factors associated with new persistent opioid use included preoperative tobacco use, alcohol and substance use disorders, anxiety, depression, and preoperative pain disorders. “This study has important implications for psychiatrists because most of the risk factors [for opioid overuse] are psychiatric disorders,” said Andrew J. Saxon, M.D., a professor and director of the Addiction Psychiatry Residency Program at the University of Washington and director for the Center of Excellence in Substance Abuse and Treatment at the Veterans Administration Puget Sound Health Care System. “Psychiatrists should be attentive to the risk history of their patients undergoing surgery,” he advised. Some patients are at a higher risk of addiction and introducing them to opioids can be like “setting a match to a powder keg,” he said.Although the added sedation from opioids generally does not cause adverse interactions with psychiatric medications, physicians should be extra vigilant regarding patients taking benzodiazepines because of the risk of respiratory depression and other complications when combined with opioids, he said. Saxon suggested that physicians follow the basic advisory on acute use of opioids contained in the “CDC Guidelines for Prescribing Opioids for Chronic Pain—United States, 2016,” issued March 18: “Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.”A surprising finding in the study involved patients who received an opioid prescription from their doctors in the 30 days before surgery. The odds for these patients of persistent opioid use after surgery were almost twice as high, even after adjusting for variables. Given that more than 50 million ambulatory surgical procedures are performed in the United States annually, the findings of the study suggest that more than 2 million people may transition to persistent opioid use following elective, outpatient surgery each year, said Brummett. Patients on Medicaid and the uninsured, groups that have shown high rates of opioid use, were not included in this research, but will be studied by this research group in the future, he said. The multilevel, multivariate logistic regression model with data from U.S. Census Bureau geographic regions examined differences in persistent opioid use between surgical types while controlling for patient characteristics including age, sex, race and ethnicity, education, history of tobacco use, mental health disorders, and pain disorders. Regional variation was found, with higher rates of new persistent opioid use in the East South Central and West South Central United States. Prolonged opioid use following surgery may not be a consequence of poorly controlled pain, according to researchers. The pain experienced after major procedures would be expected to be greater than for minor procedures, which could more likely result in continued opioid use for long periods. However, that was not the case. The study found that new persistent opioid use did not differ much between major and minor procedures. Patients likely continued using opioids for reasons other than for treating the intensity of surgical pain, the study concluded. While overestimating the safety of this prescribed medication, patients may use an opioid medication for other purposes such as back and neck pain, headache, osteoarthritis, and insomnia or may use the drug to treat emotional pain and distress. The study was funded by the Michigan Department of Health and Human Services and the Agency for Health Care Research and Quality. ■An abstract of “New Persistent Opioid Use after Minor and Major Surgical Procedures in U.S. Adults” can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessCan Childhood Infections Trigger Mental Disorders?JoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:17 Aug 2017https://doi.org/10.1176/appi.pn.2017.8b13AbstractUnderstanding the role post-infectious autoimmunity plays in a large spectrum of psychiatric symptoms could lead to new avenues for the treatment and prevention of childhood mental illness.The latest and largest-scale study to test the pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) hypothesis supports the curious role of infections in the development of mental illness.Strep infection such as strep throat or scarlet fever has been linked with obsessive-compulsive disorder (OCD) and tic disorders, a controversial concept first defined by Susan Swedo, M.D., then a pediatrician-researcher at the National Institute of Mental Health (NIMH). Dramatic symptoms appear suddenly after the infection, and may include motor or vocal tics, obsessions, compulsions, and anxiety attacks. Sonja Orlovska, M.D., says one of the main findings from the recent Danish research study testing the PANDAS hypothesis is “the connection between somatic and mental illness.”Almost 20 years ago, Swedo and colleagues published a study about the first PANDAS cases they identified, “Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections: Clinical Description of the First 50 Cases” (American Journal of Psychiatry, 1998). Since then, numerous research groups have tried to prove or disprove the hypothesis. The 2017 Danish study, “Association of Streptococcal Throat Infection With Mental Disorders: Testing Key Aspects of the PANDAS Hypothesis in a Nationwide Study,” published online in JAMA Psychiatry May 24, shows that children with preceding strep throat infections did indeed have an elevated risk of mental disorders, particularly OCD and tic disorders. However, the study also found non-streptococcal throat infection to be associated with increased risks, though to a lesser degree. This finding may support a more recent broader concept called pediatric acute-onset neuropsychiatric syndrome (PANS).“Our study contradicts the PANDAS hypothesis to some extent,” wrote first author and co-researcher Sonja Orlovska, M.D., affiliated with the Mental Health Centre Copenhagen and the University of Copenhagen, Denmark, in an email to Psychiatric News. “Still, the risk of OCD remained highest after a step versus non-strep throat infection, pointing to a specific association between strep infection and OCD, in line with PANDAS.”Swedo, now director of the Pediatrics and Developmental Neuroscience Branch at NIMH, called the Danish study an important addition to the growing body of PANS/PANDAS literature. “Their finding of increased rates of any mental disorder following strep infection suggests that post-infectious autoimmunity may play a role in a large spectrum of psychiatric symptoms, which could lead to new avenues for treatment and prevention of childhood mental illness,” she said in a statement to Psychiatric News.The Danish researchers concluded that their results may favor the essential elements of PANS, because it offers an alternative to PANDAS with wider diagnostic criteria and without the restriction of streptococcal infection. Data Specifics From the Danish Study This PANS/PANDAS population-based cohort study used data from 1,067,743 individuals under 18 years of age in the nationwide Danish registers between January 1, 1996, and December 31, 2013, with up to 17 years of follow-up. The Danish National Health Service Register provided information on individuals with the registration of a streptococcal test. Data analysis was conducted from January 1, 2016, to February 28, 2017.Of the children included in the study (519,821 girls and 547,922 boys), 638,265 received a streptococcal test, 349,982 of whom had positive test results at least once.Children with positive streptococcal test results had an increased risk of any mental disorder (n = 15,408; IRR, 1.18), particularly of OCD (n = 556; IRR, 1.51) and tic disorders (n = 993; IRR, 1.35), compared with individuals who had never been tested for streptococcal infection, according the study. Furthermore, the risk of any mental disorder and OCD was more elevated after a streptococcal throat infection than after a non-streptococcal infection. Nonetheless, individuals with a non-streptococcal throat infection also had an increased risk of any mental disorder (n = 11,315; IRR, 1.08), OCD (n = 316; IRR, 1.28), and tic disorders (n = 662; IRR, 1.25).The study was supported in part by grants from the Lundbeck Foundation and the Program for Clinical Research Infrastructure established by the Lundbeck Foundation and the Novo Nordisk Foundation. ■An abstract of “Association of Streptococcal Throat Infection With Mental Disorders: Testing Key Aspects of the PANDAS Hypothesis in a Nationwide Study” can be accessed here. “Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections: Clinical Description of the First 50 Cases” is available here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessHigher Levels of Lithium in Drinking Water May Lower Dementia RiskJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:5 Oct 2017https://doi.org/10.1176/appi.pn.2017.10a17AbstractA large population study explores the impact of lithium in groundwater for preventing dementia.A study published in JAMA Psychiatry in August attempts to answer the question, “Could lithium, a naturally occurring element in drinking water, reduce the incidence of dementia?” iStock/diane39Without a cure or treatment that slows or stops the progression of dementia, researchers have been looking to prevention—such as targeted interventions and modifiable risk factors associated with dementia. The mood stabilizer lithium has been considered as a potential treatment for Alzheimer’s disease (AD). Positive evidence in several small clinical trials has suggested that low-dose lithium may improve cognition. Lithium blocks an enzyme crucial to the development of AD’s plaques and tangles and has been shown to prevent AD in mice.“The prospect that a relatively safe, simple, and cheap intervention (i.e., optimizing lithium concentrations in drinking water) could lead to the primary prevention of dementia is a tantalizing prospect,” wrote John J. McGrath, M.D., Ph.D., of the Queensland Centre for Mental Health Research in Australia, in an accompanying editorial.In the current study, Lars Vedel Kessing, M.D., D.M.Sc., of the University of Copenhagen and colleagues found that higher concentrations of lithium in the drinking water in areas of Denmark were associated with a lower risk of developing dementia. The researchers measured lithium in drinking water from 151 communities around Denmark and mapped where people with dementia and age- and sex-matched controls lived from 1986 to 2013. They collected longitudinal, individual geographic data on municipality of residence and data from drinking water measurements combined with time-specific data from all patients aged 50 to 90 with a hospital contract and with a diagnosis of dementia from January 1, 1970, through December 31, 2013. The mean lithium exposure in drinking water since 1986 was estimated for all study individuals. A total of 73,731 patients with dementia and 733,653 controls were included in the study. The researchers found that higher long-term exposure to lithium in drinking water was associated with a lower incidence of dementia, but this association was nonlinear. Compared with people exposed to the lowest levels of lithium (up to 5 μg/L), people exposed to 5.1 to 10 μg/L had a 22 percent higher risk of dementia, people exposed to 10.1 to 15 μg/L had about the same risk of dementia, and people exposed to 15 μg/L or more had a 17 percent lower risk of dementia.The study’s authors do not suggest increasing lithium in the water supply; it is unclear how much lithium would be safe and effective to use. “There is strong epidemiological evidence in animal and human studies that certain low levels of lithium are neuroprotective,” Anna Fels, M.D., a practicing psychiatrist in New York City and a clinical professor of psychiatry at Weill Cornell Medical College, told Psychiatric News. “More studies should be done, and if they continue to find benefits, there should be ways the public could access water with lithium in tablets or another form that is measured and pharmaceutical grade.” “If the findings of Kessing and colleagues are supported in future studies, even a marginal reduction in the incidence of dementia could result in major societal and economic gains,” wrote McGrath. ■“Association of Lithium in Drinking Water With the Incidence of Dementia” can be accessed here. The related editorial, “Could Lithium in Drinking Water Reduce the Incidence of Dementia?,” is available here. ISSUES NewArchived

Back to table of contents Previous article Next article Professional NewsFull AccessGovernment, Private Sector Leaders Develop Cultural Competency Tools at APA EventJoAnn Blake,, Mark MoranJoAnn Blake,Search for more papers by this author, Mark MoranSearch for more papers by this authorPublished Online:16 Oct 2017https://doi.org/10.1176/appi.pn.2017.10b28AbstractSummit participants worked together to derive best practices, training modules, and metrics for measuring improvement in cultural competency and inclusiveness at their agencies and institutions.Fear of people who are different in some way from the majority population—because of physical characteristics, dress, or language—is a learned response rooted in a neurobiological mechanism. And it can be changed. Psychiatrist Ramaswamy Viswanathan, M.D., D.M.Sc., the 2016 APA George Tarjan Award winner, said physicians need to be able to reach across cultural boundaries to connect with their patients.David HathcoxSo said Mohammed Milad, Ph.D., in an address last month at APA headquarters to more than 50 leaders in industry, government, and the nonprofit sector attending the Cultural Competence and Inclusive Excellence Summit. He is an associate professor of psychiatry at Harvard Medical School and the director of the animal models and behavioral neuroscience lab at Massachusetts General Hospital. Milad described the network of brain structures that generate day-to-day reactions to perceived differences: the amygdala, where negative, defensive, and protective associations are stored that trigger the feeling of fear; the frontal cortex, which can provide a cognitive regulation of fear; and the hippocampus, which communicates between the amygdala and prefrontal cortex depending on the context of any given scenario or situation.“We are the product of neuroactivity,” Milad said. “Everything we think and feel is mediated by brain structures, so if you want to understand bias and how to change it, we need to understand where it comes from. A broad understanding of the biology of fear-based bias can be useful in educating people about their emotions and understanding where our biases come from.”‘Establishing the Human Connection’At last month’s Cultural Competency and Inclusive Excellence Summit at APA headquarters in Arlington, Va., psychiatrist Ramaswamy Viswanathan, M.D., of SUNY Downstate Medical Center and the APA Trustee for Minority and Underrepresented Groups, shared a narrative describing a “best practice” in cultural competency drawn from his practice of consultation/liaison psychiatry.“Often I encounter patients who are angry or anxious and are refusing help or even life-saving treatment. One factor that reinforces the patient’s resistance is his or her feeling [of being] alienated. It is important to establish a human connection to gain the patient’s confidence before one engages in a dialogue to understand and solve the patient’s resistance.” Viswanathan described vignettes in which he was able to make a cultural connection with patients that produced clinically meaningful results. For instance, a non-English-speaking Chinese patient who had initially agreed to mitral valve replacement surgery suddenly refused it on the eve of the surgery. By approaching the patient with some rudimentary Chinese language greetings, Viswanathan was able to open a conversation that ultimately led her to reconsider the surgery. “In another situation, elderly Caribbean-American patients with cognitive impairment who were initially untrusting became trusting after I engaged in a little conversation about cricket, a favorite sport in Caribbean countries,” he said.He emphasized that biases can be challenged and changed. “Fear can be inhibited or extinguished,” Milad said. “The brain is the most plastic structure in our anatomy and is amenable to change. We can change the connections that underlie fear and bias and rewire those connections.” His remarks began a day of small-group discussions aimed at identifying and implementing best practices to develop cultural competence and drive inclusion in organizations of all types, as well as metrics for assessing change. The all-day event, sponsored by APA, General Motors, and the Ohio State University Wexner Medical Center, followed up on a similar event in 2016, which in turn was catalyzed by the 2015 STEM Diversity Forum convened by the White House Office of Science and Technology Policy. (“STEM” stands for science, technology, engineering, and math.)“The summit last month at APA, following on the very successful summit two years ago at the White House, addressed how to chart a strategy toward organizational excellence,” said Ranna Parekh, M.D., M.P.H., director of APA’s Division of Diversity and Health Equity. “The most visionary leaders in health care, government, and private industry agree that cultural competency and inclusiveness are critical elements of organizational excellence. We want to thank our partners for making the summit an enormous success.”Speakers at the summit included, in addition to Milad, Jayne B. Morrow, Ph.D., senior science policy advisor at the National Institute of Standards and Technology at the Department of Commerce; Ted Childs, principal of Ted Childs, LLC, a global strategic diversity consulting firm; and Subha Barry, senior vice president and managing director at Working Mother Media. After each presentation, participants broke into small groups for workshops in which they were tasked with developing tools and products. Among them: Assessment tools that can be used across public and private sectors to measure cultural competency at an agency or institution.Resources for training administrators and employees in cultural competency, along with cost estimates for implementing such training. An adaptable cross-sector “inclusion scorecard” to track cultural competence and inclusive excellence over time. Among those attending the summit was psychiatrist Ramaswamy Viswanathan, M.D., the recipient of the 2016 APA George Tarjan Award, which honors a psychiatrist who has advanced the cause of international medical graduates. Viswanathan described a “best practice” from his own practice of consultation/liaison psychiatry (see box).The summit was preceded the night before by a “networking” event in which Childs delivered a keynote address, followed by remarks by Joan Y. Rede, M.D., dean for diversity and community partnership at Harvard Medical School, and APA President Anita Everett, M.D. In opening remarks, APA CEO and Medical Director Saul Levin, M.D., M.P.H., said that cultural competence has become critical in health care and to the profession of psychiatry and to APA. In comments to Psychiatric News, Levin said, “We wanted to host the summit here at APA headquarters as a sign to our partners in government and the private sector as well as to our own members that APA strives to be ahead of the curve in this area. I believe psychiatrists in particular need to understand the nature and importance of unconscious bias and its effect on the quality of care for our patients.” ■Resources related to cultural competency can be found on the APA website here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessHigh Mortality Rate Found in Youth Newly Diagnosed With PsychosisJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:31 May 2017https://doi.org/10.1176/appi.pn.2017.5a11AbstractPsychiatrists know that young patients with psychosis entering adulthood are particularly vulnerable. A new study shows just how serious a risk they face.Young people experiencing first-episode psychosis (FEP) are 24 times more likely to die within the year of diagnosis than their age-matched peers, reported a study published April 6 in Schizophrenia Bulletin. The findings highlight the importance of intensive clinical intervention at the early stages of psychotic illness and the need for widely available coordinated specialty care programs. NIMH’s Michael Schoenbaum, Ph.D., hopes this study’s findings will alert mental health professionals to improve the follow-up care of young patients with psychosis.“We expected to see the elevated mortality from previous research, but none of that prepared us for the excess mortality on the scale we observed,” said Michael Schoenbaum, Ph.D., lead author and senior advisor for mental health services, epidemiology, and economics at the National Institute of Mental Health (NIMH).The unusually high 12-month death rate in youth with FEP—1,968 per 100,000—should be a “wake-up call,” Schoenbaum told Psychiatric News. In the general population, only people over 70 years old have 12-month mortality approaching the rates observed among patients with psychosis in this study.“Right now, we’re a long way from providing meaningful and effective care. Here is one particular catastrophic result of what happens when patients fall through the cracks,” he said. “We need to invest heavily in establishing and maintaining a close therapeutic relationship with the psychosis patient.”Furthermore, the health care system is failing these patients, said William T. Carpenter, Jr., M.D., a professor of psychiatry and pharmacology at the University of Maryland School of Medicine and editor-in-chief of Schizophrenia Bulletin. “These data substantiate the human cost of a health care system that doesn’t implement evidence-based care for people with psychotic disorders.” Carpenter was not directly involved with the study.Schoenbaum and colleagues used health care insurance claims data from the Multi-Payer Claims Database (MPCD) to assess the 12-month health outcomes in a group of 5,488 insured young adults aged 16 to 30 years who received a diagnosis of FEP. MPCD links to information from the Social Security Administration’s full Death Master File, allowing documentation associated with all-cause mortality associated with FEP.“It’s rare to be able to look at mortality in population health data. We happen to have access to a population-based data set that contains health information linked to information on mortality,” Schoenbaum said. The data, however, did not tell the researchers how these young people died. Given the high death rates, the team expected that patients with FEP would have received more care. However, that’s not what they found. A total of 61 percent of the patients studied did not fill any antipsychotic prescriptions, and 41 percent did not receive psychotherapy in the year following FEP diagnosis. “On the one hand, it’s encouraging that many did receive some psychotherapy, which has been declining in the United States, but it’s surprising that so few received antipsychotic medication,” Schoenbaum said. He added that detailed clinical information would be needed to determine whether the kind of treatment these patients received was appropriate or effective. Overall, 69 percent of the youth with FEP had at least one visit with a mental health specialty provider for medication management, psychotherapy, or both over the 12-month period. These individuals had about one outpatient contact per month. Among those using hospital services, 23 percent were hospitalized in the year after the initial diagnosis. More than half of these individuals had at least one visit to the emergency department in the year following the diagnosis. Although several countries have implemented comprehensive treatment programs for young FEP patients, including lower-dose antipsychotic medication, psychotherapy, family education, and support services, the United States has been slow to adopt early intervention, according to Schoenbaum. “People in these countries that have national health systems are less likely to fall through the cracks because they are treated by the same system throughout their lives,” Schoenbaum said. “Other studies have shown that early coordinated treatment for psychosis produces the best results. However, we know that the typical duration of untreated psychosis in the United States is around 17 months,” Robert Heinssen, Ph.D., director of the Division of Intervention Services at NIMH and co-author on the paper, said in a press release. “This study reinforces federal and state support for funding evidence-based psychosis treatment programs across the country, and the need for communities to invest in more treatment programs.”The study was funded by NIMH. ■An abstract of “Twelve-Month Health Care Use and Mortality in Commercially Insured Young People With Incident Psychosis in the United States” can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Professional NewsFull AccessWhite House Opioid Commission Targets Trouble Spots, Misses SomeJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:28 Nov 2017https://doi.org/10.1176/appi.pn.2017.12a25AbstractThe commission makes a wide range of recommendations, but comes up short on how to fund treatment and provide greater access to it.While the recent report of the President’s Commission on Combating Drug Addiction and the Opioid Crisis raises the visibility of the opioid crisis, several serious barriers must be overcome to end the epidemic, according to an analysis by APA staff. The commission, led by New Jersey Gov. Chris Christie, issued the 138-page report on November 1, with 56 recommendations on how to fight the opioid crisis.“They should be thinking about strengthening access to health care, not weakening it. This is a very expensive endeavor, and there’s no funding for it.”—Andrew Saxon, M.D.Among the greatest barriers to treating opioid addiction remain the lack of health insurance coverage and access to and availability of substance use treatment, APA noted. In 2016, close to 20 million adults needed treatment for substance use disorders (SUDs), but only 2.1 million received it, according to the National Survey on Drug Use and Health. “The commission says it wants more treatment available and funding for it, but the administration has been trying to repeal the Affordable Care Act [ACA] and cut Medicaid, which is contradictory when many people who need treatment rely on Medicaid,” said Andrew Saxon, M.D., a professor of psychiatry at the University of Washington, director of the Center of Excellence in Substance Abuse Treatment and Education at the VA Puget Sound Health Care System, and chair of APA’s Council on Addiction Psychiatry. “The commission should be thinking about strengthening access to health care, not weakening it. This is a very expensive endeavor, and there’s no funding for it.”Besides emphasizing the absence of new funding and insufficient treatment resources, APA staff found only limited details on the implementation of some of the commission’s recommendations. APA strongly supports a number of recommendations in the commission’s report. Among them: Improved access to treatment: The commission recommends steps to increase the use of medication-assisted treatment (MAT), including establishing a federal incentive to enhance access to MAT. Federal agencies should research promising models for pregnant and postpartum women with SUDs and their newborns. APA supports increased access to MAT; it also recommends the use of integrated care so that more people will have access to care.Parity: The commission recommends that Congress grant the Department of Labor (DOL) increased authority to levy monetary penalties on insurers and employer-based plans that are self-funded and permit the DOL to investigate health insurers independently for violations of the Mental Health Parity and Addiction Equity Act. APA recommends enforcing the parity law with a standardized parity compliance tool to ensure health plans do not impose less favorable limits on treatment for mental illness and SUDs than on other medical conditions. Media campaign: The commission recommends that the Trump administration fund and collaborate with private-sector and nonprofit partners to design and implement a national media campaign addressing the hazards of substance use, the dangers of opioids, and stigma. APA recommends addressing stigma with a national prevention strategy, including a public awareness campaign, to educate the public and health care professionals about addiction as a chronic brain disease that can be effectively treated with evidence-based interventions. “A component of the public awareness campaign should be that medication is the primary treatment for opioid use disorder and other therapies are adjuncts. Only a minority of those receiving care are getting medication. Proper dosing is very important, and the lack of success could be from inadequate treatment,” said Saxon.Reimbursement: The commission and APA recommend improving reimbursement rates to health care professionals to better cover the true costs of providing SUD treatment. The commission also recommends that federal agencies revise regulations and reimbursement policies to allow for SUD treatment via telemedicine. Drug courts: The commission recommends that the Department of Justice (DOJ) broadly establish federal drug courts within the federal district court system in all federal judicial districts. Those with an SUD who violate probation terms should be diverted into drug courts rather than incarcerated. The commission recommends that the National Institute on Corrections, the Bureau of Justice Assistance, the Substance Abuse and Mental Health Services Administration, and other national, state, local, and tribal stakeholders use MAT with pretrial detainees and continue treatment on release. APA recommends that drug courts, driving-while-intoxicated courts, and veterans courts should be available to those who qualify and include high-quality, culturally competent, and gender-relevant evaluation, treatment, and monitoring for adults and juveniles.Improved access to naloxone: The commission recommends that states, if necessary, make statutory or regulatory changes to allow emergency medical technicians to administer naloxone, including in higher doses, in response to the rising number of fentanyl overdoses. APA supports improved access to naloxone. Research: The commission recommends that the relevant federal agencies review existing research programs on the prevention and treatment of pain management and addiction. APA supports increasing funding for research. The commission recommends that Congress and the federal government provide additional resources to the National Institute on Drug Abuse (NIDA), National Institute of Mental Health, and National Institute on Alcohol Abuse and Alcoholism for research. NIDA should continue research in concert with the pharmaceutical industry to develop and test innovative medications for the treatment of SUDs and OUDs. APA supports increased funding in research.Raising the buprenorphine treatment limit: The commission recommends removing reimbursement and policy barriers to SUD treatment, including those, such as patient limits, that limit access to MAT and other evidence-based treatment modalities. APA disagrees with the commission ’s recommendation of removing the cap on the number of patients who can be treated by providers who can prescribe or dispense buprenorphine as this could lead to quality and diversion issues. ■The report of the President’s Commission on Combating Drug Addiction and the Opioid Crisis can be accessed here. APA’s comments are available here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessReport Highlights Alternative Treatment Options for OCDJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:31 May 2017https://doi.org/10.1176/appi.pn.2017.5b9AbstractFor patients who fail to respond to first-line treatments, remote cognitive-behavioral therapy, adjunctive use of antipsychotics, and neuromodulatory techniques may offer some relief.While in-person cognitive-behavioral therapy (CBT) with or without medication remains the preferred initial treatment for obsessive-compulsive disorder (OCD), studies suggest that some 25 to 35 percent of OCD patients continue to experience symptoms of the disorder after treatment. There is growing evidence to suggest computer-based CBT, novel pharmacological agents, and neuromodulatory techniques also might benefit these patients, according to a review article published April 4 in the Journal of the American Medical Association.For the report, Matthew Hirschtritt, M.D., M.P.H., a PGY-3 at the University of California, San Francisco School of Medicine, and colleagues searched PubMed, EMBASE, and PsycINFO for studies published between January 1, 2011, and September 30, 2016, that addressed screening, diagnosis, and treatment approaches for OCD in adults 18 and older. Of the 792 articles identified, 27 were analyzed for the review.The authors noted that while the latest data indicate that CBT continues to be the most effective psychotherapy for OCD—and most effective therapy overall when performed by experienced practitioners—there are significant barriers to CBT treatment. Such barriers include a lack of available therapists, high out-of-pocket costs, and intense time demands on the patient. Remote treatment for OCD may offer one way to begin to chip away at these barriers. “Evidence from a meta-analysis suggests that remote CBT (via an online platform) demonstrates efficacy similar to that of in-person treatment,” Hirschtritt and colleagues wrote.“The reassurance and knowledge patients gain [using remote CBT via online platform] can be therapeutic and quite effective,” Hirschtritt said in an interview with Psychiatric News. He emphasized that online therapy is best used as a supplementary treatment between in-person visits with health care practitioners and to provide structure. “For clinicians across psychiatry, this is another tool in their tool box,” he said. Selective serotonin reuptake inhibitors (SSRI) remain the recommended first-line pharmacologic intervention for OCD. For patients who do not respond to SSRIs, the adjunctive use of typical or atypical antipsychotics may offer some relief, the authors noted. Preliminary evidence suggests augmentation with ketamine, riluzole, N-acetylcysteine, memantine, lamotrigine, celecoxib, ondansetron, and some nutraceuticals may also reduce OCD symptoms in treatment-resistant patients, but the authors noted that more work is needed to support the routine use of these agents in treating OCD.For the most severe treatment-resistant OCD cases, there is some evidence to suggest neurosurgery and deep-brain stimulation may decrease symptoms of the disorder, the authors wrote. “Despite the severe impairment and burden of OCD, it often goes unrecognized and undertreated or untreated,” Hirschtritt and colleagues noted. “Conditions that can commonly be confused with OCD, such as generalized anxiety disorder, should be considered and ruled out. Important moderators of treatment efficacy (presence of comorbid tics or hoarding symptoms, level of insight) should also be assessed because these may help guide choice of initial treatment.”The study was funded by the Tourette Syndrome Association of America, the Brain and Behavior Research Foundation, the Patterson Foundation, and the State of Connecticut Department of Mental Health and Addiction Services. ■An abstract of “Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment” can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Professional NewsFull AccessMental Illness Prevalent in U.S. HouseholdsJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:28 Aug 2017https://doi.org/10.1176/appi.pn.2017.8b11AbstractAbout 1 in 5 people experienced mental illness in the year before they were surveyed, but the numbers do not include several vulnerable groups.Mental illness impacts many households in the United States. In 2014, about 43.6 million adults (18.3 percent of the population) had a mental illness in the previous year, according to a recent report by the Substance Abuse and Mental Health Services Administration (SAMHSA). The latest SAMHSA’s Center for Behavioral Health Statistics and Quality (CBHSQ) report is based on combined data collected from 2012 to 2014 during the annual National Survey on Drug Use and Health (NSDUH). The 2012-2014 NSDUH data came from 142,000 respondents, 18 years and older, who were asked if they had “any mental illness” (AMI) within the past year. AMI was defined as the presence of any mental, behavioral, or emotional disorder in the past year based on DSM-IV diagnoses. This specific series of SAMHSA reports surveys only residential households. “It does not include military personnel, people in jails and hospitals, and homeless people not using shelters,” said Phillip Walls, press officer for SAMHSA. “The numbers would be higher if we integrated these groups [into the research], but we have a separate survey for institutions.”The number of Americans experiencing mental illness in the latest report is slightly lower compared with the previous SAMHSA report, 2010-2012. That report found that 45.9 million American adults, or 20 percent, experienced mental illness at least once annually, though the difference between the two reports is not statistically significant, said Walls.The SAMHSA study breaks down mental illness rates by state and sub-state regions. New Jersey had the lowest national rates of overall mental illness at 15.83 percent. Other states with comparatively low rates included Illinois (16.36 percent) and North Dakota (16.45 percent). The rates for both Florida and South Dakota were 16.46 percent. Oregon had the highest rate of adults who experienced mental illness in the past year at 22.72 percent, followed by Utah (21.7 percent), West Virginia (21.7 percent), Maine (21.3 percent), and Rhode Island (21.11 percent). “Although the prevalence of adults with mental illness ranges widely among the states, it is important to note that there are many people with AMI in every state, which is expected because mental illness is common. … The presence of AMI in every state reinforces that mental illness is a major public health concern in the United States. Factors that potentially contribute to the variation may need further study.”Across the census regions, estimates of any mental illness were 19 percent in the West, 18.54 in the Midwest, 18.14 in the South, and 17.95 in the Northeast. ■“State and Sub-State Estimates of Any Mental Illness From the 2012-2014 National Surveys on Drug Use and Health,” can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Government NewsFull AccessCould FDA's Proposed Plan Help Smokers With Mental Disorders Quit For Good?JoAnn BlakeJoAnn BlakePublished Online:28 Aug 2017https://doi.org/10.1176/appi.pn.2017.9a5AbstractThe agency has proposed a new public health strategy to reduce cigarette smoking, while encouraging inventive products that are less toxic and addictive than burning tobacco.The Food and Drug Administration's plan to reduce nicotine in combustible cigarettes to non-addictive levels could be good news especially for people with mental illness. That's because they are more prone to smoking and have more difficulty quitting than the general population, said Jennifer Tidey, Ph.D., a professor of psychiatry and human behavior at Brown University. iStock/Dmitrii Kotin"This is a different direction for the FDA. Instead of trying to get people to stay away from the product, they are trying to make the product less addictive," said Tidey, who has conducted research on very-low-nicotine cigarettes at Brown's Center for Alcohol and Addiction Studies. Cigarette smoking and tobacco use have fallen dramatically among the U.S. population over the past few decades, but the use has remained stubbornly high among people with psychiatric disorders. They consume nearly half of all cigarettes smoked in the United States, and more than 75 percent of people with mental illness say they want to quit, but cannot, Tidey said. Although very-low-nicotine cigarettes will not make smoking safe (because these cigarettes still contain other harmful chemicals), Tidey said research has shown they may help smokers cut back on cigarettes, switch to less harmful options such as e-cigarettes, and make it easier to quit. The FDA proposes that lowering nicotine levels could decrease the likelihood that future generations will become addicted to cigarettes and encourage current smokers to quit. "Unless we change course, 5.6 million young people alive today will die prematurely later in life from tobacco use," said FDA Commissioner Scott Gottlieb, M.D., in a statement announcing a comprehensive plan for tobacco and nicotine regulation in late July. "Envisioning a world where cigarettes would no longer create or sustain addiction, and where adults who still need or want nicotine could get it from alternative and less harmful sources, needs to be the cornerstone of our efforts—and we believe it's vital that we pursue this common ground," he said.Addiction psychiatrist Doug Ziedonis, M.D., Ph.D., a professor of psychiatry at the University of California, San Diego, said he believes that more effort and resources should be directed toward helping people with mental illness quit smoking altogether, rather than move to a middle ground of ver-low-nicotine or e-cigarettes. "E-cigarettes don't seem to be a route that would lead to smoking cessation," he said. The FDA stated it would issue a regulatory notice to seek public comment on the potential public health benefits and any possible adverse effects of lowering nicotine in cigarettes. The FDA also plans to file an "Advance Notice of Proposed Rulemaking" on nicotine levels, which is the first step in a time-consuming regulatory process that includes public comment periods that can last months. Additionally, the FDA intended to seek public comment on the role that flavors, including menthol, in tobacco products may play in attracting youth and helping some smokers switch to potentially less harmful forms of nicotine delivery; and to solicit additional comments and scientific data related to the patterns of use and resulting public health impacts from premium cigars.No dates have been set for these directives, but Michael Filberbaum, a press officer with the FDA, told Psychiatric News, "We expect to take meaningful steps in 2017 to advance important regulatory components that address the key aspects of this new policy."Very low-nicotine cigarettes mentioned in the FDA's plan differ from "light" cigarettes, which Congress removed from the market in 2009. The tobacco in light cigarettes contained the same amount of nicotine, but had ventilated filters attached to deliver less nicotine. However, light cigarettes made smokers puff harder and inhale more deeply, which ended up providing similar doses of nicotine as regular cigarettes, according to researchers. ■ ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessMinimal Exercise May Help Prevent Future DepressionJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:30 Nov 2017https://doi.org/10.1176/appi.pn.2017.11a11AbstractResearch over the years has shown that regular physical activity can help relieve depression, but this study may be the first to recommend a specific “dose” of exercise.Even one hour per week of relatively low-level exercise can provide significant protection against future depression, according to a large population study published October 3 in AJP in Advance. iStock/PeopleImages“The majority of the protective effect of exercise against depression is realized within the first hour of exercise each week and was observed regardless of intensity,” wrote Samuel B. Harvey, Ph.D., an associate professor of psychiatry at the University of New South Wales in Sydney, Australia, and colleagues. While acknowledging that higher levels of exercise are required to achieve cardiovascular benefits, the authors assert that “informing individuals that significant mental health benefits may be achieved with small changes in their behavior may be valuable in facilitating behavioral change.” Because low levels of exercise were found protective, they suggest everyday activities, such as walking or cycling, may protect against depression. The cohort for the study consisted of more than 33,908 Norwegian adults with no symptoms of common mental disorders or limiting physical health conditions, monitored over 11 years. Participants were asked about their exercise habits and symptoms of depression and anxiety at the beginning and end of the study. Of the 22,564 individuals tracked over the study period, 1,578 (7 percent) developed case-levels symptoms of depression. “If causality is assumed and there are no other major confounders, our results suggest that at least 12% of new cases of depression could be prevented if all adults participated in at least 1 hour of exercise each week,” Harvey and colleagues wrote.The study did not find that exercise protected against anxiety. The prevalence of case-level anxiety at follow-up was similar regardless of the participants’ levels of baseline exercise; therefore, no association between baseline exercise levels and later case-level anxiety could be made.In phase 1 of the study—known as the Health Study of Nord-Trondelag County (HUNT 1)—researchers asked the residents of a rural county in Norway aged 20 years or older to complete questionnaires about their lifestyles and medical histories and undergo a physical exam. As part of the baseline exam, study participants were asked questions about symptoms of depression and anxiety, as well as how often they engaged in exercise and the intensity of their exercise. At follow-up (HUNT 2), the study participants were asked to complete the Hospital Anxiety and Depression Scale, a self-report questionnaire with 14 items covering depression and anxiety items over the previous two weeks.Participants who reported undertaking no exercise at baseline had 44 percent increased odds of developing case-level depression compared with those who exercised one to two hours per week.“Those who engaged in less exercise at baseline tended to have higher resting pulse, lower levels of perceived social support, and more subthreshold symptoms of depression and anxiety, and they were more likely to develop new-onset physical illnesses over the course of the study,” noted the researchers. The combined physical and social benefits of exercise may mediate the protective effects against depression, according to the study. The study was funded by the National Institute for Health Research Biomedical Research Centre at South London, Maudsley NHS Foundation Trust, and King’s College London. ■“Exercise and the Prevention of Depression: Results of the HUNT Cohort Study” can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull Access‘Night Owl’ Schedule Linked to Depression in Type 2 DiabetesJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:19 May 2017https://doi.org/10.1176/appi.pn.2017.5a4AbstractThe study provides further evidence that good sleep hygiene is an important component to maintaining health for people with diabetes.Patients with type 2 diabetes who are night owls are more likely to report symptoms of depression than early birds, who follow early-to-bed, early-to-rise sleep routines, according to a study presented at the annual meeting of the Endocrine Society in Orlando, Fla., last month.Patients with type 2 diabetes are already known to be at a greater risk for depression than the general population. Previous studies have shown that untreated depression can lead to adverse patient outcomes involving diabetes self-care, blood glucose control, and complications of diabetes, said lead investigator Sirimon Reutrakul, M.D., an associate professor at Mahidol University Faculty of Medicine, in Bangkok, Thailand. Diabetics with a “later or evening chronotype,” a preference to go to bed late and wake up late, tend to experience more symptoms of depression than those with the disease who turn in early and wake up early, an “early or morning chronotype.” A chronotype is the tendency, possibly from a genetic-environment interaction, for an individual to sleep at certain times during a 24-hour period. Previous studies have also found higher rates of depression among night owls in the general population.These findings, said Reutrakul, support an association between circadian system regulation and psychological functioning in patients with type 2 diabetes. She emphasized, though, that this research does not prove cause and effect. “We need to further explore a combination of interventions that help with circadian timing, such as light therapy and melatonin,” she said. “Learning more about the relationship between depression and circadian functioning might help us figure out strategies to improve physical and mental health for patients with diabetes.”Because geographic location may influence chronotypes (with a greater morning preference near the equator), the investigators studied diabetic patients in Chicago and Thailand. Chronotype was assessed using the Morningness-Eveningness in the Thailand group. Depressive symptoms were evaluated by the Center for Epidemiologic Studies Depression scale (CES-D). Sleep quality was determined using the Pittsburgh Sleep Quality Index (PSQI). Demographics, diabetes history, and complications were collected. HbA1c values were retrieved from medical records. Researchers found that the “later phenotype” was significantly associated with higher CES-D scores. This finding remained constant even after the researchers adjusted for sleep quality, age, sex, ethnicity, insulin use, PSQI score, and other factors that could affect depression. The U.S. group consisted of 194 patients, and 70 percent were women. Of the 282 patients in the Thai group, 67 percent were women. Chicago patients answered the questionnaires between February and early April; patients in Thailand, where there is little seasonal weather variation, participated throughout the year.The study, “Later Chronotype Is Associated With Greater Depressive Symptoms in Type 2 Diabetes Patients: A Study in Two Different Ethnic Cohorts,” was funded by Rush University Medical Center in Chicago, the Endocrine Society of Thailand, Mahidol University Faculty of Medicine, and Faculty of Medicine Ramathibodi Hospital in Bangkok. ■ ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessStudy Highlights Effective, Low-Cost Suicide Prevention StrategiesJoAnn BlakeJoAnn BlakePublished Online:16 Nov 2017https://doi.org/10.1176/appi.pn.2017.10b2AbstractSeveral low-cost emergency department interventions may help drive down the number of people who die by suicide each year.Three interventions for the follow up of patients at risk for suicide who entered a general hospital emergency department (ED) were found to be cost-effective in a National Institute of Mental Health (NIMH) study published September 15 in Psychiatric Services. In previous studies, these interventions were found to reduce suicide risk significantly, but they have not been adopted widely. One of the interventions studied, sending a series of caring postcards or letters to suicidal patients as a follow-up to their ED visit, was found to be less expensive than usual care. Under usual care, patients discharged from the ED who are identified as at risk for suicide are sent home with a list of names and phone numbers of mental health professionals in the community; thus, it is up to patients to take the initiative to schedule an appointment. The subsequent visit is also part of usual care. The other two interventions—telephone outreach and cognitive-behavioral therapy (CBT)—cost more than the postcards and usual care, but the costs were still well below the standard benchmark of cost-effectiveness the researchers set. Michael Schoenbaum, Ph.D., notes that suicide-prevention interventions don't have to be expensive to be effective."The purpose of these interventions is to provide psychosocial support to individuals after ED discharge, help maintain contact, and nudge people toward follow-up treatment," said lead investigator Michael Schoenbaum, Ph.D., senior advisor for mental health services, epidemiology, and economics in NIMH's Division of Services and Intervention Research. For the study, researchers built a computer model of a general hospital ED and used patient data from previously published relevant studies. General hospital EDs are high-risk settings that treat more than 500,000 people each year for self-injuries, according to the Centers for Disease Control and Prevention. The subjects were aged 18 and older and had sought treatment in a general hospital ED. The study authors estimated that follow-up postcards reduced the rate of suicide attempts or reattempts by 45 percent compared with usual care alone; phone outreach, one to three months after discharge, reduced the rate of suicide attempts or reattempts by 34 percent; and up to nine sessions of CBT reduced the rate of suicide attempts or reattempts by 50 percent, across the one-year study period. Special software was used to carry out repeated simulations of the chain of events for a roughly year-long period from the time an individual entered the modeled ED. Thousands of simulations showed the range of outcomes possible and the probabilities of each. Researchers computed the mean expected costs and life-years per person during the study period for each of the four interventions (usual care, postcards, phone outreach, and CBT), as well as the incremental costs, life-years, and cost-effectiveness ratio of postcards, phone outreach, and CBT compared with usual care, Schoenbaum said. Interventions can affect costs in two ways, according to the study: the direct cost of delivery, including the intervention itself and any associated health care use, and by altering the incidence of subsequent suicide attempts and death. For delivery costs, researchers used data on health service use reporting in a corresponding clinical trial, which referred to the relevant CPT codes and assigned costs based on national rates from the 2014 Medicare Physician Fee Schedule. For ED visits and hospitalization, researchers calculated average costs based on an analysis of corresponding events in the Healthcare Cost and Utilization Project database for people discharged alive and for those who died while hospitalized.Mean costs per suicide-risk patient were $1,962 with usual care, according to the modeling analysis. Compared with usual care, mean costs were 0.07 percent lower with postcards, and 0.05 percent and 0.25 percent higher with phone outreach and CBT, respectively. Each intervention reduced mortality. The estimated mean incremental cost per life-year was $4,300 for phone outreach and $18,800 for CBT—well below a conservative threshold of $50,000 that the researchers set as the amount society is willing to spend per life year saved. "Based on the science already done and published, and now the costs, we are at the point where we can recommend widespread use of these interventions," Schoenbaum said. "There is enough clinical evidence supporting the interventions, and we can afford them."However, he noted that the success of these interventions is influenced by the extent to which people at risk of suicide are identified in the ED. "We need to be better at identifying people in the first place," he said. "We're missing many of the people who are presenting with a physical problem who may also be suicidal, but they will tell us only if we ask them. Also, the ED [health professionals] may classify some people wrongly because they regard a poisoning or injury as suspicious. They may misidentify a person as a risk who is not (false positive), and some patients may misrepresent being injured just to get shelter and food for the evening."Support for this research was provided under professional services contracts with the National Institute of Mental Health. ■An abstract of "Modeling the Cost-Effectiveness of Interventions to Reduce Suicide Risk Among Hospital Emergency Department Patients" can be accessed here. ISSUES NewArchived

Back to table of contents Previous article Next article Clinical and Research NewsFull Access10-Year Study Suggests Progress on BullyingJoAnn BlakeJoAnn BlakeSearch for more papers by this authorPublished Online:13 Jun 2017https://doi.org/10.1176/appi.pn.2017.6b2AbstractThe number of students in Maryland schools reporting bullying in the past month fell more than 50 percent between 2005 and 2014.Bullying in U.S. schools appears to be trending downward, according to a report in the June issue of Pediatrics. The study, which analyzed reports of bullying in Maryland schools over a 10-year period, showed a striking drop in the numbers of students who reported experiencing bullying in the past month, from a high of 28.5 percent in 2005 to 13.4 percent in 2014.Catherine P. Bradshaw, Ph.D., M.Ed., says the findings suggest that “strategies, policies, and increased awareness can make an impact. We need to keep our efforts going and not take our foot off the gas.”The authors noted that very few other studies have followed bullying over multiple years, and virtually none of the large, population-based research has included longitudinal data across 13 indicators of bullying behaviors.The research team was led by Tracy Evian Waasdorp, Ph.D., M.Ed., a research scientist at the Children’s Hospital of Philadelphia and the Johns Hopkins Bloomberg School of Public Health. The group gathered reports about bullying from anonymous online surveys of 246,306 students in grades 4 through 12 from 109 Maryland schools within a large public school district. Survey questions included whether the students had experienced bullying in the past month, and if so, the type of bullying experienced; whether they had seen others bullied; and how safe they felt at school. Bullying indicators included such behaviors as physical pushing and hitting to verbal threats and rumors; the survey also asked about perpetrating bullying, witnessing bullying, and retaliating aggressively.Using longitudinal linear modeling to analyze changes over time, the researchers found that while bullying remains prevalent in schools, 10 of the 13 bullying-related indicators measured suggested positive improvements. Physical, verbal, and relational (having rumors spread) bullying experiences decreased 2 percent each year to below 10 percent in 2014. The study also found that the number of students who believe adults “do enough to stop” bullying is growing (38.8 percent expressed this opinion in 2005 compared with 71.3 in 2014). More students also reported they feel safe at school (78.6 percent in 2005 compared with 88.5 percent in 2014). “Rather than being in a crisis mode, the set of indicators is moving in a positive direction,” said study co-author Catherine P. Bradshaw, Ph.D., M.Ed., a professor and associate dean for Research and Faculty Development at the University of Virginia. The findings suggest that “strategies, policies, and increased awareness can make an impact. We need to keep our efforts going and not take our foot off the gas.” Bullying Prevalence Rates VaryTackling bullying remains a top priority for mental health professionals to improve child well-being. There is still a large bullying problem, “and the complexity and impact of bullying may be hard to judge from only examining prevalence rates,” Stephen S. Leff, Ph.D., and Chris Feudtner, M.D., Ph.D., M.P.H., of the Children’s Hospital of Philadelphia wrote in a related editorial.Estimates of bullying and cyberbullying prevalence reported by national surveys tend to vary. According to the latest report by the National Center for Education Statistics, bullying fell to 22 percent in 2013, down from 28 percent in 2011. Moreover, the bullying rate had hovered close to 30 percent in 2005 and rose to 32 percent in 2007.The lack of a uniform definition of bullying has hindered the ability to understand the true magnitude, scope, and impact of bullying and track trends over time, according to the Centers for Medicare and Medicaid Services. Unlike several other studies on bullying, Waasdorp and colleagues used the World Health Organization and CDC’s definition of bullying as follows: “A person is bullied when he or she is exposed, repeatedly and over time, to negative actions on the part of one or more persons. Bullying often occurs in situations where this is a power or status difference. Bullying includes actions such as making threats, spreading rumors, attacking someone physically and verbally, and excluding someone from a group on purpose.” Waasdorp and colleagues were surprised to find that cyberbullying (via email and blogs) fell from 6 percent in 2005 to 3.6 percent in 2014. However, the authors noted that because social media platforms have changed so much since 2005, broader definitions of cyberbullying are needed. The variation in study results also may be attributed to different definitions and measurements, said Bradshaw. She noted that in this study, students were asked if they had been bullied or been the perpetrator within the past 30 days (not if they had ever been bullied) and were asked to report on a large number of indicators (13). The study did not separate out and calculate rates for vulnerable youth groups such as lesbian, gay, bisexual, and transgender, she said. Schools Have More Work to DoStuart W. Twemlow, M.D., a psychiatrist and former professor of psychiatry and behavioral sciences in the Menninger Department of Psychiatry at Baylor University College of Medicine, expressed skepticism that the results of the Pediatrics study suggest any significant shifts in bullying, except for parental awareness. “Adults now know more about the serious effects of bullying, and they’ve become protective of their children,” said Twemlow, who co-wrote with John Sacco, Ph.D., Why School Antibullying Programs Don’t Work and Preventing Bullying and School Violence. Twemlow said he believes the prevalence of bullying has remained at about 30 percent in most elementary schools, while there may be a decrease in more “refined” forms of bullying in high school that occur during activities such as sports and debate. Educational programs don’t work unless the whole school becomes involved, he said. Bullying that has just occurred must be handled in an appropriate way, which is to “go to the source”—those involved in the incidents including the bully, the victim, and the audience, said Twemlow. School authorities should refrain from picking out the bully and victimizing him or her publicly, which could worsen the situation, he said. There is emerging research that some widely used approaches such as “zero tolerance” policies are not effective against bullying and should be discontinued, according to a 2016 report on bullying from the National Academies of Science, Policy, and Practice.The current political climate may also influence bullying behavior among children and teens in years to come, Twemlow said. Bradshaw agreed. “It’s a moving target. Who knows how today’s events will affect bullying? Maybe we will see a change. But right now, this is a positive story.”The research was supported in part by grants from the U.S. Department of Education, the William T. Grant Foundation, and the National Institute of Justice. ■“10-Year Trends in Bullying and Related Attitudes Among 4th- to 12th-Graders” can be accessed here. The editorial “Tackling Bullying: Grounds for Encouragement and Sustained Focus” is available here. ISSUES NewArchived