Gina L. Henderson

AtLANTA – Encouraging alcoholic patients to attend Alcoholics Anonymous meetings can help them in the long run, but the role of the clinician only begins there, experts said at the annual meeting of the American Psychiatric Association.

When referring patients to AA, it is important to let patients know what they will encounter, Dr. Marc Galanter said. “As a clinician, you want your patients to come back and talk about the meetings, and what meetings will be comfortable for them” to attend.

Patients most likely to join are those experiencing the worst depression, said Dr. Galanter, professor of psychiatry, director of the division of alcoholism and drug abuse at New York University, and author of “What is Alcoholics Anonymous?” (New York, N.Y.: Oxford University Press, 2016). “We’ve found that the social support and engagement initially are connected to the relief of distress.

“I suggest you ask your patients to go to three or four meetings, and talk with them afterward. The outcome for people who go to any AA meeting or [Narcotics Anonymous] meeting is a lot better than for those who do not go at all.”

Getting patients to attend AA meetings is a key step toward recovery, but recovery and abstinence are not synonymous, said Dr. A. Kenison Roy III, a member of the department of psychiatry at Tulane University and Louisiana State University who is affiliated with Addiction Recovery Resources, a treatment program in New Orleans. He cited a web-based study of 9,341 people by Lee Ann Kaskutas showing that the belief that recovery is abstinence is broadly held (Sage Open. 2015. doi: 10.1177/2158244015574938).

Dr. Joseph Westermeyer said the average person who achieves strong recovery is someone who has been an active member in AA for about 7 years.

Heavy users have to come to terms with the possibility of changing their lives completely, said Dr. Westermeyer, professor of psychiatry at the University of Minnesota, Minneapolis.

“The act of losing members of your social network is not fun [and] very lonely,” said Dr. Westermeyer, who has worked with many population groups, including people in their mid-teens to mid-30s, Native American AA groups, and veterans. “If you want to induce an adjustment reaction, just go away from home. But it can happen.”

Some of AA’s 12 Steps work well for veterans, such as the emphasis on strong peer support. But other guiding principles, such as emphasis on powerlessness, run counter to the way veterans think, he said. “Vets have problems with that powerlessness step,” Dr. Westermeyer said. “They never want to surrender.”

During the question-and-answer period, one person asked how the use of maintenance medications should be handled in light of the AA’s emphasis on total abstinence.

“Prescription meds are always an outside issue,” Dr. Galanter said. “We advise patients not to advertise that they’re on maintenance. Their sponsor should know. Preparing patients for immersion in that culture is one of the things we can do.”

Dr. Galanter, Dr. Roy, and Dr. Westermeyer reported no relevant financial disclosures.

[email protected]

AtLANTA – Encouraging alcoholic patients to attend Alcoholics Anonymous meetings can help them in the long run, but the role of the clinician only begins there, experts said at the annual meeting of the American Psychiatric Association.

When referring patients to AA, it is important to let patients know what they will encounter, Dr. Marc Galanter said. “As a clinician, you want your patients to come back and talk about the meetings, and what meetings will be comfortable for them” to attend.

Patients most likely to join are those experiencing the worst depression, said Dr. Galanter, professor of psychiatry, director of the division of alcoholism and drug abuse at New York University, and author of “What is Alcoholics Anonymous?” (New York, N.Y.: Oxford University Press, 2016). “We’ve found that the social support and engagement initially are connected to the relief of distress.

“I suggest you ask your patients to go to three or four meetings, and talk with them afterward. The outcome for people who go to any AA meeting or [Narcotics Anonymous] meeting is a lot better than for those who do not go at all.”

Getting patients to attend AA meetings is a key step toward recovery, but recovery and abstinence are not synonymous, said Dr. A. Kenison Roy III, a member of the department of psychiatry at Tulane University and Louisiana State University who is affiliated with Addiction Recovery Resources, a treatment program in New Orleans. He cited a web-based study of 9,341 people by Lee Ann Kaskutas showing that the belief that recovery is abstinence is broadly held (Sage Open. 2015. doi: 10.1177/2158244015574938).

Dr. Joseph Westermeyer said the average person who achieves strong recovery is someone who has been an active member in AA for about 7 years.

Heavy users have to come to terms with the possibility of changing their lives completely, said Dr. Westermeyer, professor of psychiatry at the University of Minnesota, Minneapolis.

“The act of losing members of your social network is not fun [and] very lonely,” said Dr. Westermeyer, who has worked with many population groups, including people in their mid-teens to mid-30s, Native American AA groups, and veterans. “If you want to induce an adjustment reaction, just go away from home. But it can happen.”

Some of AA’s 12 Steps work well for veterans, such as the emphasis on strong peer support. But other guiding principles, such as emphasis on powerlessness, run counter to the way veterans think, he said. “Vets have problems with that powerlessness step,” Dr. Westermeyer said. “They never want to surrender.”

During the question-and-answer period, one person asked how the use of maintenance medications should be handled in light of the AA’s emphasis on total abstinence.

“Prescription meds are always an outside issue,” Dr. Galanter said. “We advise patients not to advertise that they’re on maintenance. Their sponsor should know. Preparing patients for immersion in that culture is one of the things we can do.”

Dr. Galanter, Dr. Roy, and Dr. Westermeyer reported no relevant financial disclosures.

[email protected]

AtLANTA – Encouraging alcoholic patients to attend Alcoholics Anonymous meetings can help them in the long run, but the role of the clinician only begins there, experts said at the annual meeting of the American Psychiatric Association.

When referring patients to AA, it is important to let patients know what they will encounter, Dr. Marc Galanter said. “As a clinician, you want your patients to come back and talk about the meetings, and what meetings will be comfortable for them” to attend.

Patients most likely to join are those experiencing the worst depression, said Dr. Galanter, professor of psychiatry, director of the division of alcoholism and drug abuse at New York University, and author of “What is Alcoholics Anonymous?” (New York, N.Y.: Oxford University Press, 2016). “We’ve found that the social support and engagement initially are connected to the relief of distress.

“I suggest you ask your patients to go to three or four meetings, and talk with them afterward. The outcome for people who go to any AA meeting or [Narcotics Anonymous] meeting is a lot better than for those who do not go at all.”

Getting patients to attend AA meetings is a key step toward recovery, but recovery and abstinence are not synonymous, said Dr. A. Kenison Roy III, a member of the department of psychiatry at Tulane University and Louisiana State University who is affiliated with Addiction Recovery Resources, a treatment program in New Orleans. He cited a web-based study of 9,341 people by Lee Ann Kaskutas showing that the belief that recovery is abstinence is broadly held (Sage Open. 2015. doi: 10.1177/2158244015574938).

Dr. Joseph Westermeyer said the average person who achieves strong recovery is someone who has been an active member in AA for about 7 years.

Heavy users have to come to terms with the possibility of changing their lives completely, said Dr. Westermeyer, professor of psychiatry at the University of Minnesota, Minneapolis.

“The act of losing members of your social network is not fun [and] very lonely,” said Dr. Westermeyer, who has worked with many population groups, including people in their mid-teens to mid-30s, Native American AA groups, and veterans. “If you want to induce an adjustment reaction, just go away from home. But it can happen.”

Some of AA’s 12 Steps work well for veterans, such as the emphasis on strong peer support. But other guiding principles, such as emphasis on powerlessness, run counter to the way veterans think, he said. “Vets have problems with that powerlessness step,” Dr. Westermeyer said. “They never want to surrender.”

During the question-and-answer period, one person asked how the use of maintenance medications should be handled in light of the AA’s emphasis on total abstinence.

“Prescription meds are always an outside issue,” Dr. Galanter said. “We advise patients not to advertise that they’re on maintenance. Their sponsor should know. Preparing patients for immersion in that culture is one of the things we can do.”

Dr. Galanter, Dr. Roy, and Dr. Westermeyer reported no relevant financial disclosures.

[email protected]

An amphetamine-based extended-release orally disintegrating tablet for patients aged 6 years and older diagnosed with attention-deficit/hyperactivity disorder won Food and Drug Administration approval on Jan. 28.

Adzenys XR-ODT is the first and only extended-release orally disintegrating tablet for ADHD, Neos Therapeutics, the drug’s manufacturer, said in a statement. The newly approved agent is bioequivalent to Adderall XR, and patients taking Adderall can be switched to the new drug. Equivalent doses of the two drugs are outlined on the drug label.

“The novel features of an extended-release orally disintegrating tablet ... make Adzenys XR-ODT attractive for use in both children (6 and older) and adults,” Dr. Alice R. Mao, medical director, Memorial Park Psychiatry, Houston, said in the statement.

As a condition of the approval, Neos Therapeutics must report the status of three postmarketing studies annually of children diagnosed with ADHD taking Adzenys XR-ODT, according to the approval letter. One is a single-dose, open-label study of children aged 4 years to under 6 years; the second is a randomized, double-blind, placebo-controlled titration study of children aged 4-5 years; and the third is a 1-year, open-label safety study of patients aged 4-5 years.

For patients aged 6-17 years, the starting dose is 6.3 mg once daily in the morning, and for adults, it is 12.5 mg once daily in the morning, according to the label. The medication will be available in four other dose strengths: 3.1 mg, 9.4 mg, 15.7 mg, and 18.8 mg.

The most common adverse reactions to the drug among pediatric patients include loss of appetite, insomnia, and abdominal pain. Among adult patients, adverse reactions include dry mouth, loss of appetite, and insomnia.

An amphetamine-based extended-release orally disintegrating tablet for patients aged 6 years and older diagnosed with attention-deficit/hyperactivity disorder won Food and Drug Administration approval on Jan. 28.

Adzenys XR-ODT is the first and only extended-release orally disintegrating tablet for ADHD, Neos Therapeutics, the drug’s manufacturer, said in a statement. The newly approved agent is bioequivalent to Adderall XR, and patients taking Adderall can be switched to the new drug. Equivalent doses of the two drugs are outlined on the drug label.

“The novel features of an extended-release orally disintegrating tablet ... make Adzenys XR-ODT attractive for use in both children (6 and older) and adults,” Dr. Alice R. Mao, medical director, Memorial Park Psychiatry, Houston, said in the statement.

As a condition of the approval, Neos Therapeutics must report the status of three postmarketing studies annually of children diagnosed with ADHD taking Adzenys XR-ODT, according to the approval letter. One is a single-dose, open-label study of children aged 4 years to under 6 years; the second is a randomized, double-blind, placebo-controlled titration study of children aged 4-5 years; and the third is a 1-year, open-label safety study of patients aged 4-5 years.

For patients aged 6-17 years, the starting dose is 6.3 mg once daily in the morning, and for adults, it is 12.5 mg once daily in the morning, according to the label. The medication will be available in four other dose strengths: 3.1 mg, 9.4 mg, 15.7 mg, and 18.8 mg.

The most common adverse reactions to the drug among pediatric patients include loss of appetite, insomnia, and abdominal pain. Among adult patients, adverse reactions include dry mouth, loss of appetite, and insomnia.

An amphetamine-based extended-release orally disintegrating tablet for patients aged 6 years and older diagnosed with attention-deficit/hyperactivity disorder won Food and Drug Administration approval on Jan. 28.

Adzenys XR-ODT is the first and only extended-release orally disintegrating tablet for ADHD, Neos Therapeutics, the drug’s manufacturer, said in a statement. The newly approved agent is bioequivalent to Adderall XR, and patients taking Adderall can be switched to the new drug. Equivalent doses of the two drugs are outlined on the drug label.

“The novel features of an extended-release orally disintegrating tablet ... make Adzenys XR-ODT attractive for use in both children (6 and older) and adults,” Dr. Alice R. Mao, medical director, Memorial Park Psychiatry, Houston, said in the statement.

As a condition of the approval, Neos Therapeutics must report the status of three postmarketing studies annually of children diagnosed with ADHD taking Adzenys XR-ODT, according to the approval letter. One is a single-dose, open-label study of children aged 4 years to under 6 years; the second is a randomized, double-blind, placebo-controlled titration study of children aged 4-5 years; and the third is a 1-year, open-label safety study of patients aged 4-5 years.

For patients aged 6-17 years, the starting dose is 6.3 mg once daily in the morning, and for adults, it is 12.5 mg once daily in the morning, according to the label. The medication will be available in four other dose strengths: 3.1 mg, 9.4 mg, 15.7 mg, and 18.8 mg.

The most common adverse reactions to the drug among pediatric patients include loss of appetite, insomnia, and abdominal pain. Among adult patients, adverse reactions include dry mouth, loss of appetite, and insomnia.

The National Center for Health Workforce Analysis predicts that between 2010 and 2025, the field of psychiatry will see a decrease of 1 to 2 full-time equivalents (FTEs) per 100,000 psychiatrists. Yet, the need for providers with expertise in treating psychiatric patients remains great, particularly in light of persistence of mental illness stigma.

As we begin a new year, we asked members of our Editorial Advisory Board how they’d like to see the specialty respond to these trends so that patients with mental illness will get the care that they need. Here are some of their responses:

“Ultimately, the answer to this question depends on creating and maintaining access to effective professional care and social supports for the true health care ‘customers’ we serve – for example, people with mental illnesses and their families. This will require changes in how psychiatric care is described, provided, and paid for. We are indeed witnessing a redefinition of the definition of a ‘health care provider.’ And we are not going out of business! Psychiatrists will be teachers, researchers, systems leaders, and expert providers in the future. Clinical psychiatrists grounded as medical specialists will collaborate with patients, family members, nurses, psychologists, social workers, alcohol/drug counselors, primary care physicians, and community advocates to the goal of enhancing patient-centered care, which is evaluated and controlled by patients and their families.

“In addition to learning and practicing interdisciplinary teamwork in their training and practice venues, psychiatrists will continue to evolve functional roles in both patient care and clinical systems. These new functions will spawn new definitions of subspecialties in psychiatry well beyond our current category. The needs of children and the elderly will be addressed.

“Some psychiatrists will choose to provide patients with specialized, therapeutic relationships, as I did for 42 years. And, for the past decade, I practiced addiction psychiatry with patients of different ages, races, nationalities, and economic circumstances. What a privilege!

“It is indeed good news that psychiatry is holding its own attracting new trainees in 2015. Continuing interest in psychiatry speaks to the dynamism and challenges of our profession and its appeal to medical students, by far the most going into psychiatry are female. When I meet with our Minnesota psychiatry residents, they tell me after residency they need a job that will allow them to have a family and pay off their training cost debt.

“In addition, here are a few more thoughts:

• ‘Cognitive specialties’ such as psychiatry do continue to face stiff competition from historically much-better-paying, procedurally oriented medical specialties.

• Participation in postgraduate medical school internships are fundamental to the training of psychiatrists so that we can understand the treatment and management of a wide range of patients and medical conditions.

• Learning patient care and clinical skills as physicians involves adhering to Hippocratic medical ethics. This is our basic training.

• That said, concepts of population disease management and associate cost rationing are worthy ethical issues that are often in conflict with Hippocratic patient-centeredness.

• The power and control of most physicians who provide patient care in the United States are superseded by private and governmental organizations, and most physicians nationwide are employees.

• Clinical psychiatric practice in large organizations and/or for psychiatrists who have insurance company provider contracts is governed by clinical guidelines, care algorithms, and pay-for-performance rules not under the control of physicians.

“Most independent, private psychiatrists in Minnesota doing direct clinical patient care have opted out of all provider contracts and Medicare. They have chosen to do direct pay practice because of obstacles to low pay for doing psychotherapy or conducting family meetings, disruptive and intrusive insurance company practices including prior authorizations, time-consuming coding requirements, mandated electronic medical records (concerns about checklists and privacy/confidentiality), stigma associated with data transfer, and interception of continuity of care between treatment settings. Many direct pay psychiatrists also have consultation jobs in mental health centers, the Department of Veterans Affairs, or are doing insurance reviews and like to manage their schedules.”

–Lee H. Beecher, M.D.

“As a psychiatrist currently working in a general hospital and family medicine clinic setting, it seems to me that it would be wise for the specialty of psychiatry to more closely align itself with general medicine. There is a great deal of talk about co-locating mental health, substance abuse, and primary care in medical homes – but, with the exception of a few brave programs, not much has changed.

“I have been observing a trend that nurse practitioners are picking up the slack for the dearth of geriatric psychiatrist, and this is becoming the trend in several states. Another trend is for family practitioners to partner with a psychologist and to write the prescriptions the psychologists suggest to the physician – of course, they are just biding time until psychologists can prescribe. Unfortunately, it seems to me that it’s OK for these ‘psychiatrist extenders’ to prescribe and care for these patients, who unfortunately are seen as least desirable. I know of one context where a retired surgeon is nearly ubiquitous in caring for the geriatric nursing home population and, in my opinion, those specialists are not very learned in this area – as evidenced by their often inappropriate care of elderly patients with major neurocognitive disorder.

“I recall the last time there was a huge shortage of psychiatrists, it was right after World War II. The nation opened the doors for general practitioners to become psychiatrists. And quite a few took advantage of that opportunity. I foresee the same thing happening, but instead of general practitioners, this time it will be psychologists, nurse practitioners, and physician assistants. I am less concerned about the trade association issues and more concerned with the quality of patient care issues. My concern is that children, the elderly, the poor, and people of color will become the second-class patients that the ‘psychiatrist extenders’ will be slotted to treat.

“Of course, there is hope that modern science will develop scientific tests to accurately identify Alzheimer’s disease, and it will become easier to prevent and treat this major public health disorder. I am hoping the same will occur with some of the childhood neurodevelopmental disorders.”

–Carl C. Bell, M.D.

“Several strategies should be developed to motivate the general psychiatrist to go into child and geriatric psychiatry, such as loan-repayment programs, and increasing salaries. Additionally, we should make sure that general psychiatrists get more training in child and geriatric psychiatry.”

–Antonio Y. Hardan, M.D.

“This is a systemic problem that has been building over a period longer than 20 years and is now reaching critical proportions.

“Some of the components include:

• The number of medical school graduates hasn’t kept up with the increase in population.

• Though the proportion of graduates going into psychiatry hasn’t declined, all the cognitive specialties face stiff competition from better paying procedure specialties.

• Private practice is being challenged by the many opportunities offered to psychiatrists by institutions that do not focus on clinical care.

• The private practice of psychiatry is being compartmentalized by institutions and organizations that hire psychiatrists.

• Many who have had enough from harassment by insurers, bureaucrats, and insurance companies are retiring early.”

–Rodrigo A. Muñoz, M.D.

“Psychiatry needs to expand its use and innovation of collaborative team-based models of care that support front-line mental health and medical professionals treating these populations. Videoconferencing can be used to increase access to care for these patients, their providers, and care givers in traditional medical settings of hospitals and clinics as well as nontraditional settings such as schools, care facilities, homes, and offices.

“Additional technologies (for example, Web-based treatments and mobile applications) should be leveraged as ‘force multipliers’ to allow providers with child and geriatric expertise the greatest clinical reach in supporting these efforts. Attention and resources need to be directed at developing pilots that can inform the wider deployment of team-based models of care that preserve the quality of treatment while remaining economically sustainable within the current dynamic funding environment.

–James (Jay) H. Shore, M.D.

The National Center for Health Workforce Analysis predicts that between 2010 and 2025, the field of psychiatry will see a decrease of 1 to 2 full-time equivalents (FTEs) per 100,000 psychiatrists. Yet, the need for providers with expertise in treating psychiatric patients remains great, particularly in light of persistence of mental illness stigma.

As we begin a new year, we asked members of our Editorial Advisory Board how they’d like to see the specialty respond to these trends so that patients with mental illness will get the care that they need. Here are some of their responses:

“Ultimately, the answer to this question depends on creating and maintaining access to effective professional care and social supports for the true health care ‘customers’ we serve – for example, people with mental illnesses and their families. This will require changes in how psychiatric care is described, provided, and paid for. We are indeed witnessing a redefinition of the definition of a ‘health care provider.’ And we are not going out of business! Psychiatrists will be teachers, researchers, systems leaders, and expert providers in the future. Clinical psychiatrists grounded as medical specialists will collaborate with patients, family members, nurses, psychologists, social workers, alcohol/drug counselors, primary care physicians, and community advocates to the goal of enhancing patient-centered care, which is evaluated and controlled by patients and their families.

“In addition to learning and practicing interdisciplinary teamwork in their training and practice venues, psychiatrists will continue to evolve functional roles in both patient care and clinical systems. These new functions will spawn new definitions of subspecialties in psychiatry well beyond our current category. The needs of children and the elderly will be addressed.

“Some psychiatrists will choose to provide patients with specialized, therapeutic relationships, as I did for 42 years. And, for the past decade, I practiced addiction psychiatry with patients of different ages, races, nationalities, and economic circumstances. What a privilege!

“It is indeed good news that psychiatry is holding its own attracting new trainees in 2015. Continuing interest in psychiatry speaks to the dynamism and challenges of our profession and its appeal to medical students, by far the most going into psychiatry are female. When I meet with our Minnesota psychiatry residents, they tell me after residency they need a job that will allow them to have a family and pay off their training cost debt.

“In addition, here are a few more thoughts:

• ‘Cognitive specialties’ such as psychiatry do continue to face stiff competition from historically much-better-paying, procedurally oriented medical specialties.

• Participation in postgraduate medical school internships are fundamental to the training of psychiatrists so that we can understand the treatment and management of a wide range of patients and medical conditions.

• Learning patient care and clinical skills as physicians involves adhering to Hippocratic medical ethics. This is our basic training.

• That said, concepts of population disease management and associate cost rationing are worthy ethical issues that are often in conflict with Hippocratic patient-centeredness.

• The power and control of most physicians who provide patient care in the United States are superseded by private and governmental organizations, and most physicians nationwide are employees.

• Clinical psychiatric practice in large organizations and/or for psychiatrists who have insurance company provider contracts is governed by clinical guidelines, care algorithms, and pay-for-performance rules not under the control of physicians.

“Most independent, private psychiatrists in Minnesota doing direct clinical patient care have opted out of all provider contracts and Medicare. They have chosen to do direct pay practice because of obstacles to low pay for doing psychotherapy or conducting family meetings, disruptive and intrusive insurance company practices including prior authorizations, time-consuming coding requirements, mandated electronic medical records (concerns about checklists and privacy/confidentiality), stigma associated with data transfer, and interception of continuity of care between treatment settings. Many direct pay psychiatrists also have consultation jobs in mental health centers, the Department of Veterans Affairs, or are doing insurance reviews and like to manage their schedules.”

–Lee H. Beecher, M.D.

“As a psychiatrist currently working in a general hospital and family medicine clinic setting, it seems to me that it would be wise for the specialty of psychiatry to more closely align itself with general medicine. There is a great deal of talk about co-locating mental health, substance abuse, and primary care in medical homes – but, with the exception of a few brave programs, not much has changed.

“I have been observing a trend that nurse practitioners are picking up the slack for the dearth of geriatric psychiatrist, and this is becoming the trend in several states. Another trend is for family practitioners to partner with a psychologist and to write the prescriptions the psychologists suggest to the physician – of course, they are just biding time until psychologists can prescribe. Unfortunately, it seems to me that it’s OK for these ‘psychiatrist extenders’ to prescribe and care for these patients, who unfortunately are seen as least desirable. I know of one context where a retired surgeon is nearly ubiquitous in caring for the geriatric nursing home population and, in my opinion, those specialists are not very learned in this area – as evidenced by their often inappropriate care of elderly patients with major neurocognitive disorder.

“I recall the last time there was a huge shortage of psychiatrists, it was right after World War II. The nation opened the doors for general practitioners to become psychiatrists. And quite a few took advantage of that opportunity. I foresee the same thing happening, but instead of general practitioners, this time it will be psychologists, nurse practitioners, and physician assistants. I am less concerned about the trade association issues and more concerned with the quality of patient care issues. My concern is that children, the elderly, the poor, and people of color will become the second-class patients that the ‘psychiatrist extenders’ will be slotted to treat.

“Of course, there is hope that modern science will develop scientific tests to accurately identify Alzheimer’s disease, and it will become easier to prevent and treat this major public health disorder. I am hoping the same will occur with some of the childhood neurodevelopmental disorders.”

–Carl C. Bell, M.D.

“Several strategies should be developed to motivate the general psychiatrist to go into child and geriatric psychiatry, such as loan-repayment programs, and increasing salaries. Additionally, we should make sure that general psychiatrists get more training in child and geriatric psychiatry.”

–Antonio Y. Hardan, M.D.

“This is a systemic problem that has been building over a period longer than 20 years and is now reaching critical proportions.

“Some of the components include:

• The number of medical school graduates hasn’t kept up with the increase in population.

• Though the proportion of graduates going into psychiatry hasn’t declined, all the cognitive specialties face stiff competition from better paying procedure specialties.

• Private practice is being challenged by the many opportunities offered to psychiatrists by institutions that do not focus on clinical care.

• The private practice of psychiatry is being compartmentalized by institutions and organizations that hire psychiatrists.

• Many who have had enough from harassment by insurers, bureaucrats, and insurance companies are retiring early.”

–Rodrigo A. Muñoz, M.D.

“Psychiatry needs to expand its use and innovation of collaborative team-based models of care that support front-line mental health and medical professionals treating these populations. Videoconferencing can be used to increase access to care for these patients, their providers, and care givers in traditional medical settings of hospitals and clinics as well as nontraditional settings such as schools, care facilities, homes, and offices.

“Additional technologies (for example, Web-based treatments and mobile applications) should be leveraged as ‘force multipliers’ to allow providers with child and geriatric expertise the greatest clinical reach in supporting these efforts. Attention and resources need to be directed at developing pilots that can inform the wider deployment of team-based models of care that preserve the quality of treatment while remaining economically sustainable within the current dynamic funding environment.

–James (Jay) H. Shore, M.D.

The National Center for Health Workforce Analysis predicts that between 2010 and 2025, the field of psychiatry will see a decrease of 1 to 2 full-time equivalents (FTEs) per 100,000 psychiatrists. Yet, the need for providers with expertise in treating psychiatric patients remains great, particularly in light of persistence of mental illness stigma.

As we begin a new year, we asked members of our Editorial Advisory Board how they’d like to see the specialty respond to these trends so that patients with mental illness will get the care that they need. Here are some of their responses:

“Ultimately, the answer to this question depends on creating and maintaining access to effective professional care and social supports for the true health care ‘customers’ we serve – for example, people with mental illnesses and their families. This will require changes in how psychiatric care is described, provided, and paid for. We are indeed witnessing a redefinition of the definition of a ‘health care provider.’ And we are not going out of business! Psychiatrists will be teachers, researchers, systems leaders, and expert providers in the future. Clinical psychiatrists grounded as medical specialists will collaborate with patients, family members, nurses, psychologists, social workers, alcohol/drug counselors, primary care physicians, and community advocates to the goal of enhancing patient-centered care, which is evaluated and controlled by patients and their families.

“In addition to learning and practicing interdisciplinary teamwork in their training and practice venues, psychiatrists will continue to evolve functional roles in both patient care and clinical systems. These new functions will spawn new definitions of subspecialties in psychiatry well beyond our current category. The needs of children and the elderly will be addressed.

“Some psychiatrists will choose to provide patients with specialized, therapeutic relationships, as I did for 42 years. And, for the past decade, I practiced addiction psychiatry with patients of different ages, races, nationalities, and economic circumstances. What a privilege!

“It is indeed good news that psychiatry is holding its own attracting new trainees in 2015. Continuing interest in psychiatry speaks to the dynamism and challenges of our profession and its appeal to medical students, by far the most going into psychiatry are female. When I meet with our Minnesota psychiatry residents, they tell me after residency they need a job that will allow them to have a family and pay off their training cost debt.

“In addition, here are a few more thoughts:

• ‘Cognitive specialties’ such as psychiatry do continue to face stiff competition from historically much-better-paying, procedurally oriented medical specialties.

• Participation in postgraduate medical school internships are fundamental to the training of psychiatrists so that we can understand the treatment and management of a wide range of patients and medical conditions.

• Learning patient care and clinical skills as physicians involves adhering to Hippocratic medical ethics. This is our basic training.

• That said, concepts of population disease management and associate cost rationing are worthy ethical issues that are often in conflict with Hippocratic patient-centeredness.

• The power and control of most physicians who provide patient care in the United States are superseded by private and governmental organizations, and most physicians nationwide are employees.

• Clinical psychiatric practice in large organizations and/or for psychiatrists who have insurance company provider contracts is governed by clinical guidelines, care algorithms, and pay-for-performance rules not under the control of physicians.

“Most independent, private psychiatrists in Minnesota doing direct clinical patient care have opted out of all provider contracts and Medicare. They have chosen to do direct pay practice because of obstacles to low pay for doing psychotherapy or conducting family meetings, disruptive and intrusive insurance company practices including prior authorizations, time-consuming coding requirements, mandated electronic medical records (concerns about checklists and privacy/confidentiality), stigma associated with data transfer, and interception of continuity of care between treatment settings. Many direct pay psychiatrists also have consultation jobs in mental health centers, the Department of Veterans Affairs, or are doing insurance reviews and like to manage their schedules.”

–Lee H. Beecher, M.D.

“As a psychiatrist currently working in a general hospital and family medicine clinic setting, it seems to me that it would be wise for the specialty of psychiatry to more closely align itself with general medicine. There is a great deal of talk about co-locating mental health, substance abuse, and primary care in medical homes – but, with the exception of a few brave programs, not much has changed.

“I have been observing a trend that nurse practitioners are picking up the slack for the dearth of geriatric psychiatrist, and this is becoming the trend in several states. Another trend is for family practitioners to partner with a psychologist and to write the prescriptions the psychologists suggest to the physician – of course, they are just biding time until psychologists can prescribe. Unfortunately, it seems to me that it’s OK for these ‘psychiatrist extenders’ to prescribe and care for these patients, who unfortunately are seen as least desirable. I know of one context where a retired surgeon is nearly ubiquitous in caring for the geriatric nursing home population and, in my opinion, those specialists are not very learned in this area – as evidenced by their often inappropriate care of elderly patients with major neurocognitive disorder.

“I recall the last time there was a huge shortage of psychiatrists, it was right after World War II. The nation opened the doors for general practitioners to become psychiatrists. And quite a few took advantage of that opportunity. I foresee the same thing happening, but instead of general practitioners, this time it will be psychologists, nurse practitioners, and physician assistants. I am less concerned about the trade association issues and more concerned with the quality of patient care issues. My concern is that children, the elderly, the poor, and people of color will become the second-class patients that the ‘psychiatrist extenders’ will be slotted to treat.

“Of course, there is hope that modern science will develop scientific tests to accurately identify Alzheimer’s disease, and it will become easier to prevent and treat this major public health disorder. I am hoping the same will occur with some of the childhood neurodevelopmental disorders.”

–Carl C. Bell, M.D.

“Several strategies should be developed to motivate the general psychiatrist to go into child and geriatric psychiatry, such as loan-repayment programs, and increasing salaries. Additionally, we should make sure that general psychiatrists get more training in child and geriatric psychiatry.”

–Antonio Y. Hardan, M.D.

“This is a systemic problem that has been building over a period longer than 20 years and is now reaching critical proportions.

“Some of the components include:

• The number of medical school graduates hasn’t kept up with the increase in population.

• Though the proportion of graduates going into psychiatry hasn’t declined, all the cognitive specialties face stiff competition from better paying procedure specialties.

• Private practice is being challenged by the many opportunities offered to psychiatrists by institutions that do not focus on clinical care.

• The private practice of psychiatry is being compartmentalized by institutions and organizations that hire psychiatrists.

• Many who have had enough from harassment by insurers, bureaucrats, and insurance companies are retiring early.”

–Rodrigo A. Muñoz, M.D.

“Psychiatry needs to expand its use and innovation of collaborative team-based models of care that support front-line mental health and medical professionals treating these populations. Videoconferencing can be used to increase access to care for these patients, their providers, and care givers in traditional medical settings of hospitals and clinics as well as nontraditional settings such as schools, care facilities, homes, and offices.

“Additional technologies (for example, Web-based treatments and mobile applications) should be leveraged as ‘force multipliers’ to allow providers with child and geriatric expertise the greatest clinical reach in supporting these efforts. Attention and resources need to be directed at developing pilots that can inform the wider deployment of team-based models of care that preserve the quality of treatment while remaining economically sustainable within the current dynamic funding environment.

–James (Jay) H. Shore, M.D.

Dr. Paul J. Fink, a longtime Clinical Psychiatry News columnist and editorial adviser, and leader in the field of psychiatry, died June 4. He was 80.

Dr. Fink, a psychotherapist, psychiatry professor, and speaker, was a fierce advocate for his beloved specialty. "I have been an activist most of my life," he wrote. "Part of my role and that of other physicians is to help those less fortunate."

He took that role seriously. For example, he worked to prevent child abuse and to promote the treatment of trauma. He was a true believer in the findings of the Adverse Childhood Experiences Study, which showed that life experiences such as childhood maltreatment are major risk factors for the leading causes of death and illness in the United States. He called this study "the most important proof of the validity of one of the major building blocks of psychoanalysis."

In recent years, Dr. Fink advocated on behalf of men serving life sentences at the State Correctional Institution at Graterford, Pa., a maximum security prison. "Some psychiatrists fail to speak up because they are afraid that their visibility will scare patients away," he wrote. "But being only concerned with self allows ... injustices to continue."

Many of his writings – and much of his work – focused on the need to change the language to make it less stigmatizing toward people with mental illness. "Patients need to be referred to as people with schizophrenia rather than schizophrenics," he wrote. "It is wrong to identify the patient as the disease. Rarely, if ever, would we refer to a person as a ‘coronary’ or an ‘appendix.’ "

When Dr. Fink served as president of the American Psychiatric Association, he chose the defeat of stigma as his theme. Just last year, he said that of the hundreds of articles he wrote over the years, the one he valued most was based on a talk delivered at an American College of Psychiatrists meeting called "The enigma of stigma" (Psychiatr. Ann. 1983;669-90).

In addition to his clinical and volunteer work, Dr. Fink was a professor of psychiatry at Temple University in Philadelphia. Among other activities, Dr. Fink was a member of the Leadership Council on Child Abuse & Interpersonal Violence, a founding member of the Philadelphia Youth Violence Reduction Partnership Program, and chairman of the city’s Youth Homicide Committee. He chaired three departments of psychiatry in his career and received numerous awards, including the APA/National Institute of Mental Health Vestermark Psychiatry Educator Award and the Francis J. Braceland Award for Public Service.

As his 80th birthday approached last year, Dr. Fink pondered how he wanted to be remembered. "At this point, I am asking myself: Should I focus on putting my affairs in order? Or should I keep plugging along and continue fighting against stigma on behalf of people with mental illness so that my kids will be able to say with pride: ‘He was my Dad.’

"I think I’ll do both."

When members of the editorial advisory board learned of Dr. Fink’s death, we received several testimonials. Among them:

• Dr. Lee H. Beecher: Since 1991 when I joined the board, I saw Dr. Paul Fink as our Thought Leader. His CPN column and commentaries are timely insights into both psychiatry’s clinical challenges and recommendations for social policy. Always embracing a biopsychosocial perspective, Dr. Fink by his experience and example successfully challenged psychiatrists to provide both leadership in evaluating emerging systems of health care and excellence in doing patient care. I will miss Paul’s energy, passion, exuberance, honesty, and penetrating inquiry. We owe Dr. Fink a great deal for his valuable service to our profession!

• Dr. Steven R. Daviss: I’m so sorry to hear of Dr. Fink’s passing. A giant in psychiatry, he will be greatly missed.

• Dr. Rodrigo A. Muñoz: Paul and I had a great personal relationship for longer than 30 years and were partners in many APA struggles. The ones I remember the most: Paul was one of the first in the APA to recognize that our organization was changing rapidly. Paul led for many years the fight against discrimination. Paul was a champion in the fight for the integrity and the science of psychiatry. Paul believed to the end that the strength of the organization was in its members, and fought some of his best battles to protect the members and their work.

A memorial service will be held for Dr. Fink on Monday, June 16, at 1 p.m. at the College of Physicians of Philadelphia.

Dr. Paul J. Fink, a longtime Clinical Psychiatry News columnist and editorial adviser, and leader in the field of psychiatry, died June 4. He was 80.

Dr. Fink, a psychotherapist, psychiatry professor, and speaker, was a fierce advocate for his beloved specialty. "I have been an activist most of my life," he wrote. "Part of my role and that of other physicians is to help those less fortunate."

He took that role seriously. For example, he worked to prevent child abuse and to promote the treatment of trauma. He was a true believer in the findings of the Adverse Childhood Experiences Study, which showed that life experiences such as childhood maltreatment are major risk factors for the leading causes of death and illness in the United States. He called this study "the most important proof of the validity of one of the major building blocks of psychoanalysis."

In recent years, Dr. Fink advocated on behalf of men serving life sentences at the State Correctional Institution at Graterford, Pa., a maximum security prison. "Some psychiatrists fail to speak up because they are afraid that their visibility will scare patients away," he wrote. "But being only concerned with self allows ... injustices to continue."

Many of his writings – and much of his work – focused on the need to change the language to make it less stigmatizing toward people with mental illness. "Patients need to be referred to as people with schizophrenia rather than schizophrenics," he wrote. "It is wrong to identify the patient as the disease. Rarely, if ever, would we refer to a person as a ‘coronary’ or an ‘appendix.’ "

When Dr. Fink served as president of the American Psychiatric Association, he chose the defeat of stigma as his theme. Just last year, he said that of the hundreds of articles he wrote over the years, the one he valued most was based on a talk delivered at an American College of Psychiatrists meeting called "The enigma of stigma" (Psychiatr. Ann. 1983;669-90).

In addition to his clinical and volunteer work, Dr. Fink was a professor of psychiatry at Temple University in Philadelphia. Among other activities, Dr. Fink was a member of the Leadership Council on Child Abuse & Interpersonal Violence, a founding member of the Philadelphia Youth Violence Reduction Partnership Program, and chairman of the city’s Youth Homicide Committee. He chaired three departments of psychiatry in his career and received numerous awards, including the APA/National Institute of Mental Health Vestermark Psychiatry Educator Award and the Francis J. Braceland Award for Public Service.

As his 80th birthday approached last year, Dr. Fink pondered how he wanted to be remembered. "At this point, I am asking myself: Should I focus on putting my affairs in order? Or should I keep plugging along and continue fighting against stigma on behalf of people with mental illness so that my kids will be able to say with pride: ‘He was my Dad.’

"I think I’ll do both."

When members of the editorial advisory board learned of Dr. Fink’s death, we received several testimonials. Among them:

• Dr. Lee H. Beecher: Since 1991 when I joined the board, I saw Dr. Paul Fink as our Thought Leader. His CPN column and commentaries are timely insights into both psychiatry’s clinical challenges and recommendations for social policy. Always embracing a biopsychosocial perspective, Dr. Fink by his experience and example successfully challenged psychiatrists to provide both leadership in evaluating emerging systems of health care and excellence in doing patient care. I will miss Paul’s energy, passion, exuberance, honesty, and penetrating inquiry. We owe Dr. Fink a great deal for his valuable service to our profession!

• Dr. Steven R. Daviss: I’m so sorry to hear of Dr. Fink’s passing. A giant in psychiatry, he will be greatly missed.

• Dr. Rodrigo A. Muñoz: Paul and I had a great personal relationship for longer than 30 years and were partners in many APA struggles. The ones I remember the most: Paul was one of the first in the APA to recognize that our organization was changing rapidly. Paul led for many years the fight against discrimination. Paul was a champion in the fight for the integrity and the science of psychiatry. Paul believed to the end that the strength of the organization was in its members, and fought some of his best battles to protect the members and their work.

A memorial service will be held for Dr. Fink on Monday, June 16, at 1 p.m. at the College of Physicians of Philadelphia.

Dr. Paul J. Fink, a longtime Clinical Psychiatry News columnist and editorial adviser, and leader in the field of psychiatry, died June 4. He was 80.

Dr. Fink, a psychotherapist, psychiatry professor, and speaker, was a fierce advocate for his beloved specialty. "I have been an activist most of my life," he wrote. "Part of my role and that of other physicians is to help those less fortunate."

He took that role seriously. For example, he worked to prevent child abuse and to promote the treatment of trauma. He was a true believer in the findings of the Adverse Childhood Experiences Study, which showed that life experiences such as childhood maltreatment are major risk factors for the leading causes of death and illness in the United States. He called this study "the most important proof of the validity of one of the major building blocks of psychoanalysis."

In recent years, Dr. Fink advocated on behalf of men serving life sentences at the State Correctional Institution at Graterford, Pa., a maximum security prison. "Some psychiatrists fail to speak up because they are afraid that their visibility will scare patients away," he wrote. "But being only concerned with self allows ... injustices to continue."

Many of his writings – and much of his work – focused on the need to change the language to make it less stigmatizing toward people with mental illness. "Patients need to be referred to as people with schizophrenia rather than schizophrenics," he wrote. "It is wrong to identify the patient as the disease. Rarely, if ever, would we refer to a person as a ‘coronary’ or an ‘appendix.’ "

When Dr. Fink served as president of the American Psychiatric Association, he chose the defeat of stigma as his theme. Just last year, he said that of the hundreds of articles he wrote over the years, the one he valued most was based on a talk delivered at an American College of Psychiatrists meeting called "The enigma of stigma" (Psychiatr. Ann. 1983;669-90).

In addition to his clinical and volunteer work, Dr. Fink was a professor of psychiatry at Temple University in Philadelphia. Among other activities, Dr. Fink was a member of the Leadership Council on Child Abuse & Interpersonal Violence, a founding member of the Philadelphia Youth Violence Reduction Partnership Program, and chairman of the city’s Youth Homicide Committee. He chaired three departments of psychiatry in his career and received numerous awards, including the APA/National Institute of Mental Health Vestermark Psychiatry Educator Award and the Francis J. Braceland Award for Public Service.

As his 80th birthday approached last year, Dr. Fink pondered how he wanted to be remembered. "At this point, I am asking myself: Should I focus on putting my affairs in order? Or should I keep plugging along and continue fighting against stigma on behalf of people with mental illness so that my kids will be able to say with pride: ‘He was my Dad.’

"I think I’ll do both."

When members of the editorial advisory board learned of Dr. Fink’s death, we received several testimonials. Among them:

• Dr. Lee H. Beecher: Since 1991 when I joined the board, I saw Dr. Paul Fink as our Thought Leader. His CPN column and commentaries are timely insights into both psychiatry’s clinical challenges and recommendations for social policy. Always embracing a biopsychosocial perspective, Dr. Fink by his experience and example successfully challenged psychiatrists to provide both leadership in evaluating emerging systems of health care and excellence in doing patient care. I will miss Paul’s energy, passion, exuberance, honesty, and penetrating inquiry. We owe Dr. Fink a great deal for his valuable service to our profession!

• Dr. Steven R. Daviss: I’m so sorry to hear of Dr. Fink’s passing. A giant in psychiatry, he will be greatly missed.

• Dr. Rodrigo A. Muñoz: Paul and I had a great personal relationship for longer than 30 years and were partners in many APA struggles. The ones I remember the most: Paul was one of the first in the APA to recognize that our organization was changing rapidly. Paul led for many years the fight against discrimination. Paul was a champion in the fight for the integrity and the science of psychiatry. Paul believed to the end that the strength of the organization was in its members, and fought some of his best battles to protect the members and their work.

A memorial service will be held for Dr. Fink on Monday, June 16, at 1 p.m. at the College of Physicians of Philadelphia.

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.